Discussion: Introduction to Population-Focused Health
Tina_Brown1582
PublicHealthNursing_Population-CenteredHealthCareintheCommunity-Mosby2015.pdf
Po lic
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C o m m
u n i t y - O r i e n t e d N u r s i n g P r a c t i c e
Services � Personal health services � Populations/Aggregate Services � Community services
Interventions � Disease prevention � Health promotion � Health protection � Health maintenance � Health restoration � Health surveillance
Overarching Concept � Community-oriented nursing practice
Subconcepts � Public health nursing
� Population focused � Population centered
Foundational Pillars � Assurance � Assessment � Policy development
Settings � Community � Environment � School � Industry � Church � Prisons � Playground � Home
Clients � Individuals � Families � Groups � Populations � Communities
HEALTH SURVEILLA N
CE
HEALTH RESTO RA
TIO N
HEALTH M A IN
TEN A N
C E
Assurance
H EA
LT H P
RO M
OT ION
H EA
LT H P
RO TE
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N
As se
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en t
P u b l i c H e a l t h N u r s i n g
� P o p u l a t i o n F o c u s e d
� P o p u l a t i o n C e n t e r e d
D IS
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COMMUNITY NURSING DEFINITIONS Community-Oriented Nursing Practice is a philosophy of nursing service delivery that involves the generalist or specialist public health and community health nurse providing “health care” through community diagnosis and investigation of major health and environmental problems, health surveillance, and monitoring and evaluation of community and population health status for the purposes of preventing disease and disability and promoting, protecting, and maintaining “health” in order to create conditions in which people can be healthy.
Public Health Nursing Practice is the synthesis of nursing theory and public health theory applied to promoting and preserving health of populations. The focus of practice is the community as a whole and the effect of the community’s health status (resources) on the health of individuals, families, and groups. Care is provided within the context of preventing disease and disability and promoting and protecting the health of the community as a whole. Public Health Nursing is population focused, which means that the population is the center of interest for the public health nurse. Community Health Nurse is a term that is used interchangeably with Public Health Nurse.
Community-Based Nursing Practice is a setting-specific practice whereby care is provided for “sick” individuals and families where they live, work, and go to school. The emphasis of practice is acute and chronic care and the provision of comprehensive, coordinated, and continuous services. Nurses who deliver community-based care are generalists or specialists in maternal–infant, pediatric, adult, or psychiatric–mental health nursing.
COMMUNITY-ORIENTED NURSING
PUBLIC HEALTH NURSING: POPULATION FOCUSED/ POPULATION CENTERED
COMMUNITY-BASED NURSING
Philosophy PRIMARY focus is on “health care” of communities and populations
SECONDARY focus is on “health care” of individuals, families, and groups in community to unserved clients by health care system
Focus is on “illness care” of individuals and families across the life span
Goal Prevent disease; preserve, protect, promote, or maintain health
Prevent disease; preserve, protect, promote, or maintain health
Manage acute or chronic conditions
Service context Community and population health care “the greatest good for the greatest number”
Personal health care to unserved clients
Family-centered illness care
Community type Varied: local, state, nation, world community
Varied, usually local community Human ecological
Client characteristics • Nation • State • Community • Populations at risk • Aggregates • Healthy • Culturally diverse • Autonomous • Able to define problem • Client primary decision maker
• Individuals/families at risk if unserved by health care system
• Usually healthy • Culturally diverse • Autonomous • Able to define own problem • Client primary decision maker
• Individuals • Families • Usually ill • Culturally diverse • Autonomous • Client able to define own
problem • Client involved in
decision making
Practice setting • Community • Organization • Government • Community agencies
• May be organization • May be government • Community agencies • Home • Work • School • Playground
• Community agencies • Home • Work • School
Interaction patterns • Governmental • Organizational • Groups • May be one-to-one
• One-to-one • Groups • May be organizational
• One-to-one
Type of service • Indirect • May be direct care of
populations
• Direct care of at-risk persons • Indirect (program management)
• Direct illness care
Emphasis on levels of prevention
• Primary • Primary • Secondary: screening • Tertiary: maintenance and
rehabilitation
• Secondary • Tertiary • May be primary
Select Examples of Similarities and Differences Between Community-Oriented and Community- Based Nursing
COMMUNITY-ORIENTED NURSING
PUBLIC HEALTH NURSING: POPULATION FOCUSED/ POPULATION CENTERED
COMMUNITY-BASED NURSING
Roles Client and delivery oriented: community/ population
• Educator • Consultant • Advocate • Planner • Collaborator • Data collector/evaluator • Health status monitor • Social engineer • Community developer/partner • Facilitator • Community care agent • Assessor • Policy developer/maker • Assuror of health care • Enforcer of laws/compliance • Disaster responder Population oriented • Program manager, aggregates • Health initiator • Program evaluator • Counselor • Change agent—population
health • Educator • Population advocate
Client and delivery oriented: individual, family, group
• Individual/family oriented— as needed
• Caregiver • Social engineer • Educator • Counselor • Advocate • Case manager Group Oriented • Leader, personal health
management • Change agent, screening • Community advocate • Case finder • Community care agent • Assessment • Policy developer • Assurance • Enforcer of laws/compliance
Client and delivery oriented: individual, family
• Caregiver • Educator • Counselor • Advocate • Care manager Group Oriented • Leader, disease
management • Change agent, managed
care services
Priority of nurses’ activities
• Community development • Community assessment/
monitoring • Health policy/politics • Community education • Interdisciplinary practice • Program management • Community/population
advocacy
• For individual and family clients—as needed
• Case finding • Client education • Community education • Interdisciplinary practice • Case management, direct care • Program planning,
implementation • Individual and family advocacy
• Care management, direct care
• Patient education • Individual and family
advocacy • Interdisciplinary practice • Continuity of care
provider
Select Examples of Similarities and Differences Between Community-Oriented and Community- Based Nursing—cont’d
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PUBLIC HEALTH NURSING Population-Centered Health Care in the Community
Marcia Stanhope, PhD, RN, FAAN Education and Practice Consultant and Professor Emerita College of Nursing University of Kentucky Lexington, Kentucky
Jeanette Lancaster, PhD, RN, FAAN Professor and Dean Emerita School of Nursing University of Virginia Charlottesville, Virginia
9 T H E D I T I O N
3251 Riverport Lane St. Louis, Missouri 63043
PUBLIC HEALTH NURSING: POPULATION-CENTERED HEALTH CARE IN THE COMMUNITY, EDITION NINE
ISBN: 978-0-323-32153-2
Copyright © 2016 by Elsevier Inc.
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Notices
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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
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Previous editions copyrighted 2014, 2008, 2004, 2000, 1996, 1992, 1988, 1984
Library of Congress Cataloging-in-Publication Data Public health nursing (Stanhope) Public health nursing : population-centered health care in the community / [edited by] Marcia Stanhope, Jeanette Lancaster.—9th edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-323-32153-2 (pbk. : alk. paper) I. Stanhope, Marcia, editor. II. Lancaster, Jeanette, editor. III. Title. [DNLM: 1. Community Health Nursing. 2. Public Health Nursing. WY 106] RT98 610.73′43—dc23 2015007429
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vii
Marcia Stanhope, PhD, RN, FAAN Marcia Stanhope is currently an education consultant with Berea College, Berea Kentucky, as in Berea, Kentucky an Associ- ate with Tuft and Associate Search Firm, Chicago, Illinois, and Professor Emerita from the University of Kentucky, College of Nursing, Lexington, Kentucky. In recent years she received the Provost Public Scholar award for contributions to the commu- nities of Kentucky. She was appointed to the Good Samaritan Endowed Chair in Community Health Nursing 12 years ago. She has practiced community and home health nursing, has served as an administrator and consultant in home health, and has been involved in the development of a number of nurse- managed centers. She has taught community health, public health, epidemiology, primary care nursing, and administration courses. Dr. Stanhope was the former Associate Dean and for- merly directed the Division of Community Health Nursing and Administration at the University of Kentucky. She has been responsible for both undergraduate and graduate courses in population-centered, community-oriented nursing. She has also taught at the University of Virginia and the University of Alabama, Birmingham. Her presentations and publications have been in the areas of home health, community health and community-focused nursing practice, nurse-managed centers, and primary care nursing. Dr. Stanhope holds a diploma in nursing from the Good Samaritan Hospital, Lexington, Ken- tucky, and a bachelor of science in nursing from the University of Kentucky. She has a master’s degree in public health nursing from Emory University in Atlanta and a doctorate of science in nursing from the University of Alabama, Birmingham. Dr. Stan- hope is the co-author of four other Elsevier publications: Hand- book of Community-Based and Home Health Nursing Practice, Public and Community Health Nurse’s Consultant, Case Studies in Community Health Nursing Practice: A Problem-Based Learn- ing Approach, and Foundations of Community Health Nursing: Community-Oriented Practice.
A B O U T T H E A U T H O R S
Jeanette Lancaster, PhD, RN, FAAN Jeanette Lancaster is Professor and Dean Emerita at the University of Virginia, School of Nursing in Charlottesville, Virginia. She served as Dean of the School of Nursing at the University of Virginia from 1989 until 2008. From 2008 to 2009 she served as a visiting professor at the University of Hong Kong where she taught courses in public health nursing and worked with faculty to develop their scholarship programs. She then taught at the University of Virginia from 2010 until 2012. She also taught at Vanderbilt University and is an Associate with Tuft & Associates, Inc, an executive search firm. She has prac- ticed psychiatric nursing and taught both psychiatric and com- munity health nursing. She formerly directed the master’s program in community health nursing at the University of Alabama, Birmingham, and served as Dean of the School of Nursing at Wright State University in Dayton, Ohio. Her pub- lications and presentations have been largely in the areas of community and public health nursing leadership and change and the significance of nurses to effective primary health care. Dr. Lancaster is a graduate of the University of Tennessee Health Science Center Memphis. She holds a master’s degree in psychi- atric nursing from Case Western Reserve University and a doc- torate in public health from the University of Oklahoma. Dr. Lancaster is the author of another Elsevier publication, Nursing Issues in Leading and Managing Change, and the co-author with Dr. Marcia Stanhope of Foundations of Community Health Nursing: Community-Oriented Practice.
viii
INTRODUCING DRS HALE AND TURNER In this edition, we are pleased to have Professor Patty Hale, RN, FNP, PhD, FAAN, Graduate Program Director, Department of Nursing, at James Madison University, Harrisburg, Virginia, and Lisa Turner, PhD, RN, PHCNS-BC, Assistant Professor of Nursing, Berea College, Berea, Kentucky, join us in this edition of the text as Assistant Editors.
A C K N O W L E D G E M E N T S
Dr. Hale holds a BSN from the University of Wisconsin- Milwaukee, an MSN and FNP from the University of Virginia, and a PhD from the University of Maryland.
Dr. Turner holds a BSN and MSN from the University of Virginia and a PhD from the University of Kentucky.
A SPECIAL THANKS TO CONTRIBUTORS Each edition our goal has been to offer special thanks to those who contributed to past editions of the text. To continue that tradition we want to extend heartfelt thanks to those who con- tributed to the 8th edition. They are Jean Bokinskie, Bonnie Jerome D’Emili, Diane Downing, James Fletcher, Karen Landen- burger, Robert McKeown, Susan Patton, Molly Rose, Juliann Sebastian, Mary Silva, and Jeanne Sorrell.
Jeanette Lancaster and Marcia Stanhope
DEDICATIONS: It has been my special privilege to be advised and mentored by a number of exemplary professionals and to be loved and supported by numerous friends, big and small. Their contributions have made significant differences to my life and career. This edition of the text is dedicated to the memory of Charlotte Denny and Lois Merrill, University of Kentucky; Mary Hall, Emory University; Atlanta, Dorothy Carter, my community partner, Pikev- ille, Kentucky, and Norma Mobley, University of Alabama, Birmingham; as well as to two special friends, John C. and CiCi.
I would like to dedicate my work on this 9th edition to my late husband, I. Wade Lancaster. He supported and encouraged me through the first eight editions of the text, and I am deeply grateful for his love, support, and encouragement.
Marcia Stanhope
Jeanette Lancaster
ix
Swann Arp Adams, MS, PhD Associate Professor College of Nursing and the Dept. of Epidemiology and Biostatistics Associate Director Cancer Prevention and Control Program University of South Carolina Columbia, South Carolina Chapter 12: Epidemiology
Mollie Aleshire, DNP, FNP-BC, PPCNP-BC Assistant Professor University of Kentucky College of Nursing Lexington, Kentucky Chapter 28: Family Health Risks
Jeanne L. Alhusen, PhD, CRNP, RN Assistant Professor Department of Community and Public
Health Johns Hopkins University School of Nursing Baltimore, Maryland Chapter 38: Violence and Human Abuse
Debra Gay Anderson, PhD, PHCNS-BC Associate Professor University of Kentucky College of Nursing Lexington, Kentucky Chapter 28: Family Health Risks
Dyan A. Aretakis, RN, FNP, MSN Project Director and APN3 University of Virginia Teen Health Center Charlottesville, Virginia Chapter 35: Teen Pregnancy
Tina Bloom, PhD, MPH, RN Assistant Professor and Robert Wood
Johnson Foundation Nurse Faculty Scholar, Sinclair School of Nursing
Columbia, Missouri Chapter 38: Violence and Human Abuse
C O N T R I B U T O R S
Nisha Botchwey, PhD, MCRP, MPH Associate Professor of City and Regional
Planning, Georgia Institute of Technology Affiliated Faculty, Center for Geographic Information Systems, Georgia Institute of Technology Director, Research Committee, National
Academy of Environmental Design Member, Centers for Disease Control and
Prevention Advisory Committee to the Director
Atlanta, Georgia Chapter 17: Building a Culture of Health
through Community Health Promotion
Kathryn H. Bowles, RN, PhD, FAAN vanAmeringen Professor in Nursing
Excellence; Director of the Center for Integrative Science in Aging; Beatrice Renfield Visiting Scholar Visiting Nurse Service of New York
Philadelphia, Pennsylvania Chapter 41: The Nurse in Home Health,
Palliatire Care, and Hospice
Angeline Bushy, PhD, RN, FAAN, PHCNS-BC Professor & Bert Fish Chair University of Central Florida College of Nursing Daytona Beach, Florida Chapter 19: Population-Centered Nursing in
Rural and Urban Environments
Jacquelyn C. Campbell, PhD, RN, FAAN Professor Anna D. Wolf Chair National Program Director, Robert Wood
Johnson Foundation Nurse Faculty Scholars
Department of Community-Public Health The Johns Hopkins University Baltimore, Maryland Chapter 38: Violence and Human Abuse
Ann H. Cary, PhD, MPH, RN, FNAP Professor and Dean; School of Nursing and
Health Studies, University of Missouri Kansas City; Robert Wood Johnson Foundation Executive Nurse Fellow
Kansas City, Missouri Chapter 22: Case Management
Ann Connor, DNP, MSN, RN, FNP-BC Assistant Professor, School of Nursing Emory University Atlanta, Georgia Chapter 33: Poverty and Homelessness
Lois A. Davis, RN, MSN, MA Public Health Nursing Manager Lexington—Fayette County Health
Department in Lexington, Kentucky Chapter 46: Public Health Nursing at Local,
State, and National Levels
Cynthia E. Degazon, RN, PhD Professor Emerita Hunter College of the City University of
New York New York, New York Chapter 7: Cultural Diversity in the
Community
Janna Dieckmann, PhD, RN Clinical Associate Professor School of Nursing, University of North
Carolina at Chapel Hill Chapel Hill, North Carolina Chapter 2: History of Public Health and
Public and Community Health Nursing
Sharon L. Farra, PhD, RN Assistant Professor of Nursing, Wright State University Dayton, Ohio Chapter 23: Public Health Nursing Practice
and the Disaster Management Cycle
Hartley Feld, RN, MSN, PHCNS-BC University of Kentucky, College of Nursing Lecturer/Clinical Instructor, Public and
Community Health Nursing University of Kentucky Lexington, Kentucky Chapter 28: Family Health Risks
Mary E. Gibson, PhD, RN Associate Professor in Nursing Assistant Director, Bjoring Center for
Nursing Historical Inquiry University of Virginia School of Nursing Charlottesville, Virginia Chapter 18: Community as Client:
Assessment and Analysis
x CONTRIBUTORS
Rosa M. Gonzalez-Guarda, PhD, MPH, RN, CPH Assistant Professor, Robert Wood Johnson
Foundation Nurse Faculty Scholar, University of Miami School of Nursing and Health Studies
Coral Gables, Florida Chapter 38: Violence and Human Abuse
Monty Gross, PhD, RN, CNE, CNL Clinical Nurse Educator Veterans Administration North Las Vegas, Nevada Chapter 30: Major Health Issues and Chronic
Disease Management of Adults Across the Life Span
Patty J. Hale, RN, FNP, PhD, FAAN Professor and Graduate Program Director James Madison University Harrisonburg, Virginia Chapter 14: Communicable and Infectious
Disease Risks
Susan B. Hassmiller, PhD, RN, FAAN Robert Wood Johnson Foundation Senior
Advisor for Nursing, and Director, Future of Nursing: Campaign for Action
Princeton, New Jersey Chapter 23: Public Health Nursing Practice
and the Disaster Management Cycle
Anita Thompson-Heisterman, MSN, PMHCNS-BC, PMHNP-BC Assistant Professor University of Virginia School of Nursing Claude Moore Nursing Education Building Charlottesville, Virginia Chapter 36: Mental Health Issues
DeAnne K. Hilfinger Messias, PhD, RN, FAAN Professor College of Nursing and Women’s and
Gender Studies University of South Carolina Columbia, South Carolina Chapter 12: Epidemiology
Linda Hulton, PhD, RN Professor of Nursing Coordinator of Doctor of Nursing Practice
Program James Madison University Harrisonburg, Virginia Chapter 30: Major Health Issues and Chronic
Disease Management of Adults Across the Life Span
Anita Hunter, PhD, APRN-CPNP Executive Board Member, Holy Innocents
Children’s Hospital, Inc., Mbarara, Uganda Adjunct Professor, Washington State University Vancouver, Washington Chapter 4: Perspectives in Global Health Care
Joanna Rowe Kaakinen, PhD, RN Professor, School of Nursing Linfield College-Portland Campus Portland, Oregon Chapter 27: Working with Families in the
Community for Healthy Outcomes
Linda Olson Keller, DNP, CPH, APHN- BC, RN, FAAN Clinical Associate Professor University of Minnesota School of Nursing Minneapolis, Minnesota Chapter 9: Population-Based Public Health
Nursing Practice: The Intervention Wheel
Loren Kelly, RN, MSN Clinical Educator Undergraduate Faculty at
University of New Mexico College of Nursing
Interprofessional Education Coordinator, UNM College of Nursing
Albuquerque, New Mexico Chapter 20: Promoting Health Through
Healthy Communities and Cities
Katherine K. Kinsey, PhD, RN, FAAN Nurse Administrator Philadelphia Nurse-Family Partnership Mabel Morris Family Home Visit Program Early Childhood Initiatives Sponsored by the National Nursing Centers
Consortium Philadelphia, Pennsylvania Chapter 21: The Nurse-led Health Center: A
Model for Community Nursing Practice
Pamela A. Kulbok, DNSc, RN, PHCNS-BC, FAAN Theresa A. Thomas Professor of Primary
Care Nursing and Professor of Public Health Sciences
Chair, Family Community, and Mental Health Systems
Coordinator of Public Health Nursing Leadership
Robert Wood Johnson Executive Nurse Fellow 2012-2015
University of Virginia School of Nursing Charlottesville, Virginia Chapter 17: Building a Culture of Health
through Community Health Promotion
Jeanette Lancaster, PhD, RN, FAAN Professor and Dean Emerita School of Nursing University of Virginia Charlottesville, Virginia Chapter 11: Genomics in Public Health Nursing
Susan C. Long-Marin, DVM, MPH Epidemiology Manager Mecklenburg County Health Department Charlotte, North Carolina Chapter 13: Infectious Disease Prevention and
Control
Karen S. Martin, RN, MSN, FAAN Health Care Consultant Martin Associates Omaha, Nebraska Chapter 41: The Nurse in Home Health,
Palliative Care, and Hospice
Mary Lynn Mathre, RN, MSN, CARN Addictions Nurse Consultant President, Patients Out of Time President, American Cannabis Nurses
Association Howardsville, Virginia Chapter 37: Alcohol, Tobacco, and Other
Drug Problems
Natalie McClain, PhD, RN, CPNP Clinical Associate Professor Boston College William F. Connell School of Nursing Chestnut Hill, Massachusetts Chapter 44: Forensic Nursing in the Community
Mary Ellen T. Miller, PhD, RN Assistant Professor DeSales University Center Valley, Pennsylvania Chapter 21: The Nurse-led Health Center:
A Model for Community Nursing Practice
Marie Napolitano, PhD, RN, FNP Director—Doctor of Nursing Practice
Program University of Portland Portland, Oregon Chapter 34: Migrant Health Issues
Bobbie J. Perdue, RN, PhD Professor—Nursing South Carolina State University Orangeburg, South Carolina Chapter 7: Cultural Diversity in the Community
Bonnie Rogers, DrPH, COHN-S, LNCC, FAAN North Carolina Occupational Safety and
Health Education and Research Center and the
Occupational Health Nursing Program School of Public Health University of North Carolina, Chapel Hill Chapel Hill, North Carolina Chapter 43: The Nurse in Occupational Health
xiCONTRIBUTORS
Cynthia Rubenstein, PhD, RN, CPNP-PC James Madison University Undergraduate Program Director Assistant Professor Harrisonburg, Virginia Chapter 29: Child and Adolescent Health
Barbara Sattler, RN, DrPH, FAAN Professor, Masters of Public Health
Program, School of Nursing and Health Professions, University of San Francisco
San Francisco, California Chapter 10: Environmental Health
Erika Metzler Sawin, PhD, RN Assistant Professor Department of Nursing James Madison University Harrisonburg, Virginia Chapter 14: Communicable and Infectious
Disease Risks
Kellie A. Smith, RN, EdD Assistant Professor Thomas Jefferson University School of Nursing Philadelphia, Pennsylvania Chapter 39: The Advanced Practice Nurse in
the Community
Sharon A.R. Stanley, PhD, RN, FAAN Visiting Professor, Wright State University Robert Wood Johnson Executive Nurse
Fellow, 2011-2014 Dayton, Ohio Chapter 23: Public Health Nursing Practice
and the Disaster Management Cycle
Sharon Strang, RN, DNP, APRN, FNP-BC Associate Professor and Graduate Faculty James Madison University Dept of Nursing Harrisonburg, Virginia Chapter 30: Major Health Issues and Chronic
Disease Management of Adults Across the Life Span
Sue Strohschein, MS, RN/PHN, APRN, BC Culture of Excellence Project Coordinator University of Minnesota School of Nursing Minneapolis, Minnesota Chapter 9: Population-Based Public Health
Nursing Practice: The Intervention Wheel
Melissa Sutherland, PhD, FNP-BC Associate Professor Boston College William F. Connell School of Nursing Chestnut Hill, Massachusetts Chapter 44: Forensic Nursing in the Community
Francisco S. Sy, MD, PhD Editor, AIDS Education and Prevention—An
Interdisciplinary Journal; Director, Office of Extramural Research Administration, National Institute on Minority Health and Health Disparities, National Institutes of Health
Bethesda, Maryland Chapter 13: Infectious Disease Prevention and
Control
Esther J. Thatcher, PhD, RN, APHN-BC Postdoctoral Fellow School of Nursing University of North Carolina at Chapel Hill Chapel Hill, North Carolina Chapter 18: Community as Client:
Assessment and Analysis
Lisa Pedersen Turner, PhD, RN, PHCNS-BC Assistant Professor Berea College Nursing Program Berea, Kentucky Chapter 40: The Nurse Leader in the
Community Chapter 42: The Nurse in the Schools
Lynn Wasserbauer, RN, FNP, PhD Nurse Practitioner Behavioral Health Partners University of Rochester Medical Center Rochester, New York Chapter 31: Disability Health Care Across the
Life Span
Jacqueline F. Webb, FNP-BC, MS, RN Assistant Professor Linfield College School of Nursing Portland, Oregon Chapter 27: Working with Families in the
Community for Healthy Outcomes
Carolyn A. Williams, RN, PhD, FAAN Professor and Dean Emeritus College of Nursing University of Kentucky Lexington, Kentucky Chapter 1: Community and Prevention-
Oriented, Population-Focused Practice: The Foundation of Specialization in Public Health Nursing
Lisa M. Zerull, PhD, RN Academic Liaison and Program Manager,
Winchester Medical Center, Valley Health System
Adjunct Clinical Faculty, Shenandoah University (Winchester, VA)
Editor, Perspectives out of the Church Health Center (Memphis, TN)
Chapter 45: The Nurse in the Faith Community
Elke Jones Zschaebitz, DNP, FNP-BC Family Nurse Practitioner Pediatric Primary Care Provider Wilkerson Pediatric Clinic, Kenner Army
Health Clinic Ft. Lee, Virginia And Adjunct Faculty: Clinical Faculty Advisor, Family Nurse
Practitioner Program Georgetown University School of Nursing
and Health Sciences Washington, DC Chapter 11: Genomics in Public Health
Nursing
ANCILLARY AUTHORS
Patty Bollinger, MSN, APRN-CNS Bryan College of Health Sciences Lincoln, Nebraska TEACH/Powerpoint reviewer
Joanna E. Cain, BSN, BA, RN President and Founder of Auctorial
Pursuits, Inc. Atlanta, Georgia Student Case Studies Review Questions Answer Key for Review Questions
Linda Turchin, RN, MSN, CNE Assistant Professor of Nursing Fairmont State University Fairmont, West Virginia Test Bank Reviewer
Anna K. Wehling Weepie, DNP, RN, CNE Associate Professor Allen College Waterloo, Iowa Test Bank Writer
Linda Wendling, MS, MFA Learning Theory Consultant University of Missouri—St. Louis St. Louis, Missouri TEACH for Nurses Power Point Lecture Slides
xii
Since the last edition of this text, many changes have occurred in society as well as in health care. The rapid and often startling changes in society are influencing the amount and ways in which health care is delivered. Many of the industrialized nations around the world are engaged in health care reform, and a major driver for reform is the enormous cost of providing health care to citizens. The human, financial, infrastructure, and other costs associated with war, natural and human-made dis- eases, and civil uprising continue to affect many nations, includ- ing the United States. The world, as many people know, has changed dramatically in the past few decades because of such disruptions as war, hurricanes and tsunamis, terrorism, earth- quakes, floods, and tornados that have cost lives, homes, and livelihoods. These destructive events have had enormous costs in terms of money and the damage to individuals, families, and communities. The need for stronger public health resources has grown as these disruptions have occurred in the United States and many other countries. Public health professionals play a key role in helping communities deal with both emergency and non-emergency aspects of their lives.
As is explained in Chapter 1 and discussed in other chapters throughout the text, there are three core functions of public health: assessment, policy development, and assurance. The Centers for Disease Control and Prevention (CDC, 2014, p. 1) have developed 10 essential public health services, and the list below aligns these services with the core functions:
ASSESSMENT 1. Monitor health status to identify and solve community
environmental health problems. 2. Diagnose and investigate health problems and health
hazards in the community.
POLICY DEVELOPMENT 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships and actions to identify
and solve health problems. 5. Develop policies and plans that support individual and
community health efforts.
ASSURANCE 6. Enforce laws and regulations that protect health and ensure
safety. 7. Link people to needed health services and assure the provi-
sion of health services when otherwise unavailable. 8. Assure competent public and personal health care workforce. 9. Evaluate effectiveness, accessibility, and quality of personal
and population-based health services. 10. Research for new insights and innovative solutions to health
problems (CDC, 2014, p. 1).
P R E F A C E
Chapters in this text include all of the critical roles listed above as well as guidance in how to deal with other major issues, including the quality of care, the cost of care, and access to care. The growing shortage of nurses and other health care providers will only increase the concerns about these issues. One of the ways in which quality of care could be improved would include new uses of technology to manage an information revo- lution. Great improvements in quality would require a restruc- turing of how care is delivered, a shift in how funds are spent, changing the workplace, and using more effective ways to manage chronic illness. There will be costs associated with these quality improvements.
The United States’ health care spending has slowed in recent years due to the economy. In 2013, the health care costs were at about 1.2 trillion dollars, or 16.7% of the gross domestic product. After the implementation of the Affordable Care Act, the numbers of unisured dropped from 48 million to 41 million by 2013 (KFF 2014). However, the cost burden to employers and consumers needs to be explored to see if there has been any change. This number of uninsured is larger than the population of either Canada or Australia. Despite spending more money per person in the United States for illness care than any other country, Americans are not the healthiest of all people. The infant mortality and life expectancy rates—indexes of health care—while improving, are not close to what they should be given the amount spent on health care. Some of the most important factors leading to the high health care costs are diag- nostic and treatment technologies, drugs, an aging population, more chronic illness, shortages in health care workers, and medical-legal costs. Lifestyle continues to play a big role in morbidity and mortality. It is embarrassing that, overall, citi- zens in the United States are the most obese citizens in any industrialized nation. In addition, half of all deaths are still caused by tobacco, alcohol, and illegal drug use; diet and activity patterns; microbial agents; toxic agents; firearms; sexual behav- ior; and motor vehicle accidents.
In the past two decades the greatest improvements in popu- lation health have come from public health achievements such as immunizations leading to eliminating and controlling infec- tious diseases, motor vehicle safety, safer workplaces, lifestyle improvements reducing the risk of heart disease and strokes, safer and healthier foods through improved sanitation, clean water and food fortification programs, better hygiene and nutrition to improve the health of mothers and babies, family planning, fluoride in drinking water, and recognition of tobacco as a health hazard. Continued changes in the public health system are essential if death, illness, and disability resulting from preventable problems are to continue to decline.
The need to focus attention on health promotion, lifestyle factors, and disease prevention led to the development of a major public policy about health for the nation. This policy was designed by a large number of people representing a wide range of groups interested in health. The policy, first introduced in
xiiiPREFACE
1979, was updated in 1990 and in 2000; it is reflected in the most recent document updated in 2010, titled Healthy People 2020. These four documents have identified a set of national health promotion and disease prevention objectives for each of four decades. Examples of these objectives are highlighted in chapters throughout the text.
The most effective disease prevention and health promotion strategies designed to achieve the goals and objectives of Healthy People 2020 are developed through partnerships between government, businesses, voluntary organizations, con- sumers, communities, and health care providers. According to Healthy People 2020, the partners who join a newly estab- lished consortium will work to achieve the goals and objectives of Healthy People 2020.
Healthy People 2020 emphasizes the concept of social deter- minants of health—that is, the belief that health is affected by many social, economic, and environmental factors that extend far beyond individual biology of disease. This means that improving health requires a broad approach to including the concept of health in all policies and creating environments where the healthy choice is the easy choice. To develop healthy communities, individuals, families, communities, and popula- tions must commit to these approaches. Also, society, through the development of health policy, must support better health care, the design of improved health education, and new ways of financing strategies to alter health status.
The regrettable fact is that few health indicators have been substantially improved since Healthy People 2010 was released in 2000. Healthy People 2020 retains many of the original objec- tives and adds new ones. What does this mean for nurses who work in public health? Because people do not always know how to improve their health status, the challenge of nursing is to create change. Nursing takes place in a variety of public and private settings and includes disease prevention, health pro- motion, health protection, surveillance, education, mainte- nance, restoration, coordination, management, and evaluation of care of individuals, families, and populations, including communities.
To meet the demands of a constantly changing health care system, nurses must have vision in designing new and changing current roles and identifying their practice areas. To do so effec- tively, the nurse must understand concepts, theories, and the core content of public health, the changing health care system, the actual and potential roles and responsibilities of nurses and other health care providers, the importance of health promo- tion and disease orientation, and the necessity of involving con- sumers in the planning, implemention, and evaluation of health care efforts.
Since its initial publication in 1984, this text has been widely accepted and is popular among nursing students and nursing faculty in baccalaureate, BSN-completion, and graduate pro- grams. The text was written to provide nursing students and practicing nurses with a comprehensive source book that pro- vides a foundation for designing population-centered nursing strategies for individuals, families, aggregates, populations, and communities. The unifying theme for the book is the integrat- ing of health promotion and disease prevention concepts into
the many roles of nurses. The prevention focus emphasizes traditional public health practice with increased attention to the effects of the internal and external environment on health of communities. The focus on interventions for the individual and family emphasizes the aspects of population-centered practice with attention to the effects of all of the determinants of health, including lifestyle, on personal health.
CONCEPTUAL APPROACH TO THIS TEXT The term community-oriented has been used to reflect the ori- entation of nurses to the community and the public’s health. In 1998, the Quad Council of Public Health Nursing comprised of members from the American Nurses Association Congress on Nursing Practice, the American Public Health Association Public Health Nursing section, the Association of Community Health Nursing Educators, and the Association of State and Territorial Directors of Public Health Nursing developed a statement on the Scope of Public Health Nursing Practice. Through this statement, the leaders in public and community health nursing attempted to clarify the differences between public health nursing and the newest term introduced into nursing’s vocabulary during health care reform of the 1990s, community-based nursing. The Quad Council recognized that the terms public health nursing and community health nursing have been used interchangeably since the 1980s to describe population-focused, community-oriented nursing and community-focused practice. They decided to make a clearer distinction between community-oriented and community-based nursing practice. In 2007, the definitions were further refined, and nurses once referred to as public health nurses and community health nurses are now referred to only as public health nurses in the revised standards of practice.
In this textbook, two different levels of care in the com- munity are acknowledged: community-oriented care and community-based care. Two role functions for nursing practice in the community are suggested: public health nursing (com- munity health nursing) and community-based nursing. This text focuses only on public health nursing (community health nursing), using the term community-oriented nursing, which encompasses a focus on populations within the community context or population-centered nursing practice.
For the fifth edition of this text, with consultation from C. A. Williams (author) and June Thompson (Mosby editor), Marcia Stanhope developed a conceptual model for community- oriented nursing practice. This model was influenced by a review of the history of community-oriented nursing from the 1800s to today. Marcia Stanhope studied Betty Neuman’s model intensively while in school, which influenced this model.
The model itself is presented as a caricature of reality—or an abstract—with a description of the characteristics and the philosophy on which community-oriented nursing is built. The model is shown as a flying balloon (see inside front cover of this book). The balloon represents community-oriented nursing and is filled with the knowledge, skills, and abilities needed in this practice to carry the world (the basket of the balloon) or the clients of the world who benefit from this practice.
xiv PREFACE
The subconcepts of public health nursing with the community and populations as the center of care are the boundaries of the practice. The public health foundation pillars of assurance, assessment, and policy development hold up the world of com- munities, where people live, work, play, go to school, and worship. The ribbons flying from the balloon indicate the inter- ventions used by nurses. These ribbons (interventions) serve to provide lift and direction, tying the services together for the clients who are served. The intervention names and the services are listed on the inside cover of this book. The propositions (statements of relationship) for this model are found in the definitions of practice, public health functions, clients served, specific settings, interventions, and services. Many assumptions have served as the basis for the development of this model. Community-oriented nursing is a specialty within the nursing discipline. The practice has evolved over time, becoming more complex. The practice of nursing in public health is based on a philosophy of care rather than being setting specific. It is different from community-based nursing care delivery. The development of community-oriented nursing has been influ- enced by public health practice, preventive medicine, commu- nity medicine, and shifts in the health care delivery system. Community-oriented nursing requires nurses to have specific competencies to be effective providers of care.
The definition of community-oriented nursing appears on the inside front cover of this book. This practice involves public health nurses. Community-based nurses differ from community-oriented nurses in many ways. These differences are described in the table following the definitions. The differences are described as they relate to philosophy of care, goals, service, community, clients served, practice settings, ways of interacting with clients, type of services offered to clients, prevention levels used, goals, and priority of nurses’ activities.
The four concepts of nursing, person (client), environment, and health are described for this model. These concepts appear in many works about nursing and in almost every educational curriculum for undergraduate students. Each of the four con- cepts may be defined differently in these works because of the beliefs of the persons writing the definitions.
In this text nursing is defined as community-oriented with a focus on providing health care through community diagnosis and investigation of major health and environmental problems. Health surveillance, monitoring, and evaluating community and population status are done to prevent disease and disability and to promote, protect, preserve, restore, and maintain health. This in turn creates conditions in which clients can be healthy. The person, or client, is the world, nation, state, community, population, aggregate, family, or individual.
The boundaries of the client environment may be limited by the world, nation, state, locality, home, school, work, play- ground, religion, or individual self. Health, in this model, involves a continuum of health rather than wellness, with the best health state possible as the goal. The best possible level of health is achieved through measures of prevention as practiced by the nurse.
The nurse engages in autonomous practice with the client, who is the primary decision maker about health issues. The nurse practices in a variety of environments, including, but not limited to, governments, organizations, homes, schools, churches, neighborhoods, industry, and community boards. The nurse interacts with diverse cultures, partners, other providers in teams, multiple clients, and one-to-one or aggre- gate relationships. Clients at risk for the development of health problems are a major focus of nursing services. Primary prevention–level strategies are the key to reducing risk of health problems. Secondary prevention is done to maintain, promote, or protect health, whereas tertiary prevention strategies are used to preserve, protect, or maintain health.
The community-oriented nurse has many roles related to community clients and roles that relate specifically to practice with populations (or population-centered). Community- oriented nurses engage in activities specific to community development, assessment, monitoring, health policy, politics, health education, interdisciplinary practice, program manage- ment, community/population advocacy, case finding, and deliv- ery of personal health services when these services are otherwise unavailable in the health care system. This conceptual model is the framework for this text.
ORGANIZATION The text is divided into seven sections: • Part 1, Influencing Factors in Health Care and Population-
Centered Nursing, describes the historical and current status of the health care delivery system and public health nursing practice, both domestically and internationally.
• Part 2, Forces Affecting Health Care Delivery and Popula- tion-Centered Nursing, addresses the economics, ethics, policy, and cultural issues that affect public health, nurses, and clients.
• Part 3, Conceptual and Scientific Frameworks Applied to Population-Centered Nursing Practice, provides concep- tual models and scientific bases for public health nursing practice. Selected models from nursing and related sciences are also discussed.
• Part 4, Issues and Approaches in Population-Centered Nursing, examines the management of health care, quality and safety, and populations in select community environ- ments and groups, as well as issues related to managing cases, programs, and disasters.
• Part 5, Health Promotion with Target Populations Across the Life Span, discusses risk factors and population-level health problems for families and individuals throughout the life span.
• Part 6, Promoting and Protecting the Health of Vulnerable Populations, covers specific health care needs and issues of populations at risk.
• Part 7, Nurses’ Roles and Functions in the Community, examines diversity in the role of public health nurses and describes the rapidly changing roles, functions, and practice settings.
xvPREFACE
NEW TO THIS EDITION New content has been included in the ninth edition of Public Health Nursing: Population-Centered Health Care in the Com- munity to ensure that the text remains a complete and compre- hensive resource: • NEW! In each chapter, content is applied to Quality and
Safety Education for Nurses (QSEN).
PEDAGOGY Other key features of this edition are detailed below. Each chapter is organized for easy use by students and faculty.
Additional Resources Additional Resources listed at the beginning of each chapter direct students to chapter-related tools and resources contained in the book’s Appendixes or on its Evolve website.
Objectives Objectives open each chapter to guide student learning and alert faculty to what students should gain from the content.
Key Terms Key Terms are identified at the beginning of the chapter and defined either within the chapter or in the glossary to assist students in understanding unfamiliar terminology.
Chapter Outline The Chapter Outline alerts students to the structure and content of the chapter.
How To Boxes How To boxes provide specific, application-oriented information.
Evidence-Based Practice Boxes Evidence-Based Practice boxes in each chapter illustrate the use and application of the latest research findings in public health, community health, and community-oriented nursing.
Practice Application At the end of each chapter a case situation helps students under- stand how to apply chapter content in the practice setting. Questions at the end of each case promote critical thinking while students analyze the case.
Key Points Key Points provide a summary listing of the most important points made in the chapter.
Clinical Decision-Making Activities Clinical Decision-Making Activities promote student learning by suggesting a variety of activities that encourage both inde- pendent and collaborative effort.
Appendixes The Appendixes provide additional content resources, key information, and clinical tools and references.
EVOLVE STUDENT LEARNING RESOURCES
Additional resources designed to supplement the student learn- ing process are available on this book’s website at http://evolve. elsevier.com/Stanhope, including: • Additional Resources for Students in select chapters • Answer Key to Review Questions with suggested solutions
to the Practice Application questions at the end of each chapter
• Audio Glossary with complete definitions of all key terms and other important community and public health nursing concepts
• Review Questions questions with answers • Student Case Studies with questions and answers
INSTRUCTOR RESOURCES Several supplemental ancillaries are available to assist instruc- tors in the teaching process: • TEACH for Nurses lesson plans provided for each chapter,
with Nursing Curriculum Standards, Teaching Strategies and Learning Activities, Case Studies, and more
• Test Bank with 1200 NCLEX®-style questions and answers
• PowerPoint Lecture Slides for each chapter • Image Collection with illustrations from the text • Answers to Practice Application Questions • Audio Glossary
REFERENCES Centers for Disease Control and
Prevention: Ten Great Public Health Achievements in the 20th Century. Retrieved from: www.cdc.gov/about/ history/tengpha.htm. 10/28/14.
Centers for Disease Control and Prevention, 2014, p. 1. The public health system and the 10 essential public health services. Available at http://www.cdc.gov/nphpsp/
essentialservices.html. Retrived 4/28/15.
Centers for Medicare and Medicaid Services (CMS): Office of the Actuary: National Health Expenditure Projections 2011-2021. Baltimore, MD, 2012a, U.S.Department of Health and Human Services. Retrieved from: http://www.cms
.gov/NationalHealthExpendData/. December 2014.
DeNavas-Walt C, Proctor BD, Smith JC: Income, Poverty, and Health Insurance Coverage in the United States, 2012. U.S. Census Bureau, Current Population Reports. Washington, DC, 2013, U.S. Government Printing Office, pp P60–P245.
Kaiser Family Foundation: The unisured a primer: key facts about Americans without health insurance. Menlo Park Calif. 2012a.
U.S. Department of Health and Human Services (USDHHS): Healthy People 2020: A Roadmap to Improve All American’s Health. Washington, DC, 2010, USDHHS, Public Health Service.
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xvii
CONTENTS
PART 1 Influencing Factors in Health Care and Population-Centered Nursing
1 Community and Prevention–Oriented, Population- Focused Practice: The Foundation of Specialization in Public Health Nursing, 3
2 History of Public Health and Public and Community Health Nursing, 22
3 The Changing U.S. Health and Public Health Care Systems, 44
4 Perspectives in Global Health Care, 61
PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
5 Economics of Health Care Delivery, 94 6 Application of Ethics in the Community, 121 7 Cultural Diversity in the Community, 139 8 Public Health Policy, 167
PART 3 Conceptual and Scientific Frameworks Applied to Population-Centered Nursing Practice
9 Population-Based Public Health Nursing Practice: The Intervention Wheel, 190
10 Environmental Health, 217 11 Genomics in Public Health Nursing, 242 12 Epidemiology, 256 13 Infectious Disease Prevention and Control, 286 14 Communicable and Infectious Disease Risks, 319 15 Evidence-Based Practice, 342 16 Changing Health Behavior Using Health
Education with Individuals, Families, and Groups, 355
17 Building a Culture of Health through Community Health Promotion, 377
PART 4 Issues and Approaches in Population-Centered Nursing
18 Community As Client: Assessment and Analysis, 396 19 Population-Centered Nursing in Rural and Urban
Environments, 422 20 Promoting Health Through Healthy Communities
and Cities, 441 21 The Nurse-led Health Center: A Model for Community
Nursing Practice, 455 22 Case Management, 476
23 Public Health Nursing Practice and the Disaster Management Cycle, 503
24 Public Health Surveillance and Outbreak Investigation, 529
25 Program Management, 545 26 Quality Management, 568
PART 5 Health Promotion with Target Populations Across the Life Span
27 Working with Families in the Community for Healthy Outcomes, 594
28 Family Health Risks, 622 29 Child and Adolescent Health, 644 30 Major Health Issues and Chronic Disease Management
of Adults Across the Life Span, 670 31 Disability Health Care Across the Life Span, 694
PART 6 Promoting and Protecting the Health of Vulnerable Populations
32 Vulnerability and Vulnerable Populations: An Overview, 715
33 Poverty and Homelessness, 731 34 Migrant Health Issues, 750 35 Teen Pregnancy, 766 36 Mental Health Issues, 782 37 Alcohol, Tobacco, and Other Drug Problems, 803 38 Violence and Human Abuse, 825
PART 7 Nurses’ Roles and Functions in the Community
39 The Advanced Practice Nurse in the Community, 851 40 The Nurse Leader in the Community, 867 41 The Nurse in Home Health, Palliative Care,
and Hospice, 885 42 The Nurse in the Schools, 914 43 The Nurse in Occupational Health, 937 44 Forensic Nursing in the Community, 957 45 The Nurse in the Faith Community, 970 46 Public Health Nursing at Local, State,
and National Levels, 993
APPENDIXES
Appendix A: Resource Tools Available on the Evolve Website, 1011
Appendix B: Program Planning and Design, 1012
xviii Contents
Appendix C.1: Healthier People Health Risk Appraisal, 1015 Appendix C.2: 2013 State and Local Youth Risk
Behavior Survey, 1023 Appendix C.3: Flu Pandemics, 1031 Appendix C.4: Commonly Abused Drugs, 1033 Appendix D: Friedman Family Assessment Model
(Short Form), 1046 Appendix E.1: Instrumental Activities of Daily Living
(IADL) Scale, 1048 Appendix E.2: Comprehensive Older Persons’ Evaluation, 1049 Appendix E.3: Comprehensive Occupational and
Environmental Health History, 1052 Appendix E.4: Motivational Interviewing, 1055
Appendix F.1: Essential Elements of Public Health Nursing, 1056
Appendix F.2: American Public Health Association Definition of Public Health Nursing, 1062
Appendix F.3: American Nurses Association Scope and Standards of Practice for Public Health Nursing, 1068
Appendix F.4: The Health Insurance Portability and Accountability Act (HIPAA): What Does It Mean for Public Health Nurses?, 1070
Index, 1073
1
Influencing Factors in Health Care and Population-
Centered Nursing
Population-centered nursing emphasizes the community where nursing is based in the population providing care on-site to individuals or group members of the population. It also emphasizes a focus on a defined popu- lation whereby the nurse seeks knowledge about the health issues or problems facing the total population so the nurse can then find ways to resolve the issues and problems for all members of the population. The focused approach seeks to improve health for all within the community’s population. In this section information emerges to show how community-based nursing and community oriented (focused) nursing are different in approach but similar in the goal to improve health for the populations served.
Since the late 1800s, public health nurses have been leaders in making improvements in the quality of health care for individuals, families, and aggregates, including populations and communities. As nurses around the world collaborate with one another, it is clear that, from one country to another, population-centered nursing has more similarities than differences.
Important changes in health care have been taking place since the early 1990s, and there is data to show that changes are occurring as a result of the health care reform work in the United States. Although consider- able controversy surrounded the implementation of the Patient Protection and Affordable Care Act of 2010, it is clear that change is providing more access to care and reductions in hospitalization. It is also reducing cost and providing more preventive care.
The areas in health care that have posed the greatest problems for persons over the years have been access, quality, and cost. These problems are being addressed but are still present. A number of people still have either no insurance or inadequate insurance, access to quality care is unevenly distributed across the country, and the cost of health care remains high for consumers, employers, insurers, and state and federal governments. Changes in the health care system and delivery are attempting to address these issues.
Some of the key areas of emphasis in the current efforts to reform health care include preventing disease, coordinating care, and shifting care from the hospital to the home or community facilities where possible. In the coming years, a large growth in the number of nurses employed in home health care and in nursing care facilities is expected. An area targeted for growth is that of the federal community health centers. Nurses comprise the largest category of employees in those centers. It is also expected that more new graduates will go directly into community health work rather than working for a few years in the hospital before making that transition. This trend supports the recommendations that nurses need to be prepared at the baccalaureate level.
Over the years, funding for public health has decreased, or remained neutral, while the needs for population- centered services have increased. The key question is whether health care reform will provide what is needed for population-centered care in America’s communities. There is much discussion about the new emphasis on prevention, community-oriented care, continuity, and the important role that nurses will play in health care. With anticipation that many of these projections will become a reality and that nurses will become increasingly key practitioners in promoting the health of the people, they must understand the history of public health nursing and the current status of the public health system.
Part One presents information about significant factors affecting health in the United States. Changing the level and quality of services and the priorities for funding requires that nurses be involved, informed, courageous, and committed to the task. The chapters in Part One are designed to provide essential information so that nurses can make a difference in health care by understanding their own roles and their functions in population-centered
P A R T 1
2 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
practice. Understanding how the public health system differs from the primary care system is described as well as the move- ment to integrate public health and primary care.
There is a core of knowledge known as “public health” that forms the foundation for population-centered public health nursing. This core has historically included epidemiology, bio- statistics, environmental health, health services administration,
and social and behavioral sciences. In recent years, new areas of focus within public health have included informatics, genomics, communication, cultural competence, community-based par- ticipatory research, evidence-based practice, policy and law, global health, ethics, and forensics. This book covers both the traditional and the newer content either in a full chapter or as a section in one or more chapters.
3
1 Community and Prevention–Oriented,
Population-Focused Practice: The Foundation of Specialization in Public Health Nursing
Carolyn A. Williams, RN, PhD, FAAN Dr. Carolyn A. Williams is Dean Emeritus and Professor at the College of Nursing at the University of Kentucky, Lexington, Kentucky. Dr. Williams began her career as a public health nurse. She has held many leadership roles, including President of the American Academy of Nursing; membership on the first U.S. Preventive Services Task Force, Department of Health and Human Services; and President of the American Association of Colleges of Nursing. She received the Distinguished Alumna Award from Texas Woman’s University in 1983. In 2001 she was the recipient of the Mary Tolle Wright Founder’s Award for Excellence in Leadership from Sigma Theta Tau International, and in 2007 she received the Bernadette Arminger Award from the American Association of Colleges of Nursing. In 2011 she was awarded an Honorary Doctorate of Public Service from the University of Portland, Portland, Oregon. In 2014 she received the honor of being conducted into the University of Kentucky College of Public Health Hall of Fame for international, national, state and local contributions to public health and nursing.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. State the mission of and core functions of public health
and the essential public health services and the quality performance standards program in public health.
2. Describe specialization in public health nursing and other nurse roles in the community and the practice goals of each.
3. Contrast clinical nursing practice with population focused practice in the community.
4. Describe what is meant by community and prevention– oriented, population-focused practice.
5. Name barriers to acceptance of community and prevention–oriented, population-focused practice.
6. State key opportunities for community and prevention– oriented, population-focused practice.
K E Y T E R M S aggregate, p. 11 assessment, p. 6 assurance, p. 6 capitation, p. 18 community-based nursing, p. 16 Community Health Improvement Process (CHIP), p. 6 community health nurses, p. 16 cottage industry, p. 18 integrated systems, p. 18 levels of prevention, p. 11
managed care, p. 4 policy development, p. 6 population, p. 11 population-focused practice, p. 11 public health, p. 4 public health core functions, p. 6 public health nursing, p. 10 Quad Council, p. 9 subpopulations, p. 11 —See Glossary for definitions
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks—Of special note, see the link for this site:
• Guide to Community Preventive Services • Quiz • Case Studies • Glossary • Answers to Practice Application
• Resource Tools • Resource Tool 5.A: Schedule of Clinical Preventive
Services • Resource Tool 46: Core Competencies and Skill Levels
for Public Health Nursing • Appendixes • Appendix G.1: Examples of Public Health Nursing Roles
and Implementing Public Health Functions
4 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
Whereas the majority of national attention and debate sur- rounding national health legislation has been focused primarily on insurance issues related to medical care, there are indications of a renewed interest in public health and in population-focused thinking about health and health care in the United States. For example, incorporated into the Patient Protection and Afford- able Care Act are provisions that address health promotion and prevention of disease and disability. These include (1) establish- ment of the National Prevention, Health Promotion, and Public Health Council to coordinate federal prevention, wellness, and public health activities and to develop a national strategy to improve the nation’s health (www.surgeongeneral.gov/ initiatives/prevention/about), and (2) as indicated in Chapter 3 and 5, creation of a Prevention and Public Health Fund to expand and sustain funding for prevention and public health programs (Trust for America’s Health, 2013), and (3) improve- ment of preventive efforts by covering only proven preventive services and eliminating state cost sharing for preventive ser- vices, including immunizations recommended by the U.S. Pre- ventive Services Task Force (USPHS 2000) (www.uspreventive servicestaskforce.org). Also, grants and technical assistance will be available to employers who establish wellness programs (www.dol.gov/ebsa/newsroom/2013/13).
Although populations have historically been the focus of public health practice, specifically defined populations are becoming a focus of the “business” of managed care; therefore more managed care executives are joining public health practi- tioners in becoming population oriented. Increasingly, managed care executives and program managers are using the basic sci- ences and analytic tools of the field of public health. However, their focus is on using such epidemiological and statistical strat- egies to develop databases and analytical approaches to making decisions at the level of a defined population or subpopulation enrolled in a particular care delivery organization or those covered by a particular insurance company. A population- focused approach to planning, delivering, and evaluating various aspects of care delivery is increasingly being used in an effort to achieve better outcomes in the population of interest and has never been more important.
Where is public health nursing in all of the changes swirling around in the world of health and health care? This is a crucial
The second decade of the twenty-first century finds the United States entering an era when more public attention is being given to efforts to protect and improve the health of the American people and the environment. Despite what many see as a failure to make fundamental changes in the delivery and financing of health care, significant change has occurred. Federal and state initiatives, private market forces, the development of new sci- entific knowledge and new technologies, and the expectations of the public are bringing about changes in the health care system. With the national legislation that passed in 2010—the Patient Protection and Affordable Care Act (ACA) (www.hhs.gov/ opa/affordable-care-act)—which in part was designed to increase access to care; concerns have been raised about the availability of adequate numbers of professional personnel to provide services, particularly in primary care and strained health care facilities. Despite initial turbulence in implementa- tion of the legislation, including difficulties with enrollments due to technological problems, initial reports are that good progress has been made in enrolling people and the Congres- sional Budget Office projected that by 2014 the number of uninsured people will decrease by 12 million and by 26 million by 2017 (Blumenthal and Collins, 2014). Blumenthal and Collins (2014) also reported that the Urban Institute projected that the proportion of uninsured people adults in the United States fell from 18% in the third quarter of 2013 to 13.4% in May of 2014. Before the passage of the ACA many at the national level were seriously concerned about the growing cost of medical care as a part of federal expenditures (Orszag, 2007; Orszag and Emanuel, 2010). The concern with the cost of medical care remains a national issue and Blumenthal and Collins (2014) argue that the sustainability of the expansions of coverage pro- vided by the ACA will depend on whether the overall costs of care in the United States can be controlled. If costs are not controlled the resulting increases in premiums will become increasingly difficult for all—consumers, employers, and the federal government. Other health system concerns focus on the quality and safety of services, warnings about bioterrorism, and global public health threats such as infectious diseases and con- taminated foods. Because of all of these factors, the role of public health in protecting and promoting health, as well as preventing disease and disability, is extremely important.
C H A P T E R O U T L I N E Public Health Practice: The Foundation for Healthy
Populations and Communities Definitions in Public Health Public Health Core Functions Core Competencies of Public Health Professionals Quality Improvement Efforts in Public Health
Public Health Nursing as a Field of Practice: An Area of Specialization
Educational Preparation for Public Health Nursing Population-Focused Practice versus Practice Focused on
Individuals
Public Health Nursing Specialists and Core Public Health Functions: Selected Examples
Public Health Nursing versus Community-Based Nursing Roles in Public Health Nursing Challenges for the Future
Barriers to Specializing in Public Health Nursing Developing Population-Focused Nurse Leaders Shifting Public Policy toward Creating Conditions for a
Healthy Population
5CHAPTER 1 Community and Prevention–Oriented, Population-Focused Practice
there is incontrovertible evidence that public health policies and programs were primarily responsible for increasing the average life span from 47 in 1900 to 78 in 2005, an increase of 66% in just a little over a century. They asserted that most of that increase was through improvements in sanitation, clean water supplies, making workplaces safer, improving food and drug safety, immunizing children, and improving nutrition, hygiene, and housing (Fielding et al, 2008).
In an effort to help the public better understand the role public health has played in increasing life expectancy and improving the nation’s health, in 1999 the Centers for Disease Control and Prevention (CDC) began featuring information on the Ten Great Public Health Achievements in the 20th Century. The areas featured include Immunizations, Motor Vehicle Safety, Control of Infectious Diseases, Safer and Healthier Foods, Healthier Mothers and Babies, Family Plan- ning, Fluoridation of Drinking Water, Tobacco as a Health Hazard, and Declines in Deaths from Heart Disease and Stroke (CDC, 2014). A case can be made that the payoff from public health activities is well beyond the resources directed to the effort. For example, recent data reported by the Centers for Medicare and Medicaid Services (CMS) showed that in 2012 only 3% (up from 1.5% in 1960) of all national expen- ditures supported by governmental entities supported public health functions (CMS, 2012). The expeditures in 2014 were the same.
Unfortunately, the public is largely unaware of the contribu- tions of public health practice. After the passage of Medicare and Medicaid, federal and private monies in support of public health dwindled, public health agencies began to provide per- sonal care services for persons who could not receive care else- where, and the health departments benefited by getting Medicaid and Medicare funds. The result was a shift of resources and energy away from public health’s traditional and unique prevention-oriented, population-focused perspective to include a primary care focus (U.S. Department of Health and Human Services [USDHHS], 2002).
One consequence of a successful implementation of the Affordable Care Act might actually be that the majority of the population would be covered by insurance and public health agencies will not need to provide direct clinical services in order to assure that those who need them can receive them. If this occurs public health organizations can refocus their efforts on the core functions and emphasize community-oriented, population-focused health promotion and preventive strate- gies, if ways can be found to finance such efforts. An Institute of Medicine report, For the Public’s Health: Investing in a Health- ier Future, released in 2012, began with presentation of data showing that in comparison with other wealthy Western coun- tries the United States lags well behind its peers on health status while outspending every country in the world on health. However, a key message was that health-related spending in the United States is primarily expended on clinical care costs for medical and hospital services; very little spending is for public health activities.
A central conclusion of the report was that “to improve health outcomes in the United States, there will need to be a
time for public health nursing, a time of opportunity and chal- lenge. The issue of growing costs together with the changing demography of the U.S. population, particularly the aging of the population, is expected to put increased demands on resources available for health care. In addition, the threats of bioterrorism, highlighted by the events of September 11, 2001, and the anthrax scares, will divert health care funds and resources from other health care programs to be spent for public safety. Also important to the public health community is the emergence of modern-day epidemics (such as the mosquito-borne West Nile virus, the H1N1 influenza virus, and the emerging Ebola virus crisis) and globally induced infectious diseases such as avian influenza and other causes of mortality, many of which affect the very young (see Chapters 3 and 5). Most of the causes of these epidemics are preventable. What has all of this to do with nursing?
Understanding the importance of community-oriented, population-focused nursing practice and developing the knowl- edge and skills to practice it will be critical to attaining a leader- ship role in health care regardless of the practice setting. The following discussion explains why those who practice community-based, prevention-oriented, population-focused nursing will be in a very strong position to affect the health of populations and decisions about how scarce resources will be used.
PUBLIC HEALTH PRACTICE: THE FOUNDATION FOR HEALTHY POPULATIONS AND COMMUNITIES During the last 25 years, considerable attention has been focused on proposals to reform the American health care system. These proposals focused primarily on containing cost in medical care financing and on strategies for providing health insurance cov- erage to a higher proportion of the population. In the national health legislation that passed in 2010, the Patient Protection and Affordable Care Act, the majority of the provisions and the vast majority of the discussion of the bill focused on those issues (www.hhs.gov/opa/affordable-care-act).
Because physician services and hospital care combined account for over half of the health care expenditures in the United States, it is understandable that changes in how such services would be paid for would receive much attention (kaiserEDU.org, 2010). However, as stated in the Public Health Functions Steering Committee Report on the Core Functions of Public Health (1998), while it was important to make reforms in the medical insurance system there is a clear understanding among those familiar with the history of public health and its impact that such reforms alone will not be adequate to improve the health of Americans.
Historically, gains in the health of populations have come largely from public health efforts. Safety and adequacy of food supplies, the provision of safe water, sewage disposal, public safety from biological threats, and personal behavioral changes, including reproductive behavior, are a few examples of public health’s influence. In 2008 Fielding and colleagues argued that
6 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
As part of this effort, a statement on public health in the United States was developed by a working group made up of represen- tatives of federal agencies and organizations concerned about public health. The list of essential services presented in Figure 1-1 represents the obligations of the public health system to implement the core functions of assessment, assurance, and policy development. The How To Box further explains these essential services and lists the ways public health nurses imple- ment them (U.S. Public Health Service, 1994 [updated 2008]).
Public Health Core Functions The Core Functions Project (U.S. Public Health Service, 1994 [updated 2008]) developed a useful illustration, the Health Ser- vices Pyramid (Figure 1-2), which shows that population-based public health programs support the goals of providing a founda- tion for clinical preventive services. These services focus on disease prevention; on health promotion and protection; and on primary, secondary, and tertiary health care services. All levels of services shown in the pyramid are important to the health of the population and thus must be part of a health care system with health as a goal. It has been said that “the greater the effectiveness of services in the lower tiers, the greater is the capability of higher tiers to contribute efficiently to health improvement” (U.S. Public Health Service, 1994 [updated 2008]). Because of the importance of the basic public health programs, members of the Core Functions Project argued that all levels of health care, including population-based public health care, must be funded or the goal of health of populations may never be reached.
Several new efforts to enable public health practitioners to be more effective in implementing the core functions of assess- ment, policy development, and assurance have been undertaken at the national level. In 1997 the Institute of Medicine published Improving Health in the Community: A Role for Performance Monitoring (IOM, 1997). This monograph was the product of an interdisciplinary committee, cochaired by a public health nursing specialist and a physician, whose purpose was to deter- mine how a performance monitoring system could be devel- oped and used to improve community health.
The major outcome of the committee’s work was the Com- munity Health Improvement Process (CHIP), a method for improving the health of the population on a community-wide basis. The method brings together key elements of the public health and personal health care systems in one framework. A second outcome of the project was the development of a set of 25 indicators that could be used in the community assessment process (see Chapter 18) to develop a community health profile (e.g., measures of health status, functional status, quality of life, health risk factors, and health resource use) (Box 1-1). A third product of the committee’s work was a set of indicators for specific public health problems that could be used by public health specialists as they carry out their assurance function and monitor the performance of public health and other agencies.
In 2000 the CDC established a Task Force on Community Preventive Services, which is in place and works to provide evidence-based findings and recommendations about a variety of community preventive services, programs, and policies to prevent morbidity and mortality (CDC, 2014b). The result
transforming of the way the nation invests in health to pay more attention to population-based prevention efforts; remedy the dysfunctional manner in which public health funding is allo- cated, structured, and used; and ensure stable funding for public health departments.” Further, the committee recommended that “a minimum package of public health services—those foundational and programmatic services needed to promote and protect the public’s health” be developed. The report con- cluded by recommending that “Congress authorize a dedicated, stable, and long-term financing structure—a national tax on all health care transactions—to generate the enhanced federal revenue required to deliver the minimum package of public health services in every community” (Institute of Medicine [IOM], 2012a).
Definitions in Public Health In 1988 the Institute of Medicine published a report on the future of public health, which is now seen as a classic and influ- ential document. In the report, public health was defined as “what we, as a society, do collectively to assure the conditions in which people can be healthy” (IOM, 1988, p. 1). The com- mittee stated that the mission of public health was “to generate organized community efforts to address the public interest in health by applying scientific and technical knowledge to prevent disease and promote health” (IOM, 1988, p. 1; Williams, 1995).
It was clearly noted that the mission could be accomplished by many groups, public and private, and by individuals. However, the government has a special function “to see to it that vital elements are in place and that the mission is adequately addressed” (IOM, 1988, p. 7). To clarify the government’s role in fulfilling the mission, the report stated that assessment, policy development, and assurance are the public health core func- tions at all levels of government. • Assessment refers to systematically collecting data on the
population, monitoring the population’s health status, and making information available about the health of the community.
• Policy development refers to the need to provide leadership in developing policies that support the health of the popula- tion, including the use of the scientific knowledge base in making decisions about policy.
• Assurance refers to the role of public health in ensuring that essential community-oriented health services are available, which may include providing essential personal health ser- vices for those who would otherwise not receive them. Assurance also refers to making sure that a competent public health and personal health care workforce is available. Field- ing (2009) subsequently made the case that assurance also should mean that public health officials should be involved in developing and monitoring the quality of services provided. Because of the importance of influencing a population’s
health and providing a strong foundation for the health care system, the U.S. Public Health Service and other groups strongly advocated a renewed emphasis on the population-focused essential public health functions and services that have been most effective in improving the health of the entire population.
7CHAPTER 1 Community and Prevention–Oriented, Population-Focused Practice
FIG 1-1 Public health in America. (From U.S. Public Health Service: The Core Functions Project. Washington, DC, 1994/update 2000, DC, Office of Disease Prevention and Health Promotion. Update 2008.)
PUBLIC HEALTH IN AMERICA
Vision:
Healthy people in healthy communities
Mission:
Promote physical and mental health and
prevent disease, injury, and disability
Public health
• Prevents epidemics and the spread of disease
• Protects against environmental hazards
• Prevents injuries
• Promotes and encourages healthy behaviors
• Responds to disasters and assists communities in recovery
• Ensures the quality and accessibility of health services
Essential public health services by core function
Assessment
1. Monitor health status to identify community health problems
2. Diagnose and investigate health problems and health hazards in the community
Policy Development
3. Inform, educate, and empower people about health issues
4. Mobilize community partnerships to identify and solve health problems
5. Develop policies and plans that support individual and community health efforts
Assurance
6. Enforce laws and regulations that protect health and ensure safety
7. Link people to needed personal health services and assure the provision of health
care when otherwise unavailable
8. Assure a competent public health and personal health care workforce
9. Evaluate effectiveness, accessibility, and quality of personal and population-based
health services
Serving All Functions
10. Research for new insights and innovative solutions to health problems
is The Community Guide: What Works to Promote Health, a versatile set of resources available electronically at www. thecommunityguide.org/index.html that can be used by public health specialists and others interested in a community-level approach to health improvement and disease prevention. Infor- mation is available on 22 topics, which include health problems/ issues such as obesity, mental health, asthma, cancer, diabetes, and concerns such as violence, tobacco, nutrition, vaccination, excessive consumption of alcohol, motor vehicle injury, emer- gency preparedness, and worksite initiatives (CDC, 2014b). The materials, which include systematic reviews of research, can be used to help make choices about policies and programs that have been shown to be effective (CDC, 2014b). Community Preventive Services are important because they provide tools for
public health practitioners, many of whom are public health nursing specialists, to enable them to be more effective in dealing with the core functions.
Core Competencies of Public Health Professionals To improve the public health workforce’s abilities to implement the core functions of public health and to ensure that the workforce has the necessary skills to provide the 10 essential services listed in Figure 1-1, a coalition of representatives from 17 national public health organizations (the Council of Link- ages) began working in 1992 on collaborative activities to “assure a well-trained, competent workforce and a strong, evidence-based public health infrastructure” (U.S. Public Health Service, 1994 [updated 2008]). In the spring of 2010 the Council,
8 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
HOW TO Participate, as a Public Health Nurse, in the Essential Services of Public Health 1. Monitor health status to identify community health problems.
• Participate in community assessment. • Identify subpopulations at risk for disease or disability. • Collect information on interventions to special populations. • Define and evaluate effective strategies and programs. • Identify potential environmental hazards.
2. Diagnose and investigate health problems and hazards in the community. • Understand and identify determinants of health and disease. • Apply knowledge about environmental influences of health. • Recognize multiple causes or factors of health and illness. • Participate in case identification and treatment of persons
with communicable disease. 3. Inform, educate, and empower people about health issues.
• Develop health and educational plans for individuals and fami- lies in multiple settings.
• Develop and implement community-based health education. • Provide regular reports on health status of special populations
within clinic settings, community settings, and groups. • Advocate for and with underserved and disadvantaged
populations. • Ensure health planning, which includes primary prevention
and early intervention strategies. • Identify healthy population behaviors and maintain successful
intervention strategies through reinforcement and continued funding.
4. Mobilize community partnerships to identify and solve health problems. • Interact regularly with many providers and services within
each community. • Convene groups and providers who share common concerns
and interests in special populations. • Provide leadership to prioritize community problems and
development of interventions. • Explain the significance of health issues to the public and
participate in developing plans of action. 5. Develop policies and plans that support individual and commu-
nity health efforts. • Participate in community and family decision-making processes. • Provide information and advocacy for consideration of the
interests of special groups in program development. • Develop programs and services to meet the needs of high-
risk populations as well as broader community members. • Participate in disaster planning and mobilization of community
resources in emergencies. • Advocate for appropriate funding for services.
6. Enforce laws and regulations that protect health and ensure safety. • Regulate and support safe care and treatment for dependent
populations such as children and frail older adults. • Implement ordinances and laws that protect the environment. • Establish procedures and processes that ensure competent
implementation of treatment schedules for diseases of public health importance.
• Participate in development of local regulations that protect communities and the environment from potential hazards and pollution.
7. Link people to needed personal health services and ensure the provision of health care that is otherwise unavailable. • Provide clinical preventive services to certain high-risk
populations. • Establish programs and services to meet special needs. • Recommend clinical care and other services to clients and
their families in clinics, homes, and the community. • Provide referrals through community links to needed
care. • Participate in community provider coalitions and meetings to
educate others and to identify service centers for community populations.
• Provide clinical surveillance and identification of communi- cable disease.
8. Ensure a competent public health and personal health care workforce. • Participate in continuing education and preparation to ensure
competence. • Define and support proper delegation to unlicensed assistive
personnel in community settings. • Establish standards for performance. • Maintain client record systems and community documents. • Establish and maintain procedures and protocols for client
care. • Participate in quality assurance activities such as record
audits, agency evaluation, and clinical guidelines. 9. Evaluate effectiveness, accessibility, and quality of personal and
population-based health services. • Collect data and information related to community
interventions. • Identify unserved and underserved populations within the
community. • Review and analyze data on health status of the
community. • Participate with the community in assessment of services
and outcomes of care. • Identify and define enhanced services required to manage
health status of complex populations and special risk groups.
10. Research for new insights and innovative solutions to health problems. • Implement nontraditional interventions and approaches to
effect change in special populations. • Participate in the collecting of information and data to improve
the surveillance and understanding of special problems. • Develop collegial relationships with academic institutions to
explore new interventions. • Participate in early identification of factors that are detrimen-
tal to the community’s health. • Formulate and use investigative tools to identify and impact
care delivery and program planning.
9CHAPTER 1 Community and Prevention–Oriented, Population-Focused Practice
FIG 1-2 Health Services Pyramid.
Tertiary health care
Secondary health care
Primary health care
Clinical preventive services
Population-based health care services
Sociodemographic Characteristics • Distribution of the population by age and race/ethnicity • Number and proportion of persons in groups such as migrants, homeless, or
the non–English speaking, for whom access to community services and resources may be a concern
• Number and proportion of persons aged 25 and older with less than a high school education
• Ratio of the number of students graduating from high school to the number of students who entered ninth grade 3 years previously
• Median household income • Proportion of children less than 15 years of age living in families at or below
the poverty level • Unemployment rate • Number and proportion of single-parent families • Number and proportion of persons without health insurance
Health Status • Infant death rate by race/ethnicity • Numbers of deaths or age-adjusted death rates for motor vehicle crashes,
work-related injuries, suicide, homicide, lung cancer, breast cancer, cardio- vascular diseases, and all causes, by age, race, and sex as appropriate
• Reported incidence of AIDS, measles, tuberculosis, and primary and second- ary syphilis, by age, race, and sex as appropriate
• Births to adolescents (ages 10 to 17) as a proportion of total live births • Number and rate of confirmed abuse and neglect cases among children
Health Risk Factors • Proportion of 2-year-old children who have received all age-appropriate vac-
cines, as recommended by the Advisory Committee on Immunization Practices • Proportion of adults aged 65 and older who have ever been immunized for
pneumococcal pneumonia; proportion who have been immunized in the past 12 months for influenza
• Proportion of the population who smoke, by age, race, and sex as appropriate
• Proportion of the population aged 18 and older who are obese • Number and type of U.S. Environmental Protection Agency air quality stan-
dards not met • Proportion of assessed rivers, lakes, and estuaries that support beneficial
uses (e.g., approved fishing and swimming)
Health Care Resource Consumption • Per capita health care spending for Medicare beneficiaries—the Medicare-
adjusted average per capita cost (AAPCC)
Functional Status • Proportion of adults reporting that their general health is good to excellent • Average number of days (in the past 30 days) for which adults report that
their physical or mental health was not good
Quality of Life • Proportion of adults satisfied with the health care system in the community • Proportion of persons satisfied with the quality of life in the community
BOX 1-1 Indicators Used to Develop a Community Health Profile
funded by the CDC and USDHHS, adopted an updated set of Core Competencies (“a set of skills desirable for the broad practice of public health”) for all public health professionals, including nurses. In 2014 the Core Competencies were updated again (Council on Linkages, 2010/2014). The 72 Core Compe- tencies are divided into 8 categories (Box 1-2). In addition, each competency is presented at three levels (tiers), which reflect the
different stages of a career. Specifically, Tier 1 applies to entry level public health professionals without management respon- sibilities. Tier 2 competencies are expected in those with man- agement and/or supervisory responsibilities, and Tier 3 is expected of senior managers and/or leaders in public health organizations. It is recommended that these categories of com- petencies be used by educators for curriculum review and development and by agency administrators for workforce needs assessment, competency development, performance evaluation, hiring, and refining of the personnel system job requirements. A detailed listing of the 2014 competencies can be found at www.phf.org/corecompetencies.
Using an earlier version of the Council on Linkage’s Core Competencies as a starting point, a coalition of public health nursing organizations called the Quad Council developed levels
• Analytic/assessment • Policy development/program planning • Communication • Cultural competency • Community dimensions of practice • Basic public health sciences • Financial planning and management • Leadership and systems thinking
BOX 1-2 Categories of Public Health Workforce Competencies
Compiled from Centers for Disease Control and Prevention: Genomics and disease prevention: Frequently asked questions, 2010. Accessed 1/11/11 from http://www.cdc.gov/genomics/faq.htm; Centers for Disease Control and Prevention: Genomics and disease prevention.
10 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
base. The following characteristics distinguish public health nursing as a specialty: • It is population-focused. Primary emphasis is on populations
whose members are free-living in the community as opposed to those who are institutionalized.
• It is community-oriented. There is concern for the connec- tion between the health status of the population and the environment in which the population lives (physical, bio- logical, sociocultural). There is an imperative to work with members of the community to carry out core public health functions.
• There is a health and preventive focus. The primary emphasis is on strategies for health promotion, health maintenance, and disease prevention, particularly primary and secondary prevention.
• Interventions are made at the community or population level. Target populations are defined as those living in a particular geographic area or those who have particular characteristics in common and political processes are used as a major inter- vention strategy to affect public policy and achieve goals.
• There is concern for the health of all members of the population/ community, particularly vulnerable subpopulations. In 1981 the public health nursing section of the American
Public Health Association (APHA) developed The Definition and Role of Public Health Nursing in the Delivery of Health Care to describe the field of specialization (APHA, 1981). This state- ment was reaffirmed in 1996 (APHA, 1996). In 1999 the Amer- ican Nurses Association, with input from three other nursing organizations—the Public Health Nursing Section of the APHA, the Association of State and Territorial Directors of Public Health Nursing, and the Association of Community Health Nurse Educators—published the Scope and Standards of Public Health Nursing Practice (Quad Council, 1999 [revised 2005]). In that document, the 1996 definition was supported. Since 1999 the scope and standards have been revised twice. In the latest version Public Health Nursing continues to be defined as “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (APHA, 1996 and Quad Council, 1999 [revised 2005], 2011) but the following statement was added in 2011: “Public Health Nurses engage in population-focused practice, but can and do often apply the Council of Linkages concepts at the individual and family level” (see Quad Council, 2011, p. 9).
Educational Preparation for Public Health Nursing Targeted and specialized education for public health nursing practice has a long history. In the late 1950s and early 1960s, before the integration of public health concepts into the cur- riculum of baccalaureate nursing programs, special baccalaure- ate curricula were established in several schools of public health to prepare nurses to become public health nurses. Today it is generally assumed that a graduate of any baccalaureate nursing program has the necessary basic preparation to function as a beginning staff public health nurse.
Since the late 1960s, public health nursing leaders have agreed that a specialty in public health nursing requires a master’s
of skills to be attained by public health nurses for each of the competencies. Skill levels are specified and have been updated for the generalist/staff nurse and the specialist in public health nursing (Quad Council, 2003). (See Resource Tool 45.A on the Evolve website for the Public Health Nursing Core Competencies.)
Quality Improvement Efforts in Public Health In 2003, the Institute of Medicine released a report, “Who Will Keep the Public Healthy?” that identified eight content areas in which public health workers should be educated—informatics, genomics, cultural competence, community-based participa- tory research, policy, law, global health, and ethics—in order to be able to address the emerging public health issues and advances in science and policy.
Two broad efforts designed to enhance quality improvement efforts in public health have been developed within the last 20 years: the National Public Health Performance Standards Program and the accreditation process for local and state health departments. The National Public Health Performance Stan- dards Program is a high-level partnership initiative started in 1998 and led by the Office of Chief of Public Health Practice, CDC. The collaborative partners are the American Public Health Association, Association of State and Territorial Health Officials, National Association of County and City Health Offi- cials, National Association of Local Boards of Health, National Network of Public Health Institutes, and the Public Health Foundation. The National Public Health Performance Stan- dards (NPHPS) “provide a framework to assess capacity and performance of public health systems and public health govern- ing bodies.” The program is “to improve the practice of public health, the performance of public health systems, and the infra- structure supporting public health actions” (CDC, 2014a). The performance standards, collectively developed by the partici- pating organizations, set the bar for the level of performance that is necessary to deliver essential public health services. Four principles guided the development of the standards. First, they were developed around the 10 Essential Public Health Services (see the How To Box on page 8). Second, the standards focus on the overall public health system rather than on single orga- nizations. Third, the standards describe an optimal level of per- formance. Finally, they are intended to support a process of quality improvement.
States and local communities seeking to assess their perfor- mance can access the Assessment Instruments developed by the program and other resources such as training workshops, on-site training, and technical assistance to work with them in conducting assessments (CDC, 2014a).
PUBLIC HEALTH NURSING AS A FIELD OF PRACTICE: AN AREA OF SPECIALIZATION Most of the preceding discussion has been about the broad field of public health. Now attention turns to public health nursing. What is public health nursing? Is it really a specialty, and if so, why? Public health nursing is a specialty because it has a distinct focus and scope of practice, and it requires a special knowledge
11CHAPTER 1 Community and Prevention–Oriented, Population-Focused Practice
Population-Focused Practice versus Practice Focused on Individuals The key factor that distinguishes public health nursing from other areas of nursing practice is the focus on populations, a focus historically consistent with public health philosophy. Box 1-4 lists principles on which public health nursing is built. Although public health nursing is based on clinical nursing prac- tice, it also incorporates the population perspective of public health. It may be helpful here to define the term population.
A population, or aggregate, is a collection of individuals who have one or more personal or environmental characteris- tics in common. Members of a community who can be defined in terms of geography (e.g., a county, a group of counties, or a state) or in terms of a special interest or circumstance (e.g., children attending a particular school) can be seen as constituting a population. Often there are subpopulations within the larger population, such as high-risk infants under the age of 1 year, unmarried pregnant adolescents, or individu- als exposed to a particular event such as a chemical spill. In population-focused practice, problems are defined (by assess- ments or diagnoses), and solutions (interventions), such as policy development or providing a particular preventive service, are implemented for or with a defined population or subpopu- lation (examples are provided in the Levels of Prevention Box). In other nursing specialties, the diagnoses, interventions, and treatments are usually carried out at the individual client level.
Professional education in nursing, medicine, and other clini- cal disciplines focuses primarily on developing competence in decision making at the individual client level by assessing health status, making management decisions (ideally with the client), and evaluating the effects of care. Figure 1-3 illustrates three levels at which problems can be identified. For example, community-based nurse clinicians, or nurse practitioners, focus on individuals they see in either a home or a clinic setting. The focus is on an individual person or an individual family in a
degree. Today, a master’s degree in nursing is necessary to be eligible to sit for a certification examination. In the future, a Doctor of Nursing Practice (DNP) degree will probably be required to sit for certification. the American Association of Col- leges of Nursing has proposed the DNP should be the expected level of education for specialization in an area of nursing practice (AACN, 2004, 2006). The educational expectations for public health nursing were highlighted at the 1984 Consensus Confer- ence on the Essentials of Public Health Nursing Practice and Education sponsored by the USDHHS Division of Nursing. The participants agreed “that the term ‘public health nurse’ should be used to describe a person who has received specific educational preparation and supervised clinical practice in public health nursing” (USDHHS, 1985, p. 4). At the basic or entry level, a public health nurse is one who “holds a baccalaureate degree in nursing that includes this educational preparation; this nurse may or may not practice in an official health agency but has the initial qualifications to do so” (USDHHS, 1985, p. 4). Specialists in public health nursing are defined as those who are prepared at the graduate level, with either a master’s or doctoral degree, “with a focus in the public health sciences” (USDHHS, 1985, p. 4) (Box 1-3). The consensus statement specifically pointed out that the public health nursing specialist “should be able to work with population groups and to assess and intervene successfully at the aggregate level” (USDHHS, 1985, p. 11).
The Association of Community Health Nursing Educators reaffirmed the results of the 1984 Consensus Conference (ACHNE, 2003). The educational requirements were reaffirmed by ACHNE (2009) and in the revised Scope and Standards of Public Health Nursing Practice and include both clinical specialists and nurse practitioners who engage in population-focused care as advanced practice registered nurses in public health (Quad Council, 1999 [revised 2005]). The latest iteration of the Scope and Standards of Practice for Public Health Nursing was published by the American Nurses Association in 2013 (ANA, 2013).
• Epidemiology • Biostatistics • Nursing theory • Management theory • Change theory • Economics • Politics • Public health administration • Community assessment • Program planning and evaluation • Interventions at the aggregate level • Research • History of public health • Issues in public health
BOX 1-3 Areas Considered Essential for the Preparation of Specialists in Public Health Nursing
From Consensus Conference on the Essentials of Public Health Nursing Practice and Education, Rockville, MD, 1985, U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing.
1. The client or “unit of care” is the population. 2. The primary obligation is to achieve the greatest good for the greatest
number of people or the population as a whole. 3. The processes used by public health nurses include working with the
client(s) as an equal partner. 4. Primary prevention is the priority in selecting appropriate activities. 5. Selecting strategies that create healthy environmental, social, and eco-
nomic conditions in which populations may thrive is the focus. 6. There is an obligation to actively reach out to all who might benefit from
a specific activity or service. 7. Optimal use of available resources to assure the best overall improvement
in the health of the population is a key element of the practice. 8. Collaboration with a variety of other professions, organizations, and enti-
ties is the most effective way to promote and protect the health of the people.
BOX 1-4 Eight Principles of Public Health Nursing
Sources: Quad Council of Public Health Nursing Organizations: Scope and standards of public health nursing practice, Washington, DC, 1999, revised 2005, 2007 with the American Nurses Association
12 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
subpopulation (the C arrows in Figure 1-3). The provider’s emphasis is on defining and resolving a problem for the indi- vidual; the client is an individual.
In Figure 1-3 the individual clients are grouped into three sepa- rate subpopulations, each of which has a common characteristic (the B arrows in Figure 1-3). Public health nursing specialists often define problems at the population or aggregate level as opposed to an individual level. Population-level decision making is different from decision making in clinical care. For example, in a clinical, direct care situation, the nurse may determine that a client is hyper- tensive and explore options for intervening. However, at the popu- lation level, the public health nursing specialist might explore the answers to the following set of questions: 1. What is the prevalence of hypertension among various age,
race, and sex groups? 2. Which subpopulations have the highest rates of untreated
hypertension? 3. What programs could reduce the problem of untreated
hypertension and thereby lower the risk of further cardio- vascular morbidity and mortality for the population as a whole? Public health nursing specialists are usually concerned with
more than one subpopulation and frequently with the health of the entire community (in Figure 1-3, arrow A: the entire box
FIG 1-3 Levels of health care practice.
Community level
A
Population (aggregate) level
B
Individual or family levelC
Infants (0-12 months)
Men (65 and older)
Women (15-24)
LEVELS OF PREVENTION
Primary Prevention Using general and specific measures in a population to promote health and prevent the development of disease (incidence) and using specific measures to prevent diseases in those who are predisposed to developing a particular condition.
Example: The public health nurse develops a health education program for a population of school-age children that teaches them about the effects of smoking on health.
Secondary Prevention Stopping the progress of disease by early detection and treatment, thus reduc- ing prevalence and chronicity.
Example: The public health nurse develops a program of toxin screenings for migrant workers who may be exposed to pesticides and refers for treat- ment those who are found to be positive for high levels.
Tertiary Prevention Stopping deterioration in a patient, a relapse, or disability and dependency by anticipatory nursing and medical care.
Example: The public health nurse develops a diabetes clinic in which nursing care including educational programs for nutrition and self-care are provided for a defined population of adults in a low-income housing unit of the community.
Examples in Public Health Nursing
13CHAPTER 1 Community and Prevention–Oriented, Population-Focused Practice
existing health resources, and the population groups most affected” The results were disappointing and suggested that in
1993 less than 40% of the population in the United States were served by a health department that was effectively addressing the core function of public health. In this study, compliance with the performance measures was highest for practices related to the assurance function and lowest for practices related to policy development (Turnock, 2012). It should be part of the public health nurse specialist’s role within a local health department to participate in and provide leadership for assessing community needs, the health status of populations within the community, and environmental and behavioral risks; looking at trends in the health determinants; identifying priority health needs; and determining the adequacy of existing resources within the community (see Evidence- Based Practice Box 1), and engaging in policy development efforts.
containing all of the subgroups within the community). In reality, of course, there are many more subgroups than those in Figure 1-3. Professionals concerned with the health of a whole community must consider the total population, which is made up of multiple and often overlapping subpopulations. For example, the population of adolescents at risk for unplanned pregnancies would overlap with the female population 15 to 24 years of age. A population that would overlap with infants under 1 year of age would be children from 0 to 6 years of age. In addition, a population focus requires considering those who may need particular services but have not entered the health care system (e.g., children without immunizations or clients with untreated hypertension).
Public Health Nursing Specialists and Core Public Health Functions: Selected Examples The core public health function of assessment includes activities that involve collecting, analyzing, and disseminating information on both the health status and the health-related aspects of a community or a specific population. Questions such as whether the health services of the community are avail- able to the population and are adequate to address needs are considered. Assessment also includes an ongoing effort to monitor the health status of the community or population and the services provided. Excellent examples of assessment at the national level are the efforts of the USDHHS to organize the goal setting, data collecting and analysis, and monitoring neces- sary to develop the series of publications describing the health status and health-related aspects of the U.S. population. These efforts began with Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention in 1980 and con- tinued with Promoting Health/Preventing Disease: Objectives for the Nation, Healthy People 2000, and Healthy People 2010, and are now moving forward into the future with Healthy People 2020 (U.S. Department of Health, Education, and Welfare, 1979; USDHHS, 1980, 1979, 1991, 2000, 2010; Healthy People 2020 retrieved at www.healthypeople.gov).
Many states and other jurisdictions have developed publica- tions describing the health status of a defined community, a set of communities, or populations. Unfortunately, it is difficult to find published descriptions of health assessments on particular communities unless they demonstrate new methods or reveal unusual findings about a community. Such working documents and data sets should be available in specific settings, such as a county or state health department, and should be used by public health practitioners to develop services.
In 2009 Turnock described a survey conducted to determine the extent to which local health departments were performing the core public health functions. The questions asked about assessment included the following: 1. Whether there was a needs assessment process in place that
described the health status of the community and commu- nity needs
2. Whether there had been a survey of behavioral risk factors within the last 3 years
3. Whether an analysis had been done of “the determinants and contributing factors of priority health needs, adequacy of
This study used a randomized controlled design to evaluate the effectiveness of a community participatory research-grounded intervention among women with chronic health conditions who were receiving Temporary Assistance for Needy Families (TANF). Previous descriptive studies noted that women receiv- ing TANF were likely to experience poor physical, mental, and general health. The 432 participants were assigned to either the intervention group or the wait-control group. Outcomes were assessed at baseline and at 3, 6, and 9 months. The intervention sought to (1) increase rates of health care visits for mental health and chronic health conditions, (2) increase the ability to navi- gate the Medicaid system, and (3) improve functional and health status over time among this group of women, using 9 months of public health nursing (PHN) case management and a one-time 2-hour Medicaid knowledge and skills training program. The PHN case management focused on health care access; care coordination; health education; health and social service refer- rals; obtaining preventive services, screening, and routine care; and assis- tance in meeting health goals that the participants had set for themselves. A Community Advisory Group consisting of diverse academic researchers, agency representatives, and lay community members guided the research team in developing the intervention. Furthermore, three women who were recently in the Welfare Transition Program were hired onto the research team and participated in personal and community capacity building.
Both groups showed improvement in Medicaid knowledge and skills. Those in the intervention group were more likely to have a new mental health visit as well as improvement in depression and functional status over time. No differences existed between the groups in routine or preventive care or general health.
Nurse Use The results of this study suggest that public health interventions can improve health outcomes among women receiving Temporary Assistance for Needy Families. The intervention was developed with input from the community and used community members on the research team. The researchers noted that trust between the public health nurse and the client was crucial to the success of the intervention.
EVIDENCE-BASED PRACTICE
Modified from Kneipp SM, Kairalla JA, Lutz BJ, et al: Public health nursing case management for women receiving Temporary Assistance for Needy Families: a randomized controlled trial using community- based participatory research. Am J Public Health 101:1759–1768, 2011.
14 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
Policy development is both a core function of public health and a core intervention strategy used by public health nursing specialists. Policy development in the public arena seeks to build constituencies that can help bring about change in public policy. In an interesting case study of her experience as director of public health for the state of Oregon, Christine Gebbie (1999), a nurse, describes her experiences in developing a constituency for public health. This enabled her to mobilize efforts to develop statewide goals for Healthy People 2000 as well as to update Oregon’s disease- reporting laws. Gebbie’s experiences as a state director of public health illustrate how a public health nursing specialist can provide leadership at a very broad level. Gebbie left Oregon to go to Washington, DC, to serve in the federal government as President Clinton’s key official in the national effort to control acquired immunodeficiency syndrome (AIDS). Clearly, Gebbie is an example of an individual who has provided leadership in policy development at both state and national levels. Another public health nursing specialist who has and continues to provide strong policy leadership is Ellen Hahn, PhD, director of the Kentucky Center for Smoke-Free Policy (www.mc.uky.edu/tobaccopolicy/), which is based at the Uni- versity of Kentucky’s College of Nursing. Through her research Dr. Hahn has developed considerable evidence to support important policy changes (antismoking ordinances) to reduce exposure to tobacco smoke in Kentucky, a state that has a long tradition of a tobacco culture, both in production of tobacco and in use. A number of studies conducted by Hahn and her colleagues can be found on the website identified above. Two particularly interesting ones are listed in the references at the end of this chapter (Hahn et al, 2010, 2011).
The third core public health function, assurance, focuses on the responsibility of public health agencies to make certain that activities have been appropriately carried out to meet public health goals and plans. This may result in public health agencies requiring others to engage in activities to meet goals, encourag- ing private groups to undertake certain activities, or sometimes actually offering services directly. Assurance also includes the development of partnerships between public and private agen- cies to make sure that needed services are available and that assessing the quality of the activities is carried out. A recent report suggested that much more attention should be paid by public health officials to the quality of direct care services pro- vided by clinicians in their communities (Fielding, 2009). It is important to point out that when personal services to individu- als are offered by public health agencies to ensure that they can get care they might not receive without the intervention of the official agency, the goal is to “promote knowledge, attitudes, beliefs, practices and behaviors that support and enhance health with the ultimate goal of improving… population health” (Quad Council, 1999 [revised 2005]; and see Evidence-Based Practice Box 2).
PUBLIC HEALTH NURSING VERSUS COMMUNITY-BASED NURSING The concept of public health should include all populations within the community, both free-living and those living in
HEALTHY PEOPLE 2020
In 1979 the surgeon general issued a report that began a 30-year focus on promoting health and preventing disease for all Americans. The report, enti- tled Healthy People, used morbidity rates to track the health of individuals through the five major life cycles of infancy, childhood, adolescence, adult- hood, and older age.
In 1989 Healthy People 2000 became a national effort of representatives from government agencies, academia, and health organizations. Their goal was to present a strategy for improving the health of the American people. Their objec- tives were being used by public and community health organizations to assess current health trends, health programs, and disease prevention programs.
Throughout the 1990s, all states used Healthy People 2000 objectives to identify emerging public health issues. The success of the program on a national level was accomplished through state and local efforts. Early in the 1990s, surveys from public health departments indicated that 8% of the national objec- tives had been met, and progress on an additional 40% of the objectives was noted. In the mid-course review published in 1995, it was noted that significant progress had been made toward meeting 50% of the objectives.
In light of the progress made in the past decade, the committee for Healthy People 2010 proposed two goals. The hope was to reach these goals by such measures as promoting healthy behaviors, increasing access to quality health care, and strengthening community prevention.
The major premise of Healthy People 2010 was that the health of the individual cannot be entirely separate from the health of the larger community. Therefore the vision for Healthy People 2010 was “Healthy People in Healthy Communities.”
The vision for Healthy People 2020 is: A society in which all people live long, healthy lives(see Chapter 8 for a listing of the goals for each of the decades and highlighting of the policy implications of Healthy People).
In contrast to previous years, Healthy People 2020 has a web-accessible data- base that is searchable, multilevel, and interactive to be more useful. A progress report as of March 2014 on the leading indicators is available on the website:
www.healthpeople.gov/2020//hi//hi-progressreport-execsum.pdf
The purpose of this study was to evaluate whether a brief nurse home-visiting intervention offered postnatally would be beneficial in preventing emergency health care services and promote positive parenting. The participants were the parents of infants and infants who were delivered in one of the two hospitals in Durham, North Carolina between July 1, 2009 and December 31, 2010 and randomly assigned to either the intervention group or to a control group. The project was aimed at alleviating parental stress and improving parent-child interaction among parents who attended an inner-city clinic. Participants were 199 parents of children 1 through 36 months of age. Serious life stress including poverty, low social support, personal histories of child- hood maltreatment, and substance abuse defined the parents at risk. Program effects were evaluated in terms of improvement in self-reported parenting stress and observed parent-child interaction. Positive effects were docu- mented for the group as a whole and within each of three subgroups: two community samples and a group of mothers and children in a residential drug treatment program. Program attendance and the amount of gain in observed parenting skills were the factors related to a positive outcome.
Nurse Use This program was offered in partnership with academic researchers and the public clinic. The nurses in this agency can ensure better outcomes in parent- ing by providing a long-term program for high-risk parents.
EVIDENCE-BASED PRACTICE
Dodge K, Goodman B, Murphy R. et al: Impelementation and randomized controlled trial evaluation of universal postnatal nurse home visiting, AJPJ 104(Suppl 1) S136-143m 2014.
15CHAPTER 1 Community and Prevention–Oriented, Population-Focused Practice
3. For philosophical, historical, and economic reasons, prevention-oriented population-focused practice is most likely to flourish in organizational structures that serve free-living populations (e.g., health departments, health maintenance organizations, health centers, schools, and workplaces). What roles in the health care system do public health nursing
specialists (those in section A of Figure 1-4) have? Options include director of nursing for a health department, director of the health department, state commissioner for health, director of maternal and child health services for a state or local health department, director of wellness for a business or educational organization, and director of preventive services for an inte- grated health system. Nurses can occupy all of these roles, but, with the exception of director of nursing for a health depart- ment, they are in the minority. Unfortunately, nurses who occupy these roles are often seen as “administrators” and not as public health nursing specialists. However, those who work in such roles have the opportunity to make decisions that affect the health of population groups and the type and quality of health services provided for various populations.
Where does the staff public health nurse or nurse working in the community fit on the diagram in Figure 1-4? That depends on the focus of the nurse’s practice. In many settings, most of the staff nurse’s time is spent in community-based direct care activities, where the focus is on dealing with individual clients and individual families, in which case the practice falls into section B of Figure 1-4. Although a staff public health nurse or a nurse practicing in the community may not be a public health nurse specialist, this nurse may spend some time carrying out core public health functions with a population focus, and thus that part of the role would be represented in section A of Figure 1-4. In summary, the field of public health nursing can be seen as primarily encompassing two groups of nurses: • Public health nursing specialists, whose practice is
community-oriented and uses population-focused strategies
institutions. Furthermore, the public health specialist should consider the match between the health needs of the population and the health care resources in the community, including those services offered in a variety of settings. Although all direct care providers may contribute to the community’s health in the broadest sense, not all are primarily concerned with the popula- tion focus—the big picture. All nurses in a given community, including those working in hospitals, physicians’ offices, and health clinics, may contribute positively to the health of the community. However, the special contributions of public health nursing specialists include looking at the community or popu- lation as a whole; raising questions about its overall health status and associated factors, including environmental factors (physical, biological, and sociocultural); and working with the community to improve the population’s health status.
Figure 1-4 is a useful illustration of the arenas of practice. Because most nurses working in the community and many staff public health nurses, historically and at present, focus on providing direct personal care services—including health education—to persons or family units outside of institutional settings (either in the client’s home or in a clinic environment), such practice falls into the upper right quadrant (section B) of Figure 1-4. However, specialization in public health nursing is population-focused and focuses on clients living in the com- munity and is represented by the box in the upper left quadrant (section A).
There are three reasons, in addition to the population focus, that the most important practice arena for public health nursing is represented by section A of Figure 1-4, the population of free-living clients: 1. Preventive strategies can have the greatest impact on free-
living populations, which usually represent the majority of a community.
2. The major interface between health status and the environ- ment (physical, biological, sociocultural, and behavioral) occurs in the free-living population.
FIG 1-4 Arenas for health care practice.
Primary-Population focus
Community-oriented nursing
Community based nursing
Public health nursing staff or nurses working in the
community
Specialization in public health
nursing
Clients living in the community
Clients in institutional settings
(e.g., hospital, nursing home)
C
A
D
B
Secondary-Individual and/or family focus
Focus of practice
Location of client
16 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
There is a need and a place for a nursing specialty in the community; the nurse in this specialty is more than a clinical specialist with a master’s degree who practices in a community- based setting, as was suggested by the Consensus Conference more than 25 years ago. Although in 1984 these nurses were referred to as community health nurses, today they are referred to as nurses in community-based practice (see definitions in the inside cover of this text). Those who provide community- oriented service to specific subpopulations in the community and who provide some clinical services to those populations may be seen as nurse specialists in the community. Although such practitioners may be community-based, they are also community-oriented as public health specialists but are usually focused on only one or two special subpopulations. Preparing for this specialty includes a master’s or doctoral degree with emphasis in a direct care clinical area, such as school health or occupational health, and ideally some education in the public health sciences. Examples of roles such specialists might have in direct clinical care areas include case manager, supervisor in a home health agency, school nurse, occupational health nurse, parish nurse, and a nurse practitioner who also manages a nursing clinic.
ROLES IN PUBLIC HEALTH NURSING In community-oriented nursing circles, there has been a ten- dency to talk about public health nursing from the point of view of a role rather than the functions related to the role. This can be limiting. In discussing such nursing roles, there is a preoc- cupation with the direct care provider orientation. Even in dis- cussions about how a practice can become more population focused, the focus is frequently on how an individual practitio- ner, such as an agency staff nurse, can adopt a population- focused practice philosophy. Rarely is attention given to how nurse administrators in public health (one role for public health nursing specialists) might reorient their practice toward a pop- ulation focus, which is particularly important and easier for an
for carrying out the core public health functions (section A of Figure 1-4)
• Staff public health nurses or clinical nurses working in the community nurses, who are community-based, who may be clinically oriented to the individual client, and who combine some primary preventive population-focused strategies and direct care clinical strategies in programs serving specified populations (section B of Figure 1-4)
• Sections C and D of Figure 1-4 represent institutionalized populations. Nurses who provide direct care to these clients in hospital settings fall into section D, and those who have administrative/managerial responsibility for nursing ser- vices in institutional settings fall into section C. Figure 1-4 also shows that specialization in public health
nursing, as it has been defined in this chapter, can be viewed as a specialized field of practice with certain characteristics within the broad arena of community. This view is consistent with recommendations developed at the Consensus Conference on the Essentials of Public Health Nursing Practice and Education (USDHHS, 1985). One of the outcomes of the historical confer- ence was consensus on the use of the terms community health nurse and public health nurse. It was agreed that the term com- munity health nurse could apply to all nurses who practice in the community, whether or not they have had preparation in public health nursing. Thus nurses providing secondary or ter- tiary care in a home setting, school nurses, and nurses in clinic settings (in fact, any nurse who does not practice in an institu- tional setting) could fall into the category of community health nurse. Nurses with a master’s degree or a doctoral degree who practice in community settings could be referred to as community health nurse specialists, regardless of the area of nursing in which the degree was earned. According to the con- ference statement: “The degree could be in any area of nursing, such as maternal/child health, psychiatric/mental health, or medical-surgical nursing or some subspecialty of any clinical area” (USDHHS, 1985, p. 4). The definitions of the three areas of practice have changed, however, over time.
In 1998 the Quad Council began to develop a statement on the scope of public health nursing practice (Quad Council, 1999 [revised 2005]). The council attempted to clarify the differences between the term public health nursing and the term introduced into nursing’s vocabulary during health care reform of the 1990s: community-based nursing. The authors recognized that the terms public health nursing and community health nursing had been used interchangeably since the 1980s to describe population-focused, community-oriented nursing practice and community-based practice. However, the Council decided to make a clearer distinction between community-oriented and community-based nursing practice. In contrast, community- based nursing care was described as the provision or assurance of personal illness care to individuals and families in the com- munity, whereas community-oriented nursing was the provi- sion of disease prevention and health promotion to populations and communities. It was suggested that there be two terms for the two levels of care in the community: community-oriented care and community-based care. (see the list of definitions pre- sented in Box 1-5).
• Community-oriented nursing practice is a philosophy of nursing service delivery that involves the generalist or specialist public health and com- munity health nurse. The nurse provides health care through community diagnosis and investigation of major health and environmental problems, health surveillance, and monitoring and evaluation of community and popu- lation health status for the purposes of preventing disease and disability and promoting, protecting, and maintaining health to create conditions in which people can be healthy.
• Community-based nursing practice is a setting-specific practice whereby care is provided for clients and families where they live, work, and attend school. The emphasis of community-based nursing practice is acute and chronic care and the provision of comprehensive, coordinated, and continu- ous services. Nurses who deliver community-based care are generalists or specialists in maternal/infant, pediatric, adult, or psychiatric/mental health nursing.
BOX 1-5 Definitions of the Key Nursing Areas in the Community
17CHAPTER 1 Community and Prevention–Oriented, Population-Focused Practice
nurse supervisors), others are outside of the traditional nursing roles (e.g., director of a health department).
CHALLENGES FOR THE FUTURE Barriers to Specializing in Public Health Nursing One of the most serious barriers to the development of special- ists in public health nursing is the mindset of many nurses that the only role for a nurse is at the bedside or at the client’s side (i.e., the direct care role). Indeed, the heart of nursing is the direct care provided in personal contacts with clients. On the other hand, two things should be clear. First, whether a nurse is able to provide direct care services to a particular client depends on decisions made by individuals within and outside of the care system. Second, nurses need to be involved in those fundamental decisions. Perhaps the one-on-one focus of nursing and the historical expectations of the “proper” role of women have influenced nurses to view other ways of contribut- ing, such as administration, consultation, and research, less positively. Fortunately, things are changing. Within and outside of nursing, women have taken on every role imaginable. Further, the number of male nurses is steadily growing; nursing can no longer be viewed as a profession practiced by women exclu- sively. These two developments have opened doors to new roles that may not have been considered appropriate for nurses in the past.
A second barrier to population-focused public health nursing practice consists of the structures within which nurses work and the process of role socialization within those structures. For example, the absence of a particular role in a nursing unit may suggest that the role is undesirable or inaccessible to nurses. In another example, nurses interested in using political strategy to make changes in health-related policy—an activity clearly within the domain of public health nursing—may run into obstacles if their goals differ from those of other groups. Such groups may subtly but effectively lead nurses to conclude that their involvement in political effort takes their attention away from the client and it is not in their own or in the client’s best interest to engage in such activities.
A third barrier is that few nurses receive graduate-level preparation in the concepts and strategies of the disciplines basic to public health (e.g., epidemiology, biostatistics, com- munity development, service administration, and policy for- mation). As mentioned previously, master’s level programs for public health nursing do not give the in-depth attention to population assessment and management skills that other parts of the curriculum receive, such as the direct care aspects receive. In 1995 Josten and colleagues noted that with few exceptions, graduate programs in public health nursing have not aggressively developed the population-focused skills that are needed. For individuals who want to specialize in public health nursing, these skills are as essential as direct care skills, and they should be given more attention in graduate programs that prepare nurses for careers in public health. Fortunately, the curricular expectations for academic programs leading to the Doctor of Nursing Practice (DNP) degree include serious attention to preparing nurses to develop a population
administrator to do than for the staff nurse. This is because many agencies’ nursing administrators, supervisors, or others (sometimes program directors who are not nurses) make the key decisions about how staff nurses will spend their time and what types of clients will be seen and under what circumstances. Public health nursing administrators who are prepared to prac- tice in a population-focused manner will be more effective than those who are not prepared to do so.
Although their opportunities to make decisions at the popu- lation level are limited, staff nurses benefit from having a clear understanding of population-focused practice for three reasons: • First, it gives them professional satisfaction to see how their
individual client care contributes to health at the population level.
• Second, it helps them appreciate the practice of others who are population-focused specialists.
• Third, it gives them a better foundation from which to provide clinical input into decision making at the program or agency level and thus to improve the effectiveness and efficiency of the population-focused practice. A curriculum was proposed by representatives of key public
health nursing organizations and other individuals that would prepare the staff public health nurse or generalist to function as a community-oriented practitioner (Association of State and Territorial Directors of Nursing, 2000). The AACN developed a supplement to the document “The Essentials of Baccalaureate Education for Professional Nursing Practice,” which highlights this organization’s recommendations for public health nursing (AACN, 2013).
Unfortunately, nursing roles as presently defined are often too limited to include population-focused practice, but it is important not to think too narrowly. Furthermore, roles that entail population-focused decision making may not be defined as nursing roles (e.g., directors of health departments, state or regional programs, and units of health planning and evaluation; directors of programs such as preventive services within a managed care organization). If population-focused public health nursing is to be taken seriously, and if strategies for assessment, policy development, and assurance are to be imple- mented at the population level, more consideration must be given to organized systems for assessing population needs and managing care. Clearly, public health nurse specialists must move into positions where they can influence policy formation. This means, however, that some nurses will have to assume positions that are not traditionally considered nursing.
Redefining nursing roles so that population-focused deci- sion making fits into the present structure of nursing services may be difficult in some circumstances at the present time, but future needs will require that nurses be prepared to make such decisions (IOM, 2010). At this point, it may be more useful to concentrate on identifying the skills and knowledge needed to make decisions in population-focused practice (see Appendix G.1), to define where in the health care system such decisions are made, and then to equip nurses with the knowledge, skills, and political understanding necessary for success in such posi- tions. Although some of these positions are in nursing settings (e.g., administrator of the nursing service and top-level staff
18 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
administrators, and (2) the growing popularity of nurse prac- titioner programs. However, it is time that nurse leaders give more attention to preparing nurses for leadership in the area of population-focused practice. Perhaps it is time to combine the specialty in public health nursing and nursing administration. As suggested some time ago by Williams (1985), some DNP programs are combining much of the preparation for special- ization in public health nursing and administration into a systems-oriented curriculum with differentiation in the appli- cation to practice. This is the approach that is being taken in the DNP program in the College of Nursing at the University of Kentucky (www.uknursing.uky.edu). This makes sense because regardless of how the population is defined, there will be a growing need for nurses with population-level assessment, management, and evaluation skills to assume leadership roles as urged in the Institute of Medicine’s report on the Future of Nursing (IOM, 2010).
The primary focus of the health care system of the future will be on community-oriented strategies for health promotion and disease prevention, and on community-based strategies for primary and secondary care. Directing more attention to devel- oping the specialty of public health nursing as a way to provide nursing leadership may be a good response to the health care system changes. Preparing nurses for population-focused deci- sion making will require greater attention to developing pro- grams at the doctoral level that have a stronger foundation in the public health sciences, while providing better preparation of baccalaureate-level nurses for community-oriented as well as community-based practice.
Some observers of public health have anticipated that if access to health care for all Americans becomes more of a reality, public health practitioners can turn over the delivery of personal primary care services to other providers such as health maintenance organizations and integrated health plans, and return to the core public health functions. However, assurance (making sure that basic services are available to all) is a core function of public health. Thus even under the con- dition of improved access to care, there will still be a need to monitor subpopulations in the community to ensure that necessary care is available and that its quality is at an accept- able level. When these conditions are not met, public health practitioners will have to find a solution. If the Affordable Care Act is successful in enrolling the vast majority of the population and access to basic health services is available to them, public health organizations will be in a position to focus the majority of their attention on community-oriented and population-focused health promotion and primary prevention.
Shifting Public Policy toward Creating Conditions for a Healthy Population In 2012 the Institute of Medicine published a report (IOM, 2012B), on shifting public policy from a primary focus of sup- porting medical care to creating conditions for a healthy popu- lation. A major challenge for the future is the need for public health nursing specialists to be more aggressive in their practice
perspective as well as the analytical, policy, and leadership skills necessary to be successful as a specialist in public health nursing (AACN, 2006).
Developing Population-Focused Nurse Leaders The massive organizational changes occurring in the health delivery system present a unique opportunity to establish new roles for nurse leaders who are prepared to think in population terms. In a book that is now viewed as a classic, Starr (1982) described the trend toward the use of private capital in financ- ing health care, particularly institution-based care and other health-related businesses. The movement can be thought of as the “industrialization” of health care, which operated very much like a cottage industry or a small business for a very long time. The implications and consequences of this move- ment are enormous. First, the goal was to provide investors a return on their investment. Other aspects included more atten- tion to the delivery of primary and community-based care in a variety of settings; less emphasis on specialty care; the develop- ment of partnerships, alliances, and other linkages across set- tings in an effort to build integrated systems, which would provide a broad range of services for the population served; and in some situations adoption of capitation, a payment arrangement in which insurers agree to pay providers a fixed sum for each person per month or per year, independent of the costs actually incurred. With the spread of capitation, health professionals have become more interested in the concept of populations, sometimes referred to by financial officers and others as covered lives (i.e., individuals with insurance that pays on a capitated basis). For public health specialists, it is a new experience to see individuals involved in the business aspects of health care, and frequently employed by hospitals, thinking in population terms and taking a population approach to deci- sion making.
This new focus on populations, coupled with the integration of acute, chronic, and primary care that is occurring in some health care systems, is likely to create new roles for individuals, including nurses, who will span inpatient and community- based settings and focus on providing a wide range of services to the population served by the system. Such a role might be director of client care services for a health care system, who would have administrative responsibility for a large program area. There will also be a demand for individuals who can design programs of preventive and clinical services to be offered to targeted subpopulations and those who can implement the services. Who will decide what services will be given to which subpopulation and by which providers? How will nurses be prepared for leadership in the emerging and future structures for health care delivery and health maintenance?
Physician leaders are recognizing that physicians need to be prepared to use population-focused methods, such as epidemiology and biostatistics, to make evidence-based deci- sions in the development of programs and protocols. The attention being given to preparing nurses for administrative decision making seems to be declining. This may be a result of (1) the recent lack of federal support for preparing nurse
19CHAPTER 1 Community and Prevention–Oriented, Population-Focused Practice
of the core public health function of policy development, one of the major ways public health specialists intervene, with the focus on actively engaging in influencing public decisions that will create conditions for a healthy population. This is necessary at the local, state, and national levels and encompasses a wide range of concerns from the availability of adequate nutrition to the maintenance of a healthy and safe environment in schools, to the reduction of secondhand smoke, to assuring access to needed health services. Policy development is not a solitary activity; it involves working with many groups and coalitions. Also, policy development is not just the responsibility of public health specialists; it is important that all professional nurses become more serious and adept in the process of policy development.
In the just released report, The Future of Nursing: Leading Change, Advancing Health (IOM, 2010), a key message is that “Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States” (IOM, 2010, pp. 1-11). In discussing this message, the report states that “to be effective in re-conceptualized roles, nurses must see policy as something they can shape rather than something that happens to them” (IOM, 2010, pp. 1-11). In other words, nurses need to be key actors. However, the report also makes clear that nurses need to be prepared for leadership in that area.
The history of public health nursing shows that a common attribute of leaders is to move forward to deal with unresolved problems in a positive, proactive way. This is the legacy of Lillian Wald at the Henry Street Settlement, and many others who have met a need by being innovative. Within the context of the core public health function of policy-making, public health nursing clearly has an opportunity to affect public decisions that will help create conditions for a healthy population and influence the provision of needed services to populations in the community, particularly those that are most vulnerable. As a specialty, public health nursing can have a positive impact on the health status of populations, but to do so “it will be necessary to have broad vision; to prepare nurses for leadership roles in policy making and in the design, development, management, monitoring, and evalu- ation of population-focused health care systems and to develop strategies to support nurses in these roles” (Williams, 1992, p. 268). With the focus on quality and safety education for nurses, public health nursing education will want to reflect this renewed focus and assist nurses who are population focused to develop the competencies noted in the QSEN box.
LINKING CONTENT TO PRACTICE
In this chapter emphasis is placed on defining and explaining public health nursing practice with populations. The three essential functions of public health and public health nursing are assessment, policy development, and assurance. The Council on Linkages “Core Competencies for Public Health Professionals” revised in 2014 describes the skills of public health professionals, including nurses. In assessment function, one skill is assessment of the health status of populations and their related determinants of health and illness. For policy development, one of the skills is development of a plan to implement policy and programs. For the assurance function, one skill that public health nurses will need is to incorporate ethical standards of practice as the basis of all interactions with organizations, communities, and individuals. These skills can also be linked to the 10 essential services of public health nursing found on page 8. Assessment of health status is a skill needed for implementing essential service 1, the monitoring of health status to identify community problems. Development of a plan for policy and program implementation is a skill needed for essential service 5, to support individual and community health efforts. Incorporating ethical standards is done in essential service 3 when informing, educating, and empowering people about health issues.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
QSEN Competency Competency Definition
Client-Centered Care
Recognize the client or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for client preferences, values, and needs
Teamwork and Collaboration
Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality care
Evidence-Based Practice
Integrate best current evidence with clinical expertise and client/family preferences and values for delivery of optimal health care
Quality Improvement
Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems
Safety Minimize risk for harm to clients and providers through both system effectiveness and individual performance
Informatics Use information and technology to communicate, manage knowledge, mitigate error, and support decision making
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
P R A C T I C E A P P L I C A T I O N Population-focused nursing practice is different from clinical nursing care delivered in the community. If one accepts that the specialist in public health nursing is population-focused and has a unique body of knowledge, it is useful to debate where and how public health nursing specialists practice. How does their practice compare with that of the nurse specialist in com- munity or community-based nursing?
A. In your public health class, debate with classmates which nurses in the following categories practice population- focused nursing: 1. School nurse 2. Staff nurse in home care 3. Director of nursing for a home care agency 4. Nurse practitioner in a health maintenance organization
20 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
K E Y P O I N T S • Public health is what we, as a society, do collectively to ensure
the conditions in which people can be healthy. • Assessment, policy development, and assurance are the core
public health functions; they are implemented at all levels of government.
• Assessment refers to systematically collecting data on the population, monitoring of the population’s health status, and making available information about the health of the community.
• Policy development refers to the need to provide leadership in developing policies that support the health of the popula- tion; it involves using scientific knowledge in making deci- sions about policy.
• Assurance refers to the role of public health in making sure that essential community-wide health services are available, which may include providing essential personal health services for those who would otherwise not receive them. Assurance also refers to ensuring that a compe- tent public health and personal health care workforce is available.
• The setting is frequently viewed as the feature that distin- guishes public health nursing from other specialties. A more
useful approach is to use the following characteristics: a focus on populations that are free-living in the community, an emphasis on prevention, a concern for the interface between the health status of the population and the living environment (physical, biological, sociocultural), and the use of political processes to affect public policy as a major intervention strategy for achieving goals.
• According to the 1985 Consensus Conference sponsored by the Nursing Division of the U.S. Department of Health and Human Services, specialists in public health nursing are defined as those who are prepared at the graduate level, either master’s or doctoral, “with a focus in the public health sciences” (USDHHS, 1985). This is still true today.
• Population-focused practice is the focus of specialists in public health nursing. This focus on populations and the emphasis on health protection, health promotion, and disease prevention are the fundamental factors that distin- guish public health nursing from other nursing specialties.
• A population is defined as a collection of individuals who share one or more personal or environmental characteristics. The term population may be used interchangeably with the term aggregate.
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Nursing (AACN): AACN Position Statement on the Practice Doctorate in Nursing. Washington, DC, 2004, AACN.
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American Association of Colleges of Nursing (AACN): Public Health: Recommended Baccalaureate Competencies and Curricular Guidelines for Public Health Nursing: A Supplement to The Essentials of Baccalaureate education for Professional Nursing Practice”? See URL: http:// www.aacn.nche.edu/education
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American Nurses Association (ANA): Public Health Nursing: Scope and Standards of Practice. Washington, DC, 2013, ANA.
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P R A C T I C E A P P L I C A T I O N — cont’d 5. Vice president of nursing in a hospital 6. Staff nurse in a public health clinic or community health
center 7. Director of nursing in a health department • Provide reasons for your choices.
B. Choose three categories in the preceding list, and interview at least one nurse in each of the categories. Determine the scope of practice for each nurse. Are these nurses carrying out population-focused practice? Could they? How? Answers can be found on the Evolve site.
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Define the following for your personal understanding, and
suggest ways to check whether your understanding is correct: A. Essential functions of public health B. Specialist in public health nursing C. Nurse specialist in the community
2. State your opinion about the similarities and/or differences between a clinical nursing role and the population-focused role of the public health nursing specialist. What are some of the complex issues in distinguishing between these roles?
3. Review the model of public health nursing practice of the APHA as described in this chapter. Can you elaborate on the differences between the staff nurse and the specialist nurse?
4. With three or four classmates, identify some nurses in your community who are in an administrative role and discuss with them the following: A. The way they define the populations they are serving B. Strategies they use to monitor the population’s health
status C. Strategies they use to ensure that the populations are
receiving needed services D. Initiatives they are taking to address problems
5. Do additional questions need to be asked to determine their views on population-focused practice and the responsibili- ties of the staff nurse? Elaborate.
21CHAPTER 1 Community and Prevention–Oriented, Population-Focused Practice
Association of Community Health Nursing Educators (ACHNE): Essentials of Master’s Level Nursing Education for Advanced Community/Public Health Nursing Practice. Lathrop, NY, 2003, ACHNE.
Association of Community Health Nursing Educators (ACHNE): Essentials of Baccalaureate Nursing Education for Entry Level Community/Public Health Nursing. Wheat Ridge, CO, 2009, ACHNE.
Association of State and Territorial Directors of Nursing (ASTDN): Public Health Nursing: A Partner for Healthy Populations. Washington, DC, 2000, ASTDN.
Blumenthal D, Collins S: Health care coverage under the Affordable Care Act—a progress report. N Engl J Med 371:275–281, 2014.
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Centers for Disease Control and Prevention (CDC): National Public Health Performance Standards Program, 2014a. Retrieved November 2014 from: www.phf.org/nphpsp/.
Centers for Disease Control and Prevention (CDC): The Community Guide: What Works to Promote Health, 2014b. Retrieved November 2014 from: www.thecommunityguide.org.
Centers for Medicare and Medicaid Services (CMS), Office of the Actuary, National Health Statistics Group: The Nation’s Health Dollar Calendar Year 2012: Where It Came From, Where It Went, 2012. Retrieved November 2014 from: http://www.cms.gov/Research -Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/ NationalHealthExpendData/ Downloads/PieChartSources Expenditures2012.pdf.
Consensus Conference on the Essentials of Public Health Nursing Practice and Education. Rockville, MD, 1985, U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing.
Council on Linkages between Academia and Public Health Practice: Core Competencies for Public Health Professionals. Washington, DC, 2010, revised 2014. Retrieved 9/29/14 November 2014 from: www.phf.org/ corecompetencies.
Fielding J: Commentary: public health and health care quality
assurance—strange bedfellows? Milbank Q 87:581–584, 2009.
Fielding J, Tilson H, Richland J: Medical care reform requires public health reform: expanded role for public health agencies in improving health, partnership for prevention, 2008. Retrieved November 2014 from: www.prevent.org.
Gebbie K: Building a constituency for public health. J Public Health Manag Pract 3:1, 1999.
Hahn E, Rayens M, Burkhart P, et al: Smoke-free laws, gender and reduction in hospitalization for acute myocardial infarctions. Public Health Rep 126:826–833, 2011.
Hahn E, Rayens M, Langley R, et al: Do smoke-free laws in rural, distressed counties encourage cessation? Policy Polit Nurs Pract 11:302–308, 2010.
Institute of Medicine: The future of public health. Washington, DC, 1988, National Academy Press.
Institute of Medicine (IOM): Improving Health in the Community: A Role for Performance Monitoring. Washington, DC, 1997, National Academies Press.
Institute of Medicine: Improving Health in the Community: A Role for Performance Monitoring. Washington, DC, 1997, National Academy Press.
Institute of Medicine (IOM): Who Will Keep the Public Healthy? Washington, DC, 2003, National Academies Press.
Institute of Medicine (IOM): The Future of Nursing: Leading Change, Advancing Health. Washington, DC, 2010, National Academies Press.
Institute of Medicine (IOM): For the Public’s Health: Investing in a Healthier Future [Brief Report]. 2012a. Retrieved November 2014 at: www.iom.edu.
Institute of Medicine (IOM): Primary Care and Public Health, : Exploring Integration to Improve Population Health. Washington, DC, 2012b, National Academiesy of Sciences Press.
Josten L, Clarke PN, Ostwald S, et al: Public health nursing education: back to the future for public health sciences. Fam Community Health 18:36, 1995.
KaiserEDU.org. 2010: Health policy explained. Retrieved December 1, 2010. [Historical reference].
Kentucky Center for Smoke-Free Policy: Retrieved October 7, 2010 from: www.mc.uky.edu/ tobaccopolicy/.
Orszag PR: Health Care and the Budget: Issues and Challenges for Reform [Statement before the
Committee on the Budget, U.S. Senate]. Washington, DC, June 21, 2007, Congressional Budget Office.
Orszag PR, Emanuel EJ: Health care reform and cost control. N Engl J Med 363:601–603, 2010.
Patient Protection and Affordable Care Act & Health Care and Education Affordability Reconciliation Act of 2010, 2010. Retrieved 9/28/ November 2014 from: www. hhs.gov/opa/affordable-care-act.
Public Health Functions Steering Committee: Public Health in America, 1998. Retrieved November 2014 from: www.health.gov/phfunctions/ public.htm.
Quad Council of Public Health Nursing Organizations: Scope and Standards of Public Health Nursing Practice. Washington, DC, 1999 [revised 2005], American Nurses Association.
Quad Council of Public Health Nursing Organizations: Competencies for Public Health Nursing Practice. Washington, DC, 2003 [revised 2009], Association of State and Territorial Directors of Nursing.
Quad Council of Public Health Nursing Organizations: Quad Council Competencies for Public Health Nurses, Summer 2011. November 2014 from: www.quadcouncilphn.org.
Starr P: The social transformation of American medicine. New York, 1982, Basic Books.
Trust for America’s Health: The Truth about the Prevention and Public Health Fund. June 2013. Retrieved November 2014 from: www.healthyamericans.org/ report/106.
Turnock B: Public Health: what is it and how does it work, ed 4. Boston, 2009, Jones and Bartlett.
Turnock B: Public Health: What Is It and How Does It Work? ed 5. Boston, 2012, Jones & Bartlett.
U.S. Department of Health, Education, and Welfare: Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention, DHEW (PHS) Publication No. 79-55071. Washington, DC, 1979, U.S. Government Printing Office.
U.S. Department of Health and Human Services: Promoting Health/Preventing Disease: Objectives for the Nation. Washington, DC, 1980, U.S. Government Printing Office.
U.S. Department of Health and Human Services (USDHHS): Healthy People 2000: National Health Promotion and Disease Prevention Objectives, DHHS Publication No. 91-50212.
Washington, DC, 1991, U.S. Government Printing Office.
U.S. Department of Health and Human Services (USDHHS): Healthy People 2010: Understanding and Improving Health, ed 2. Washington, DC, 2000, U.S. Government Printing Office.
U.S. Department of Health and Human Services: Health US: 2000. Washington, DC, 2002, National Center for Statistics.
U.S. Department of Health and Human Services: Health US: 2000. Washington, DC, 2002, National Center for Statistics.
U.S. Department of Health and Human Services (USDHHS): National Center for Health Statistics. Washington, DC, 2010.
U.S. Department of Health and Human Services (USDHHS): Healthy People 2020: The Road Ahead. 2010. Retrieved November 2013 from: www.healthypeople .gov/hp2020/default.asp.
U.S. Department of Health and Human Services (USDHHS): Healthy People 2020: Leading Health Indicators—Progress Update 2014. Retrieved November 2014 from: www.healthypeople.gov. [when on site click on Leading Health Indicators].
U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing: Consensus Conference on the Essentials of Public Health Nursing Practice and Education [APHA Report Series]. Washington, DC, 1985, American Public Health Association.
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U.S. Public Health Service: The Core Functions Project. Washington, DC, 1994 [updated 2008], Office of Disease Prevention and Health Promotion.
Williams CA: Population-focused community health nursing and nursing administration: a new synthesis. In McCloskey JC, Grace HK, editors: Current Issues in Nursing, ed 2. Boston, 1985, Blackwell Scientific.
Williams CA: Public health nursing: does it have a future? In Aiken LH, Fagin CM, editors: Charting Nursing’s Future: Agenda for the 1990s. Philadelphia, 1992, Lippincott.
Williams CA: Beyond the Institute of Medicine report: a critical analysis and public health forecast. Fam Community Health 18:12, 1995.
22
2 History of Public Health and Public and Community Health Nursing
Janna Dieckmann, PhD, RN Dr. Janna Dieckmann is a clinical associate professor at the University of North Carolina at Chapel Hill. She received her BSN from Case Western Reserve University and her MSN in Community Health Nursing and her PhD from the University of Pennsylvania. She has practiced as a public health nurse with both the Visiting Nurse Association of Cleveland, Ohio and the Visiting Nurse Association of Philadelphia. She uses written and oral historical materials to research the history of public health nursing and on the care of the chronically ill, and to comment on contemporary health policy.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Interpret the focus and roles of public health nurses
through an historical approach. 2. Trace the ongoing interaction between the practice of
public health and that of nursing. 3. Discuss the dynamic relationship between changes in
social, political, and economic contexts and nursing practice in the community.
4. Outline the professional and practice impact of individual leadership on population-centered nursing, especially the leadership of Florence Nightingale and Lillian Wald.
5. Identify structures for delivery of nursing care in the community such as settlement houses, visiting nurse associations, official health organizations, and schools.
6. Recognize major organizations that contributed to the growth and development of population-centered nursing.
K E Y T E R M S American Nurses Association, p. 35 American Public Health Association, p. 30 American Red Cross, p. 28 district nursing, p. 27 district nursing association, p. 27 Florence Nightingale, p. 26 Frontier Nursing Service, p. 31 Lillian Wald, p. 28 Metropolitan Life Insurance Company, p. 31 National League for Nursing, p. 35
National Organization for Public Health Nursing, p. 30 official health agency, p. 32 settlement houses, p. 28 Sheppard-Towner Act, p. 31 Social Security Act of 1935, p. 33 Town and Country Nursing Service, p. 29 visiting nurse, p. 28 William Rathbone, p. 27 —See Glossary for definitions
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz
• Case Studies • Glossary • Answers to Practice Application
23CHAPTER 2 History of Public Health and Public and Community Health Nursing
communicable diseases, such as diphtheria, cholera, and typhoid fever, have been largely controlled in the United States, but others continue to affect many lives across the globe, includ- ing human immunodeficiency virus (HIV), poliomyelitis, Ebola virus, and tuberculosis. Emerging and re-emerging communi- cable diseases with widespread impact, for example, influenza A subtypes such as 2009 H1N1, underscore the truth that health concerns are international. Even though environmental pollu- tion in residential areas now receives increased public attention, communities continue to be threatened by overcrowded garbage dumps and pollutants affecting the air, water, and soil. Natural disasters continue to challenge public health systems, and bio- terrorism and other human-made disasters have the potential to overwhelm existing resources. Research has identified means to avoid or postpone chronic disease onset, and nurses implement strategies to modify individual and community risk factors and behaviors. Finally, with the growing population percentage of older adults in the United States and their preference to remain at home, additional nursing services are required to sustain the frail, the disabled, and the chronically ill in the community.
Contemporary nursing roles in the United States developed from several sources and are a product of various ongoing social, economic, and political forces. This chapter describes the societal circumstances that influenced nurses to establish community-based and population-centered practices. For the purposes of this chapter, the term nurse will be used to refer to nurses who rely heavily on public health science to complement their focus on nursing science and practice. The nation’s need for community and public health nurses, the practice of population-centered nursing, and the organizations influencing public health nursing in the United States from the nineteenth century to the present are discussed.
PUBLIC HEALTH DURING AMERICA’S COLONIAL PERIOD AND THE NEW REPUBLIC Concern for the health and care of individuals in the commu- nity has characterized human existence. All people and all cul- tures have been concerned with the events surrounding birth, death, and illness. Human beings have sought to prevent,
Nurses use historical approaches to examine both the profes- sion’s present and its future. In doing so, several questions are asked: First, who is the population-centered nurse? In the past, population-centered nurses have been called public health nurses, district nurses, and visiting nurses, as well as home health care nurses, school nurses, and occupational health nurses. Second, how does the past contribute to the work of the population-centered nurse today? Next, what are the times and places in which these nurses have worked and continue to work? When a conscious process of critique and insight is used to look into past actions of the specialty, what can be discovered? Must contemporary nurses agree with or endorse past actions of the profession? And last, how might knowledge of population- centered nursing history serve both as a source of inspiration, and also as a creative stimulus to solve the enduring and new problems of the current period? This chapter serves as an intro- duction to these questions through tracing the development and evolution of population-centered nursing.
CHANGE AND CONTINUITY For more than 130 years, public health nurses in the United States have worked to develop strategies to respond effectively to prevailing public health problems. The history of population- centered nursing reflects changes in the specific focus of the profession while emphasizing continuity in approach and style. Nurses have worked in communities to improve the health status of individuals, families, and populations, especially those who belong to vulnerable groups. Part of the appeal of this nursing specialty has been its autonomy of practice and inde- pendence in problem solving and decision-making, conducted in the context of a multidisciplinary practice. Many varied and challenging public health nursing roles originated in the late 1800s when public health efforts focused on environmental conditions such as sanitation, control of communicable dis- eases, education for health, prevention of disease and disability, and care of aged and sick persons in their homes.
Although the manifestations of these threats to health have changed over time, the foundational principles and goals of public health nursing have remained the same. Many
C H A P T E R O U T L I N E Change and Continuity Public Health during America’s Colonial Period and the
New Republic Nightingale and the Origins of Trained Nursing America Needs Trained Nurses School Nursing in America The Profession Comes of Age Public Health Nursing in Official Health Agencies and in
World War I Paying the Bill for Public Health Nurses African-American Nurses in Public Health Nursing Between the Two World Wars: Economic Depression and the
Rise of Hospitals
Increasing Federal Action for the Public’s Health World War II: Extension and Retrenchment in Public Health
Nursing The Rise of Chronic Illness Declining Financial Support for Practice and Professional
Organizations Professional Nursing Education for Public Health Nursing New Resources and New Communities: The 1960s and
Nursing Community Organization and Professional Change Public Health Nursing from the 1970s into the Twenty-First
Century Public Health Nursing Today
24 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
Year Milestone
1601 The Act for the Relief of the Poor (the Elizabethan Poor Law) passed 1751 Pennsylvania Hospital founded in Philadelphia 1793 Baltimore Health Department established 1798 Marine Hospital Service established; in 1912 renamed the U.S. Public Health Service 1813 Ladies’ Benevolent Society of Charleston, South Carolina, founded 1815 Sisters of Mercy established in Dublin, Ireland, where nuns visited the poor 1836 Lutheran deaconess movement founded in Kaiserswerth, Germany 1851 Florence Nightingale visits Kaiserswerth for 3 months of nurse training 1859 District nursing established in Liverpool, England, by William Rathbone 1860 Florence Nightingale Training School for Nurses established at St. Thomas Hospital in London, England 1866 New York Metropolitan Board of Health established 1872 American Public Health Association established 1873 New York Training School opens at Bellevue Hospital, New York City, as first Nightingale-model nursing school in the United States 1877 Women’s Board of the New York Mission hires nurse Frances Root to visit the sick poor 1881 Clara Barton and a circle of her acquaintances found the American Red Cross in Washington, DC on May 21, 1881 1885 Visiting Nurse Association established in Buffalo, NY 1886 Visiting nurse agencies established in Philadelphia and Boston 1892 First organized movement against tuberculosis 1893 Lillian Wald and Mary Brewster organize a visiting nursing service for the poor of New York, which later became the famous Henry Street
Settlement and the Visiting Nurse Service of New York Society of Superintendents of Training Schools of Nurses in the United States and Canada established (in 1912 it became known as the National
League of Nursing Education)
TABLE 2-1 Milestones in the History of Public Health and Community Health Nursing: 1601 to 2014
understand, and control disease. Their ability to preserve health and treat illness has depended on the contemporary level of science, use and availability of technologies, and degree of social organization.
In the early years of America’s settlement, as in Europe, the care of the sick was usually informal and was provided by household members, almost always women. The female head of the household was responsible for caring for all household members, which meant more than nursing them in sickness and during childbirth. She was also responsible for growing or gathering healing herbs for use throughout the year. For the increasing numbers of urban residents in the early 1800s, this traditional system became insufficient.
American ideas of social welfare and community-based care of the sick were strongly influenced by the traditions of British settlers in the New World. Just as American law is based on English common law, colonial Americans established systems of care for the sick, poor, aged, mentally ill, and dependents based on England’s Elizabethan Poor Law of 1601. In the United States, as in England, local poor laws guaranteed medical care for poor, blind, and “lame” individuals, even those without family. Early county or township government was responsible for the care of all dependent residents, but provided almshouse charity carefully, economically, and only for local residents. Travelers and wanderers from elsewhere were returned to their native counties for care. In 1751, Pennsylvania Hospital was founded in Philadelphia, the first hospital in what would become the United States. Yet until much later, hospitals were few and found only in large cities.
Early colonial public health efforts included the collection of vital statistics, improvements to sanitation systems, and
control of communicable diseases introduced through seaports. Colonists lacked an organized and on-going means to ensure support and enforcement of public health efforts. Epidemics intermittently taxed the limited local organization for health during the seventeenth, eighteenth, and nineteenth centuries (Rosen, 1958).
After the American Revolution, the threat of disease, espe- cially yellow fever epidemics, encouraged public support for new government-sponsored, official boards of health. New York City, with a population of 75,000 by 1800, established basic public health services, which included monitoring water quality, constructing sewers and a waterfront wall, draining marshes, planting trees and vegetables, and burying the dead (Rosen, 1958).
Increased urbanization and early industrialization in the new United States contributed to increased incidence of disease, including epidemics of smallpox, yellow fever, cholera, typhoid, and typhus. Tuberculosis and malaria remained endemic at a high incidence rate, and infant mortality was about 200 per 1000 live births (Pickett and Hanlon, 1990). American hospitals in the early 1800s were generally unsanitary and staffed by poorly trained workers; institutions were a place of last resort. Physicians received a limited education through proprietary schools or simple apprenticeship. Medical care was difficult to secure, although public dispensaries (similar to outpatient clinics) and private charitable efforts attempted to address gaps in the availability of sickness services, especially for the urban poor and working classes. Environmental conditions in urban neighborhoods, including inadequate housing and sanitation, were additional risks to health. Table 2-1 presents milestones of public health efforts that occurred from 1601 to the present.
25CHAPTER 2 History of Public Health and Public and Community Health Nursing
Year Milestone
1896 Associated Alumnae of Training Schools for Nurses established (in 1911 it became the American Nurses Association) 1902 School nursing started in New York City, by Nurse Lina Rogers of Henry Street Settlement 1903 First Nurse Practice Acts passed 1908 National Association of Colored Graduate Nurses founded 1909 Metropolitan Life Insurance Company provides first insurance reimbursement for nursing care 1910 Public health nursing program instituted at Teachers College, Columbia University, NYC 1912 National Organization for Public Health Nursing formed; Lillian Wald is first president 1916 Public Health Nursing textbook by Mary Sewall Gardner published 1918 Vassar Training Camp for Nurses organized
U.S. Public Health Service (USPHS) establishes division of public health nursing to work in the war effort Worldwide influenza epidemic begins
1921 Maternity and Infancy Act (Sheppard-Towner) passed; 2978 Prenatal and Child Health Centers 1925 Frontier Nursing Service using nurse-midwives established in Kentucky 1933 Pearl McIver is first nurse employed by the U.S. Public Health Service 1935 Social Security Act passed
Association of State and Territorial Directors of Nursing founded 1941 United States enters World War II 1943 Bolton Act provides $5 million for nursing education; establishes Cadet Nurse Corps, with Lucille Petry as chief; 124,000 nurses graduate by 1948
when Corps ends USPHS Division of Nurse Education begun; becomes Division of Nursing in 1946
1944 First basic program in nursing accredited as including sufficient public health content 1946 Nurses classified as professionals by U.S. Civil Service Commission
Hill-Burton Act approved, providing funds for hospital construction in underserved areas and requiring these hospitals to provide care for poor people
Passage of National Mental Health Act 1950 25,091 nurses employed in public health 1951 National organizations recommend that college-based nursing education programs include public health content 1952 National Organization for Public Health Nursing merges into the new National League for Nursing
Closure of Metropolitan Life Insurance Nursing Program 1964 Passage of Civil Rights Act and Economic Opportunity Act
Public health nurse defined by the American Nurses Association (ANA) as a graduate of a BSN program 1965 ANA position paper recommends that nursing education take place in institutions of higher learning 1966 Medicare and Medicaid (Titles 18 and 19, of the Social Security Act) are implemented on July 1
(legislation passed in 1965) 1977 Passage of Rural Health Clinic Services Act, which provided indirect reimbursement for nurse practitioners in rural health clinics 1978 Association of Graduate Faculty in Community Health Nursing/Public Health Nursing founded (later, Association of Community Health Nursing
Educators) 1979 Publication of Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention 1980 Medicaid amendment to the Social Security Act to provide direct reimbursement for nurse practitioners in rural health clinics
ANA and APHA develop statements on the role and conceptual foundations of community and public health nursing, respectively 1983 Beginning of Medicare prospective payment system 1985 National Center for Nursing Research established in the National Institutes of Health 1988 Institute of Medicine reports on The Future of Public Health 1990 Essentials of Baccalaureate Nursing Education, from Association of Community Health Nursing Educators 1991 More than 60 nursing organizations join in support of health care reform; publish Nursing’s Agenda for Health Care Reform 1993 American Health Security Act of 1993: blueprint for national health care reform; legislation fails; states and the private sector left to design own
programs 1994 National Institute of Nursing Research, as part of the National Institutes of Health (was NCNR) 1996 The Definition and Role of Public Health Nursing, updated: Public Health Nursing Section, American Public Health Association 1998 The Public Health Workforce: An Agenda for the 21st Century, U.S. Public Health Service; examines current workforce in public, health, and
educational needs, and the use of distance learning strategies to prepare future public health workers 1999 The Public Health Nursing Quad Council works with American Nurses Association on new Scope and Standards of Public Health Nursing Practice;
differentiates between community-oriented and community-based nursing practice 2001 Public health gains a national presence in addressing concerns about biological and other terrorism, following September 11 attacks 2002 Department of Homeland Security established to provide leadership to protect against intentional threats to the health of the public
TABLE 2-1 Milestones in the History of Public Health and Community Health Nursing: 1601 to 2014—cont’d
Continued
26 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
In some areas, charitable organizations addressed the gap between known communicable disease epidemics and the lack of local government resources. For example, the Howard Asso- ciation of New Orleans, Louisiana, responded to periodic yellow fever epidemics between 1837 and 1878 by providing physi- cians, lay nurses, and medicine. The Association established infirmaries and used sophisticated outreach strategies to locate cases (Hanggi-Myers, 1995)(Figure 2-1).
NIGHTINGALE AND THE ORIGINS OF TRAINED NURSING The origins of professional nursing are found in the work of Florence Nightingale in nineteenth-century Europe. With tremendous advances in transportation, communication, and other forms of technology, the Industrial Revolution led to deep social upheaval. Even with the advancement of science, medicine, and technology during the two previous centu- ries, nineteenth-century public health measures continued to be unsophisticated. Organization and management of cities
The federal government’s early efforts for public health aimed to secure America’s maritime trade and major coastal cities by providing health care for merchant seamen and by protecting seacoast cities from epidemics. The U.S. Public Health Service, still the most important federal public health agency in the twenty-first century, was established in 1798 as the Marine Hospital Service. The first Marine Hospital opened in Norfolk, Virginia, in 1800. Additional legislation to establish quarantine regulations for seamen and immigrants was passed in 1878.
During the early 1800s, experiments in providing nursing care at home focused on moral improvement and less on illness intervention. The Ladies’ Benevolent Society of Charleston, South Carolina, provided charitable assistance to the poor and sick beginning in 1813. In Philadelphia, following a brief train- ing program, lay nurses cared for postpartum women and new- borns in their homes. In Cincinnati, Ohio, the Roman Catholic Sisters of Charity began a visiting nurse service in 1854 (Rod- abaugh and Rodabaugh, 1951). Although these early programs provided services at the local level, they were not adopted else- where and their influence on later public health nursing is unclear.
During the mid-nineteenth century, national interest increased for addressing public health problems and improving urban living conditions. New responsibilities for urban boards of health reflected changing ideas of public health, and these boards began to address communicable diseases and environ- mental hazards. Soon after it was founded in 1847, the Ameri- can Medical Association (AMA) formed a hygiene committee to conduct sanitary surveys and to develop a system to collect vital statistics. The Shattuck Report, published in 1850 by the Massachusetts Sanitary Commission, called for major innova- tions: The establishment of a state health department and local health boards in every town; sanitary surveys and collection of vital statistics; environmental sanitation; food, drug, and com- municable disease control; well-child care; health education; tobacco and alcohol control; town planning; and the teaching of preventive medicine in medical schools (Kalisch and Kalisch, 2004). However, these recommendations were not implemented even in Massachusetts until 1869, and in other states much later.
FIG 2-1 A New Orleans nurse visiting a family on the doorstep of their home. (Courtesy of the New Orleans Public Library WPA Photograph Collection.)
Year Milestone
2003 Public Health Nursing Competencies finalized by the Quad Council of Public Health Nursing Organizations 2003–2005 Multiple natural disasters including earthquakes, tsunamis, and hurricanes demonstrate the weak infrastructure for managing disasters in the
United States and other countries and emphasize the need for strong public health programs that included disaster management 2007 An entirely new Public Health Nursing: Scope and Standards of Practice is released through the ANA, reflecting the efforts of the Quad Council of
Public Health Nursing Organizations 2010 The Patient Protection and Affordable Care Act is signed by President Barack Obama 2012 The Association of State and Territorial Directors of Nursing (ASTDN) becomes the Association of Public Health Nurses (APHN) 2013 The revised Public Health Nursing: Scope and Standards of Practice, prepared by representatives of the Quad Council of Public Health Nursing
Organizations, is released by the American Nurses Association
TABLE 2-1 Milestones in the History of Public Health and Community Health Nursing: 1601 to 2014—cont’d
APHA, American Public Health Association; BSN, Bachelor of Science in Nursing; NCNR, National Center for Nursing Research; NYC, New York City.
27CHAPTER 2 History of Public Health and Public and Community Health Nursing
connections, and knowledge of hospitals, the British govern- ment sent her 40 ladies, 117 hired nurses, 15 paid servants, and extensive supplies for patient care.
In Scutari, Nightingale progressively improved soldiers’ health outcomes, using a population-based approach that strengthened environmental conditions and nursing care. Using simple epidemiological measures, she documented a decreased mortality rate from 415 per 1000 men at the beginning of the war to 11.5 per 1000 at the end (Palmer, 1983; Cohen, 1984). Paralleling Nightingale’s efforts, public health nurses typically identify health care needs that affect the entire population, mobilize resources, and organize themselves and the commu- nity to meet these needs.
Nightingale’s fame was established even before she returned to England in 1856 after the Crimean War. She then reorganized hospital nursing practice and established hospital-based nursing education to replace untrained lay nurses with trained Night- ingale nurses. Nightingale also emphasized public health nursing: “The health of the unity is the health of the commu- nity. Unless you have the health of the unity, there is no community health” (Nightingale, 1894/1984, p. 455). She dif- ferentiated “sick nursing” from “health nursing.” The latter emphasized that nurses should strive to promote health and prevent illness. Nightingale (1859/1946, p. v) wrote that the task of nurses is to “put the constitution in such a state as that it will have no disease, or that it can recover from disease.” Proper nutrition, rest, sanitation, and hygiene were necessary for health. Nurses continue to focus on the vital role of health promotion, disease prevention, and environment in their practice with indi- viduals, families, and communities.
Nightingale’s contemporary and friend, British philanthro- pist William Rathbone, founded the first district nursing asso- ciation in Liverpool, England. Rathbone’s wife had received outstanding nursing care from a Nightingale-trained nurse during her terminal illness at home. He wanted to offer similar care to relieve the suffering of poor persons unable to afford private nurses. With Rathbone’s advocacy and economic support between 1859 and 1862, the Liverpool Relief Society divided the city into nursing districts and assigned a committee of “friendly visitors” to each district to provide health care to needy people (Kalisch and Kalisch, 2004). Building on the Liv- erpool experience, Rathbone and Nightingale recommended steps to provide nursing in the home, leading to the organiza- tion of district nursing throughout England. Florence Sarah Lees Craven shaped the profession through her book A Guide to District Nurses, which highlighted, for example, that nursing care during the illness of one family member provided the nurse with influence to improve the entire family’s health status (Craven, 1889/1984).
AMERICA NEEDS TRAINED NURSES As urbanization increased during the Industrial Revolution in the 1800s, the number of occupations for American women rapidly increased. Educated women became elementary school teachers, secretaries, or saleswomen. Less educated women worked in factories of all kinds. The idea of becoming a trained
improved slowly, and many areas lacked systems of sewage disposal and depended on private enterprise for water supply. Previous caregiving structures, which relied on the assistance of family, neighbors, and friends, became inadequate in the early nineteenth century because of human migration, urbanization, and changing demand. During this period, a few groups of Roman Catholic and Protestant women provided nursing care for the sick, poor, and neglected in institutions and sometimes in the home. For example, Mary Aikenhead, also known by her religious name Sister Mary Augustine, organized the Irish Sisters of Charity in Dublin (Ireland) in 1815. These sisters visited the poor at home and established hospitals and schools (Kalisch and Kalisch, 2004).
In nineteenth-century England, the Elizabethan Poor Law continued to guarantee medical care for all. This minimal care, provided most often in almshouses supported by local govern- ment, sought as much to regulate where the poor could live as to provide care during illness. Many women who performed nursing functions in almshouses and early hospitals in Great Britain were poorly educated, untrained, and often undepend- able. As the practice of medicine became more complex in the mid-1800s, hospital work required skilled caregivers. Physicians and hospital administrators sought to advance the practice of nursing. Early innovations yielded some improvement in care, but Florence Nightingale’s efforts were revolutionary.
Florence Nightingale’s vision for trained nurses and her model of nursing education influenced the development of pro- fessional nursing and, indirectly, public health nursing in the United States. In 1850 and 1851, Nightingale had carefully studied nursing “system and method” by visiting Pastor Theodor Fliedner at his School for Deaconesses in Kaiserswerth, Germany. Pastor Fliedner also built on the work of others, including Men- nonite deaconesses in the Netherlands who were engaged in parish work for the poor and the sick, and Elizabeth Fry, the English prison reformer. Thus mid-nineteenth century efforts to reform the practice of nursing drew on a variety of interact- ing innovations across Europe.
The Kaiserswerth Lutheran deaconesses incorporated care of the sick in the hospital with client care in their homes, and their system of district nursing spread to other German cities. Amer- ican requests for the deaconesses to respond to epidemics of typhus and cholera in Pittsburgh provided only temporary assistance because local women were uninterested in joining the work. The early efforts of the Lutheran deaconesses in the United States ultimately focused on developing systems of insti- tutional care (Nutting and Dock, 1935).
Nightingale also found a way to implement her ideas about nursing practice. During the Crimean War (1854–1856) between the alliance of England and France against Russia, the British military established hospitals for sick and wounded soldiers at Scutari (now Üsküdar, in modern Istanbul). The care of sick and wounded soldiers was severely deficient, with cramped quarters, poor sanitation, lice and rats, insufficient food, and inadequate medical supplies (Palmer, 1983; Kalisch and Kalisch, 2004). When the British public demanded improved condi- tions, Nightingale sought and received an appointment to address the chaos. Because of her wealth, social and political
28 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
Nursing interventions, improved sanitation, economic improvements, and better nutrition were credited with reduc- ing the incidence of acute communicable disease by 1910. New scientific explanations of communicable disease suggested that preventive education would reduce illness. Through home visits and well-baby clinics, the visiting nurse became the key to communicating this prevention campaign. Visiting nurses worked with physicians, gave selected treatments, and kept tem- perature and pulse records. Visiting nurses emphasized educa- tion of family members in the care of the sick and in personal and environmental prevention measures, such as hygiene and good nutrition. Most public health nursing practice in the early twentieth century was generalized practice with diverse respon- sibilities. Only a few public health nurses had a specialized practice, such as caring only for patients with tuberculosis or working only in an occupational health practice. Public health nurses also established settlement houses—neighborhood centers that became hubs for health care, education, and social welfare programs. For example, in 1893 Lillian Wald and Mary Brewster, both trained nurses, began visiting the poor on New York’s Lower East Side. The nurses’ settlement they established became the Henry Street Settlement and later the Visiting Nurse Service of New York City. By 1905 the public health nurses had provided almost 48,000 visits to more than 5000 clients (Kalisch and Kalisch, 2004). Other settlement houses influenced the growth of public health nursing including the Richmond (Vir- ginia) Nurses’ Settlement, which became the Instructive Visiting Nurse Association; the Nurses’ Settlement in Orange, New Jersey; and the College Settlement in Los Angeles, California. See the box below for a photo of Lillian Wald (Figure 2-2).
Lillian Wald emerged as the key leader of public health nursing during its early decades. Wald took steps to increase access to public health nursing services nationally through insightful innovations: She persuaded the American Red Cross to sponsor rural health nursing services across the country, which stimulated local governments to sponsor public health nursing through county health departments. Beginning in 1909, Wald worked with Dr. Lee Frankel of the Metropolitan Life Insurance Company (MetLife) to implement the first insurance payment for nursing services. She argued that keeping working people and their families healthier would increase their produc- tivity. MetLife found that nursing care for communicable dis- eases, injuries, and mothers and children reduced mortality and saved money for this life insurance company. MetLife nursing services continued for 44 years, with successes such as (1) pro- viding home nursing services on a fee-for-service basis, (2) establishing an effective cost-accounting system for visiting nurses, and (3) reducing mortality from infectious diseases.
Convinced that environmental conditions as well as social conditions were the causes of ill health and poverty, Wald became actively involved in using epidemiological methods to campaign for health-promoting social policies. She advocated for creation of the U.S. Children’s Bureau as a basis for improv- ing the health and education of children nationally. She fought for better tenement living conditions in New York City, city recreation centers, parks, pure food laws, graded classes for mentally handicapped children, and assistance to immigrants.
nurse increased in popularity when Nightingale’s successes became known across the United States. During the 1870s, the first nursing schools based on the Nightingale model opened in the United States.
Trained nurse graduates of the early schools for nurses in the United States usually worked in private duty nursing or held the few positions as hospital administrators or instructors. Private duty nurses might live with families of clients receiving care, to be available 24 hours a day. Although the trained nurse’s role in improving American hospitals was very clear, the cost of private duty nursing care for the sick at home was prohibitive for all but the wealthy.
The care of the sick poor at home was made more economi- cal by using home-visiting nurses who would attend several families in a day, rather than only one patient as the private duty nurse did. In 1877 the Women’s Board of the New York City Mission hired Frances Root, a graduate of Bellevue Hospital’s first nursing class, to visit sick poor persons to provide nursing care and religious instruction (Bullough and Bullough, 1964). In 1878 the Ethical Culture Society of New York hired four nurses to work in dispensaries, a type of community-based clinic. In the next few years, visiting nurse associations (VNAs) were established in Buffalo, New York (1885), Philadelphia (1886), and Boston (1886). Wealthy people interested in chari- table activities funded both settlement houses and VNAs. Upper-class women, freed of some of the social restrictions that had previously limited their public life, participated in the char- itable work of creating, supporting, and supervising the new visiting nurses.
Public health nursing in the United States began with orga- nizing to meet urban health care needs, especially for the disad- vantaged. The public was interested in limiting disease among all classes of people, not only for religious reasons as a form of charity, but also because the middle and upper classes feared the impact of communicable diseases believed to originate in the large communities of new European immigrants. In New York City in the 1890s, about 2.3 million people lived in 90,000 tene- ment houses. Deplorable environmental conditions for immi- grants in urban tenement houses and sweatshops were common across the northeastern United States and upper Midwest. People living in poor housing conditions were ravaged by epi- demics of communicable diseases, including typhus, scarlet fever, smallpox, and typhoid fever; in the nineteenth century, tuberculosis was the leading cause of infectious disease mortal- ity (Kalisch and Kalisch, 2004). From the beginning, nursing practice in the community included teaching and prevention.
For example, in 1886 two Boston women approached the Women’s Education Association to seek local support for dis- trict nursing. To increase the likelihood of financial support, they used the term instructive district nursing to emphasize the relationship of nursing to health education. The Boston Dis- pensary provided support in the form of free outpatient medical care. In 1886 the first district nurse was hired, and in 1888 the Instructive District Nursing Association became incorporated as an independent voluntary agency. Sick poor persons, who paid no fees, were cared for under the direction of a trained physician (Brainard, 1922).
29CHAPTER 2 History of Public Health and Public and Community Health Nursing
the nation (Waters, 1909). In 1901 New York City alone had 58 different organizations with 372 trained nurses providing care in the community. Despite the numbers, 68% of visiting nurses nationally were employed in single-nurse agencies. In addition to VNAs and settlement houses, a variety of other organizations sponsored visiting nurse work, including boards of education, boards of health, mission boards, clubs, churches, social service agencies, and tuberculosis associations. With tuberculosis then responsible for at least 10% of all mortality, visiting nurses contributed to its control through gaining “the personal coop- eration of patients and their families” to modify the environ- ment and individual behavior (Buhler-Wilkerson, 1987, p. 45). Most visiting nurse agencies depended financially on the phi- lanthropy and social networks of metropolitan areas. As today, fund-raising and service delivery in less densely populated and rural areas was challenging.
The American Red Cross, through its Rural Nursing Service (later the Town and Country Nursing Service), provided a framework to initiate home nursing care in areas outside larger cities. Wald secured initial donations to support this agency, which provided care of the sick and instruction in sanitation and hygiene in rural homes. The agency also improved living conditions in villages and isolated farms. The Town and Country nurse dealt with diseases such as tuberculosis, pneumonia, and typhoid fever with a resourcefulness born of necessity. The rural nurse might use hot bricks, salt, or sandbags to substitute for hot water bottles; chairs as back-rests for the bedbound; and boards padded with quilts as stretchers (Kalisch and Kalisch, 2004). In the two years after World War I, the 100 existing Red Cross Town and Country Nursing Services expanded to 1800, and eventually to almost 3000 programs in small towns and rural areas. This service demonstrated the importance and fea- sibility of public health nursing across the country at local and county levels. Once established, ongoing responsibilities for these new agencies were passed on to local voluntary agencies or local government support.
Occupational health nursing began as industrial nursing and was a true outgrowth of early home-visiting efforts. In 1895 Ada Mayo Stewart began work with employees and families of the Vermont Marble Company in Proctor, Vermont. As a free service for the employees, Stewart provided obstetric care, sick- ness care (e.g., for typhoid cases), and some postsurgical care in workers’ homes. Although her employer provided a horse and buggy, she often made home visits on a bicycle. Unlike contemporary occupational health nurses, Stewart provided few services for work-related injuries. Before 1900 a few nurses were hired in industry, such as in department stores in Phila- delphia and Brooklyn. Between 1914 and 1943, industrial nursing grew from 60 to 11,220 nurses, reflecting increased governmental and employee concerns for health and safety in the workplace (American Association of Industrial Nurses, 1976; Kalisch and Kalisch, 2004).
SCHOOL NURSING IN AMERICA In New York City in 1902, more than 20% of children might be absent from school on a single day. The children suffered from
She firmly believed in women’s suffrage and considered its acceptance in 1917 in New York State to be a great victory. Wald supported efforts to improve race relations and championed solutions to racial injustice. She wrote The House on Henry Street (Wald, 1915) and Windows on Henry Street (Wald, 1934) to describe this public health nursing work.
Many public health nurses contributed to the development of the profession, including Jessie Sleet (Scales), a Canadian graduate of Provident Hospital School of Nursing (Chicago), who was the first African-American public health nurse; Ms. Sleet was hired by the New York Charity Organization Society in 1900. Although it proved difficult for her to find an agency willing to hire her as a district nurse, she persevered and was able to provide exceptional care for her clients until she married in 1909. At the Charity Organization Society in 1904 to 1905, she studied health conditions related to tuberculosis among African-American people in Manhattan, using interviews with families and neighbors, house-to-house canvases, direct obser- vation, and speeches at neighborhood churches. Sleet reported her research to the Society board, recommending improved employment opportunities for African-Americans and better prevention strategies to reduce the excess burden of tuberculo- sis morbidity and mortality among the African-American population (Thoms, 1929; Hine, 1989; Mosley, 1994; Buhler- Wilkerson, 2001).
In 1909 Yssabella Waters published her survey, Visiting Nursing in the United States, which documented the concentra- tion of visiting nurse services in the northeastern quadrant of
FIG 2-2 Lillian Wald. (Courtesy of the Visiting Nurse Service of New York.)
30 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
American Red Cross provided scholarships for training school graduates to attend the public health nursing course. Its success encouraged the development of other programs, using curri- cula that might seem familiar to today’s nurses. During the 1920s and 1930s, many newly hired public health nurses had to verify completion or promptly enroll in a certificate program in public health nursing. Others took leave for a year to travel to an urban center to obtain this further education.
Public health nurses were also active in the American Public Health Association (APHA), which had been established in 1872 to facilitate interprofessional efforts and promote the “practical application of public hygiene” (Scutchfield and Keck, 1997, p. 12). The APHA targeted reform efforts toward contem- porary public health issues, including sewage and garbage dis- posal, occupational injuries, and sexually transmitted diseases. In 1923 the Public Health Nursing Section was formed within the APHA to provide a forum for nurses to discuss their con- cerns and strategies within the larger APHA. The PHN Section continues to serve as a focus of leadership and policy develop- ment for public health nursing in the twenty-first century.
PUBLIC HEALTH NURSING IN OFFICIAL HEALTH AGENCIES AND IN WORLD WAR I Public health nursing in voluntary agencies and through the Red Cross grew more quickly than public health nursing in official agencies, those sponsored by state, local, and national government. By 1900, 38 states had established state health departments; however, these early state boards of health had limited impact. Only three states—Massachusetts, Rhode Island, and Florida—annually spent more than 2 cents per capita for public health services (Scutchfield and Keck, 1997).
The federal role in public health gradually expanded. In 1912 the federal government redefined the role of the U.S. Public Health Service, empowering it to “investigate the causes and spread of diseases and the pollution and sanitation of navigable streams and lakes” (Scutchfield and Keck, 1997, p. 15). The NOPHN loaned a nurse to the U.S. Public Health Service during World War I to establish a public health nursing program for military outposts. This led to the first federal government spon- sorship of nurses (Shyrock, 1959; Wilner et al, 1978).
During the 1910s, public health organizations began to target infectious and parasitic diseases in rural areas. The Rock- efeller Sanitary Commission, a philanthropic organization active in hookworm control in the southeastern United States, concluded that concurrent efforts for all phases of public health were necessary to successfully address any individual public health problem (Pickett and Hanlon, 1990). For example, in 1911, efforts to control typhoid fever in Yakima County, Wash- ington, and to improve health status in Guilford County, North Carolina, led to the establishment of local health units to serve local populations. Public health nurses were the primary staff members of local health departments. These nurses assumed a leadership role on health care issues through collaboration with local residents, nurses, and other health care providers.
The experience of Orange County, California, during the 1920s and 1930s illustrates the role of the public health nurse
the common conditions of pediculosis, ringworm, scabies, inflamed eyes, discharging ears, and infected wounds. Physi- cians began to make limited inspections of school students in 1897, but they focused on excluding sick children from school rather than on providing or obtaining medical treatment to enable children to return to school. Familiar with this community-wide problem from her work with the Henry Street Nurses’ Settlement, Lillian Wald sought to place nurses in the schools and gained consent from the city’s health commissioner and the Board of Education for a 1-month demonstration project.
Lina Rogers, a Henry Street Settlement resident, became the first school nurse. She worked with the children in New York City schools and made home visits to instruct parents and to follow up on children excluded or otherwise absent from school. The school nurses found that “many children were absent for lack of shoes or clothing, because of malnourishment, or because they were serving their families as babysitters” (Hawkins et al, 1994, p. 417). The school nurse experiment made such a significant and positive impact that it became permanent, with 12 more nurses appointed 1 month later. School nursing was soon implemented in Los Angeles, Philadelphia, Baltimore, Boston, Chicago, and San Francisco.
THE PROFESSION COMES OF AGE Established by the Cleveland Visiting Nurse Association in 1909, the Visiting Nurse Quarterly initiated a professional communi- cation medium for clinical and organizational concerns. In 1911 a joint committee of existing nurse organizations con- vened to standardize nursing services outside the hospital. Under the leadership of Lillian Wald and Mary Gardner, the committee recommended forming a new organization to address public health nursing concerns. Eight hundred agencies involved in public health nursing were invited to send delegates to a June 1912 organizational meeting in Chicago. After a heated debate on its name and purpose, the delegates established the National Organization for Public Health Nursing (NOPHN) and chose Wald as its first president (Dock, 1922). Unlike other professional nursing organizations, the NOPHN membership included both nurses and their non-nurse supporters. The NOPHN sought “to improve the educational and services stan- dards of the public health nurse, and promote public under- standing of and respect for her work” (Rosen, 1958, p. 381). With greater administrative resources than other contemporary national nursing organizations, the NOPHN was soon the dom- inant force in public health nursing (Roberts, 1955).
The NOPHN also sought to standardize public health nursing education. Visiting nurse agencies found that hospital training school graduates were unprepared for home visiting. Hospital training schools emphasized hospital care of sick patients, but public health nurses required additional educa- tional preparation to provide services through home-visiting and population-focused programs. In 1914, in affiliation with the Henry Street Settlement, Mary Adelaide Nutting began the first post–training-school course in public health nursing at Teachers College in New York City (Deloughery, 1977). The
31CHAPTER 2 History of Public Health and Public and Community Health Nursing
Nursing efforts to influence public policy bridged World War I, including advocacy for the Children’s Bureau and the Sheppard-Towner Program. Responding to lengthy advocacy by Wald and other nurse leaders, the Children’s Bureau was estab- lished in 1912 to address national problems of maternal and child welfare. Children’s Bureau experts conducted extensive scientific research on the effects of income, housing, employ- ment, and other factors on infant and maternal mortality. Their research led to federal child labor laws and the 1919 White House Conference on Child Health.
Problems of maternal and child morbidity and mortality spurred the passage of the Maternity and Infancy Act (often called the Sheppard-Towner Act) in 1921. This act provided federal matching funds to establish maternal and child health divisions in state health departments. Education during home visits by public health nurses stressed promoting the health of mother and child as well as seeking prompt medical care during pregnancy. Although credited with saving many lives, the Sheppard-Towner Program ended in 1929 in response to charges by the AMA and others that the legislation gave too much power to the federal government and too closely resem- bled socialized medicine (Pickett and Hanlon, 1990). Federal funding during the 1930s and 1940s established maternal-child health programs that continued some of the successes of Sheppard-Towner.
Some nursing innovations were the result of individual com- mitment and private financial support. In 1925 Mary Breckin- ridge established the Frontier Nursing Service (FNS), based on systems of care used in the Highlands and islands of Scotland. The unique pioneering spirit of the FNS influenced the devel- opment of public health programs geared toward improving the health care of the rural and often inaccessible populations in the Appalachian region of southeastern Kentucky (Browne, 1966; Tirpak, 1975). Breckinridge introduced the first nurse- midwives into the United States when she deployed FNS nurses trained in nursing, public health, and midwifery. Their efforts led to reduced pregnancy complications and maternal mortal- ity, and to one-third fewer stillbirths and infant deaths in an area of 700 square miles (Kalisch and Kalisch, 2004). The early efforts of the Frontier Nursing Service are recorded in the book, Wide Neighborhoods (Breckinridge, 1952). Today the FNS con- tinues to provide comprehensive health and nursing services to the people of that area and sponsors Frontier Nursing Univer- sity, which provides advanced practice nursing education for midwifery and other specialties.
AFRICAN-AMERICAN NURSES IN PUBLIC HEALTH NURSING African-American nurses seeking to work in public health nursing faced many challenges. Nursing education was abso- lutely segregated in the South until at least the 1960s, and elsewhere was also generally segregated or rationed until mid- century. Even public health nursing certificate and graduate education programs were segregated in the South; study outside the South for southern nurses was difficult to afford and study leaves from the workplace were rarely granted. The situation
in these new local health departments. Following the efforts of a private physician, social welfare agencies, and a Red Cross nurse, the county board created the public health nurse’s posi- tion, which began in 1922. Presented with a shining new Model T car sporting the bright orange seal of the county, the nurse focused on the serious communicable disease problems of diphtheria and scarlet fever. Typhoid became epidemic when a drainage pipe overflowed into a well, infecting those who drank the well water or raw milk from an infected dairy. Almost 3000 residents were immunized against typhoid. Weekly well-baby conferences provided an opportunity for mothers to learn about care of their infants, and the infants were weighed and given communicable disease immunizations. Children with orthopedic disorders and other disabilities were identified and referred for medical care in Los Angeles. At the end of a suc- cessful first year of public health nursing work, the Rockefeller Foundation and the California Health Department recognized the favorable outcomes and provided funding for more public health professionals.
The personnel needs of World War I in Europe depleted the ranks of public health nurses, at the same time the NOPHN had identified a need for more public health nurses within the United States. Jane Delano of the Red Cross (which was sending 100 nurses a day to the war) agreed that despite the sacrifice, the greatest patriotic duty of public health nurses was to stay at home. In 1918 the worldwide influenza pandemic swept the United States from coast to coast within 3 weeks, and was met by a coalition of the NOPHN and the Red Cross. Houses, churches, and social halls were turned into hospitals for the immense numbers of sick and dying. Some of the nurse volun- teers died of influenza as well (Shyrock, 1959; Wilner et al, 1978).
PAYING THE BILL FOR PUBLIC HEALTH NURSES Inadequate funding was the major obstacle to extending nursing services in the community. Most early VNAs sought charitable contributions from wealthy and middle-class supporters. Even poor families were encouraged to pay a small fee for nursing services, reflecting social welfare concerns against promoting economic dependency by providing charity. In 1909, as a result of Wald’s collaboration with Dr. Lee Frankel, the Metropolitan Life Insurance Company began a cooperative program with visiting nurse organizations that expanded availability of public health nursing services. The nurses assessed illness, taught health practices, and collected data from policyholders. By 1912, 589 Metropolitan Life nursing centers provided care through existing agencies or through visiting nurses hired directly by the Company. In 1918 Metropolitan Life calculated an average decline of 7% in the mortality rate of policyholders and almost a 20% decline in the mortality rate of policyholders’ children under age 3. The insurance company attributed this improve- ment and their reduced costs to the work of visiting nurses. Voluntary health insurance was still decades in the future; public and professional efforts to secure compulsory health insurance seemed promising in 1916, but had evaporated by the end of World War I.
32 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
elsewhere, the Relief Nursing Service had a dual purpose—to assist unemployed nurses and to provide nursing care for fami- lies on relief. Fundamental services included “(1) providing bedside care and health supervision for the family in the home; (2) arranging for medical and hospital care for emergency and obstetric cases; (3) supervising the health of children in emer- gency relief nursery schools; and (4) caring for patients with tuberculosis” (Kalisch and Kalisch, 2004, p. 283).
In another Depression-era program, more than 10,000 nurses were employed by the Civil Works Administration (CWA) and assigned to official health agencies. “While this facilitated rapid program expansion by recipient agencies and gave the nurses a taste of public health, the nurses’ lack of field experience created major problems of training and supervision for the regular staff ” (Roberts and Heinrich, 1985, p. 1162).
A 1932 survey of public health agencies found that only 7% of nurses employed in public health were adequately prepared (Roberts and Heinrich, 1985). Basic nursing education focused heavily on the care of individuals, and students received limited information on groups and the community as a unit of service. Thus in the 1930s and early 1940s, new hospital training school graduates continued to be inadequately prepared to work in public health and required considerable remedial orientation and education from the hiring agencies (NOPHN, 1944).
Public health nurses continued to weigh the relative value of preventive care compared with bedside care of the sick. They also questioned whether nursing interventions should be directed toward groups and communities, or toward individuals and their families. Although each nursing agency was unique and services varied from region to region, voluntary VNAs tended to emphasize care of the sick, whereas official public health agencies provided more preventive services. Compared with nursing in VNAs, nurses in official agencies may have had less control over their practice roles because physicians and politicians often determined services and personnel assign- ments in public health departments. See Figure 2-1 for a photo of a nurse making a home visit to a family in New Orleans.
Not surprisingly, the conflicting visions and splintering of services between “visiting” and “public health” nurses further impeded development of comprehensive population-centered nursing services (Roberts and Heinrich, 1985). In addition, some households received services from several community nurses representing several agencies, for example, visits to the same home (1) for a postpartum woman and new baby, (2) for a child sick with scarlet fever, and (3) for an older adult sick in bed. Nurses believed that multiple caregivers and agencies con- fused families and duplicated scarce nursing resources. Interest grew in the “combination service”—the merger of sick care services and preventive services into one comprehensive agency, administered jointly between a voluntary agency and an official health agency.
INCREASING FEDERAL ACTION FOR THE PUBLIC’S HEALTH Expansion of the federal government during the 1930s affected the structure of community health resources. Credited as “the
improved somewhat in 1936, when collaboration between the U.S. Public Health Service and the Medical College of Virginia (Richmond) established a certificate program in public health nursing for African-American nurses, with tuition provided by the federal government. Discrimination continued during nurses’ employment: African-American nurses in the American South were paid significantly lower salaries than their white counterparts for the same work. In 1925 just 435 African- American public health nurses were employed in the United States, and in 1930 only 6 African-American nurses held super- visory positions in public health nursing organizations (Thoms, 1929; Hine, 1989; Buhler-Wilkerson, 2001).
African-American public health nurses had a significant impact on the communities they served. The National Health Circle for Colored People was organized in 1919 to promote public health work in African-American communities in the South. One approach provided scholarships to assist African- American nurses to pursue university-level public health nursing education. Bessie B. Hawes, the first recipient of the scholarship, completed the Columbia University program in New York City. The Circle sent Hawes to Palatka, Florida, a small, isolated lumber town. Hawes’ first project recruited local school girls to promote health by dressing as nurses and march- ing in a parade while singing community songs. She conducted mass meetings, led mother’s clubs, provided school health edu- cation, and visited the homes of the sick. Eventually she gained the community’s trust, overcame opposition, and built a health center for nursing care and treatment (Thoms, 1929).
BETWEEN THE TWO WORLD WARS: ECONOMIC DEPRESSION AND THE RISE OF HOSPITALS The economic crisis during the Depression of the 1930s deeply influenced the development of nursing. Not only were agencies and communities unprepared to address the increased needs and numbers of the impoverished, but decreased funding for nursing services reduced the number of employed nurses in hospitals and in community agencies. The NOPHN’s tenacious effort to ensure inclusion of public health nursing in federal relief programs secured success after a flurry of last-minute telegrams and lobbying efforts. Federal funding led to a wide variety of programs administered at the state level, including new public health nursing programs.
The Federal Emergency Relief Administration (FERA) sup- ported nurse employment through increased grants-in-aid for state programs of home medical care. FERA often purchased nursing care from existing visiting nurse agencies, thus support- ing more nurses and preventing agency closures. The FERA program varied among states; the state FERA program in New York emphasized bedside nursing care, whereas in North Caro- lina, the state FERA prioritized maternal and child health, and school nursing services. Some Depression-era federal programs built new services; public health nursing programs of the Works Progress Administration (WPA) were sometimes later incorpo- rated into state health departments. In West Virginia, as
33CHAPTER 2 History of Public Health and Public and Community Health Nursing
the U.S. Public Health Service, the Nursing Council for National Defense received $1 million to expand facilities for nursing education. Additional programs that expanded both the total number of nurses and the number of nurses with preparation in public health nursing included the Training for Nurses for National Defense, the GI Bill, the Nurse Training Act of 1943, and Public Health and Professional Nurse Traineeships (McNeil, 1967).
As more and more nurses and physicians left civilian hospi- tals to meet the needs of the war, responsibility for client care was shifted to families, non-nursing personnel, and volunteers. “By the end of 1942, over 500,000 women had completed the American Red Cross home nursing course, and nearly 17,000 nurse’s aides had been certified” (Roberts and Heinrich, 1985, p. 1165). By the end of 1946, more than 215,000 volunteer nurse’s aides had received certificates.
In some cases, public health nursing expanded its scope of practice during World War II. For example, nurses increased their presence in rural areas, and many official agencies began to provide bedside nursing care (Buhler-Wilkerson, 1985; Kalisch and Kalisch, 2004). The federal Emergency Maternity and Infant Care Act of 1943 (EMIC) provided funding for medical, hospital, and nursing care for the wives and babies of servicemen. Health services seeking EMIC funds were required to meet the high standards of the U.S. Children’s Bureau, which resulted in increased quality of care for all. In other situations, nursing roles were constrained by wartime and postwar nursing shortages. For example, the Visiting Nurse Society of Philadel- phia ceased home birth services, drastically reduced industrial nursing services, and deferred care for the long-term chroni- cally ill client.
Reflecting the complex social changes that had occurred during the war years, in the late 1940s local health departments faced sudden increases in client demand for care of emotional problems, accidents, alcoholism, and other responsibilities new to the domain of official health agencies. Changes in medical technology offered new possibilities for screening and treat- ment of infectious and communicable diseases, such as antibi- otics to treat rheumatic fever and venereal diseases, and photofluorography for mass case finding of pulmonary tuber- culosis. Local health departments expanded, both to address underserved areas and to expand types of services, and they often fared better economically than voluntary agencies.
Job opportunities for public health nurses grew because they continued to constitute a large proportion of health department personnel. Between 1950 and 1955, the proportion of U.S. counties with full-time local health services increased from 56% to 72% (Roberts and Heinrich, 1985). With more than 20,000 nurses employed in health departments, VNAs, industry, and schools, public health nurses at the middle of the twentieth century continued to have a crucial role in translating the advances of science and medicine into saving lives and improv- ing health.
In 1946, representatives of agencies interested in community health met to improve coordination of various types of com- munity nursing and to prevent overlap of services. The resulting guidelines proposed that a population of 50,000 be required to
beginning of a new era in public nursing” (Roberts and Hein- rich, 1985, p. 1162), Pearl McIver in 1933 became the first nurse employed by the U.S. Public Health Service. In providing con- sultation services to state health departments, McIver was con- vinced that the strengths and ability of each state’s director of public health nursing would determine the scope and quality of local health services. Together with Naomi Deutsch, director of nursing for the federal Children’s Bureau, and with the support of nursing organizations, McIver and her staff of nurse consultants influenced the direction of public health nursing. Between 1931 and 1938, greater than 40% of the increase in public health nurse employment was in local health agencies. Even so, nationally more than one-third of all counties still lacked local public health nursing services.
The Social Security Act of 1935 was designed to prevent reoccurrence of the problems of the Depression. Title VI of this act provided funding for expanded opportunities for health protection and promotion through education and employment of public health nurses. More than 1000 nurses completed educational programs in public health in 1936. Title VI also provided $8 million to assist states, counties, and medical districts in the establishment and maintenance of adequate health services, as well as $2 million for research and investiga- tion of disease (Buhler-Wilkerson, 1985, 1989; Kalisch and Kalisch, 2004).
A categorical approach to federal funding for public health services reflected the U.S. Congress’s preference for funding specific diseases or specific groups, rather than providing dollar allocations to local agencies. In categorical funding, resources are directed toward specific priorities rather than toward a comprehensive community health program. When funding is directed by established national preferences, it becomes more difficult to respond to local and emerging problems. Even so, local health departments shaped their programs according to the pattern of available funds, including maternal and child health services and crippled children (in 1935), venereal disease control (in 1938), tuberculosis (in 1944), mental health (in 1947), industrial hygiene (in 1947), and dental health (in 1947) (Scutchfield and Keck, 1997). Categorical funding continues to be a preferred federal approach to address national health policy objectives.
WORLD WAR II: EXTENSION AND RETRENCHMENT IN PUBLIC HEALTH NURSING The U.S. involvement in World War II in 1941 accelerated the need for nurses, both for the war effort and at home. The Nursing Council on National Defense was a coalition of the national nursing organizations that planned and coordinated activities for the war effort. National interests prioritized the health of military personnel and workers in essential indus- tries. Many nurses joined the Army and Navy Nurse Corps. Through the influence and leadership of U.S. Representative Frances Payne Bolton of Ohio, substantial funding was pro- vided by the Bolton Act of 1943 to establish the Cadet Nurse Corps, supporting increased enrollment in schools of nursing at undergraduate and graduate levels. Under management by
34 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
variously called housekeepers, homemakers, or home health aides. These innovative programs provided a substantial basis for an approach to bedside nursing care that would be reim- bursable by commercial health insurance (such as Blue Cross) and later by Medicare and Medicaid.
The increased prevalence of chronic illness also encouraged a resurgence in combination agencies—the joint operation of official (city or county) health departments and voluntary visit- ing nurse agencies by a unified staff. The nursing profession preferred that services be provided in a coordinated, cost- effective manner respectful to the families served, as well as to avoid duplication of care. Where nursing services were special- ized, one household might simultaneously receive care from three different agencies for postpartum and newborn care, tuberculosis follow-up, and stroke rehabilitation. In cities with combination agencies, a minimal number of nurses provided improved services, ensuring continuity of care at a cheaper price. No longer would an agency “pick up and drop a baby,” but instead would follow the child through infancy, preschool, school, and into adulthood as part of one public health nursing program using one client record. The “ideal program” of the combination agency proved difficult to fund and administer, and many of the combination services implemented between 1930 and 1965 later retrenched into their former divided, public and private structures.
During the 1950s, public health nursing practice, like nursing in general, increased its focus on the psychological elements of client, family, and community care. To be more effective as helping professionals, nurses sought improved understanding of their own behavior, as well as the behavior of their clients and their coworkers. The nurse’s responsibility for health and human needs expanded to include stress and anxiety reduction associated with situational or developmental stressors, such as birth, adolescence, and parenting. Public health nurses sought a comprehensive approach to mental health that avoided dividing persons into physical components and emotional components (Abramovitz, 1961). The following Evidence- Based Practice example traces the development of nursing and home health care in the United States.
DECLINING FINANCIAL SUPPORT FOR PRACTICE AND PROFESSIONAL ORGANIZATIONS During the 1930s and 1940s hospitals became the preferred place for illness care and childbirth. Improved technology and the concentration of physicians’ work in the acute care hospital were influential, but the development of health insurance plans such as Blue Cross provided a means for the middle class to seek care outside the traditional arena of the home. Federal health policy after World War II supported the growth of institutional care in hospitals and nursing homes rather than community- based alternatives. Figure 2-3 depicts a public health nurse speaking with a family on their porch. Home visiting although valuable to health care was not consistently supported by insur- ance companies.
support a public health program and that there should be 1 nurse for every 2200 people. Nursing functions should include health teaching, disease control, and care of the sick. Communi- ties were encouraged to adopt one of the following organiza- tional patterns (NOPHN, 1946): • Administration of all community health nurse services by
the local health department; • Provision of preventive health care by health departments,
and provision of home visiting for the sick by a cooperating voluntary agency; or
• A combination service jointly administered and financed by official and voluntary agencies with all services provided by one group of nurses.
THE RISE OF CHRONIC ILLNESS Between 1900 and 1955, the national crude mortality rate decreased by 47%. Many more Americans survived childhood and early adulthood to live into middle and older ages. Although in 1900 the leading causes of mortality were pneumonia, tuber- culosis, and diarrhea/enteritis, by mid-century the leading causes had become heart disease, cancer, and cerebrovascular disease. Nurses helped to reduce communicable disease mortal- ity through immunization campaigns, nutrition education, and provision of better hygiene and sanitation. Additional factors included improved medications, better housing, and innovative emergency and critical care services. Studies such as the National Health Survey of 1935-1936 had documented the national tran- sition from communicable to chronic disease as the primary cause of significant illness and death. However, public policy and nursing services were diverted from addressing the emerg- ing problem, first by the 1930s Depression and then by World War II.
As the aged population grew from 4.1% of the total in 1900, to 9.2% in 1950, so did the prevalence of chronic illness. Faced with a client population characterized by extended life spans and increased longevity after chronic illness diagnosis, nurses addressed new challenges related to chronic illness care, long- term illness and disability, and chronic disease prevention. In official health agencies, categorical programs focusing on a single chronic disease emphasized narrowly defined services, which might be poorly coordinated with other community pro- grams. Screening for chronic illness was a popular method of both detecting undiagnosed disease and providing individual and community education.
Some VNAs adopted coordinated home care programs to provide complex, long-term care to the chronically ill, often after long-term hospitalization. These home care programs established a multidisciplinary approach to complex client care. For example, beginning in 1949, the Visiting Nurse Society of Philadelphia provided care to clients with stroke, arthritis, cancer, and fractures using a wide range of services, including physical and occupational therapy, nutrition consultation, social services, laboratory and radiographic procedures, and transportation services. During the 1950s, often in response to family demands and the shortage of nurses, many visiting nurse agencies began experimenting with auxiliary nursing personnel,
35CHAPTER 2 History of Public Health and Public and Community Health Nursing
Financing for voluntary nursing agencies was greatly reduced in the early 1950s when both the Metropolitan and John Hancock Life Insurance Companies stopped funding visiting nurse services for their policyholders. The life insurance com- panies had found nursing services financially beneficial when communicable disease rates were high in the 1910s and 1920s, but reductions in communicable disease rates, improved infant and maternal health, and the increased prevalence of expensive chronic illnesses reduced sponsor interest in financing home visiting. The American Red Cross also discontinued its pro- grams of direct nursing service by the mid-1950s.
The NOPHN had long sought additional approaches for funding public health nursing. Beginning in the 1930s, the NOPHN collaborated with the American Nurses Association (ANA) through the Joint Committee on Prepayment. Both organizations had identified the growth potential of early health insurance innovations. Voluntary nursing agencies developed a variety of initiatives to secure health insurance reimbursement for nursing services, including demonstration projects and edu- cational campaigns directed toward nurses, physicians, and insurers. Blue Cross and other hospital insurance programs gradually adopted a formula that exchanged unused days of hospitalization coverage for postdischarge nursing care at home. Unlike organized medicine and hospital associations, nursing organizations contributed substantially to securing federal medical insurance for the aged, which was implemented as the Medicare program in 1966. The support of the ANA, so integral to the passage of Medicare legislation, was publicly recognized by President Lyndon Baines Johnson at the 1965 ceremony to sign the bill.
Despite the successes and importance of the NOPHN, by the late 1940s its membership had declined and financial support was weak. At the same time, the nursing profession as a whole sought to reorganize its national organizations to improve unity, administration, and financial stability. Three existing organizations—the NOPHN, the National League for Nursing Education, and the Association of Collegiate Schools of Nursing—were dissolved in 1952. Their functions were distrib- uted primarily to the new National League for Nursing. The American Nurses Association, which merged with the National Association of Colored Graduate Nurses, continued as the second national nursing organization. Occupational health nursing and nurse-midwifery organizations declined to join the consolidation, and both nursing specialties have continued to set their own course. School nurses also soon established a separate specialty organization. Despite the optimism of the national reorganization and its success in some areas, the sub- sequent loss of independent public health nursing leadership and focus resulted in a weakened specialty.
PROFESSIONAL NURSING EDUCATION FOR PUBLIC HEALTH NURSING The National League for Nursing enthusiastically adopted the recommendations of Esther Lucile Brown’s 1948 study of nursing education, reported as Nursing for the Future (Brown, 1948). Her recommendation to establish basic nursing
FIG 2-3 A public health nurse talks with a young woman and her mother about childbirth, as they sit on a porch. (U.S. Public Health Service photo by Perry, Images from the History of Medicine, National Library of Medicine, Image ID 157037.)
No Place Like Home: A History of Nursing and Home Care in the United States (Buhler-Wilkerson, 2001) is a book-length analysis of the development of nursing care for those at home. Buhler-Wilkerson traces how the care of the sick moved from a domestic function to a charitable or public responsibility provided through visiting nurse associations and official health agencies. The central dilemma she raises is, “why, despite its potential as a preferred, rational, and possibly cost-effective alternative to institutional care, home care remains a marginalized experiment in caregiving” (p. xi).
Buhler-Wilkerson follows the origins of home care from its beginnings in Charleston, South Carolina, to its expansion into northern cities at the end of the nineteenth century. She interprets the founding of public health nursing by Lillian Wald “as a new paradigm for community-based nursing practice within the context of social reform” (p. xii), and she particularly analyzes the effects of ethnicity, race, and social class. She traces the difficulties of orga- nizing and financing care of the sick in the home, including the work of private duty nurses and the role of health insurance in shaping home services. The concluding section of the book highlights contemporary themes of “chronic illness, hospital dominance, financial viability, and struggles to survive” (p. xii) and projects the future of home care.
Buhler-Wilkerson brings to bear the stories of patients’ needs and nurses’ work against the financial challenges that have characterized home care. While focusing on one element, this book raises important questions for nurses’ work across elements of community/public health nursing. Clearly identified need does not by itself open the doors to adequate financing for nursing care of the sick, for public health nursing, or for population care for health promotion.
Nurse Use This book points out the complex issues involved in trying to provide the most effective care to patients. The needs of patients and their families may not entirely correlate with what is financially available. A lesson for each of us to learn is the following: Identified need does not always influence the avail- ability of funds to provide the desired care.
EVIDENCE-BASED PRACTICE
From Buhler-Wilkerson K: No Place Like Home: A History of Nursing and Home Care in the United States. Baltimore, 2001, Johns Hopkins Press.
36 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
preparation in colleges and universities was consistent with the NOPHN’s goal of including public health nursing concepts in all basic baccalaureate programs. The NOPHN believed that this would remedy the preparation problems found among many nurses new to the practice and would thus upgrade the public health nursing profession. Unfortunately, the implemen- tation of the plan fell short, and training programs in public health nursing for college and university faculty were very brief and inadequate. The population focus of public health nursing toward groups and the larger community was compromised and became less distinct in the hands of educators who them- selves lacked education and practice in public health nursing.
During the 1950s, public health nursing educators carefully considered steps to enhance undergraduate and graduate edu- cation. Educational programs for public health nurses were then found in schools of nursing, schools of public health, and other university departments. Although all claimed legitimacy, collegiate education for nurses gradually moved completely into schools of nursing. The Haven Hill Conference (NOPHN, 1951) and Gull Lake Conference (Robeson and McNeil, 1957) clarified roles and definitions, built expectations for graduate education, and set standards for undergraduate field experi- ences. As public health nursing education drew closer to university schools of nursing, it adopted and applied broad principles characteristic of general nursing education. For example, rather than have the education director of the place- ment agency teach nursing students as done previously, colle- giate programs themselves hired faculty who provided direct student supervision at community placements (NOPHN, 1951; Robeson and McNeil, 1957). The How To box describes the way to conduct an oral history interview in order to preserve vital information about public health nursing.
HOW TO Nurse historians are increasingly using oral history methodology to uncover and preserve the history of public health nursing and indi- vidual nurses on audio files and written transcripts. Conduct an Oral History Interview 1. Identify an issue or event of interest. 2. Research the issue or event, using a variety of written and/or
photographic materials. 3. Locate a potential oral history interviewee or narrator. 4. Obtain the agreement of the narrator to be interviewed. Arrange
an interview appointment. 5. Research the narrator’s background and the time period of
interest. 6. Write an outline of questions for the narrator. Open-ended ques-
tions are especially helpful. 7. Meet with the narrator. Bring an audio recorder to the interview. 8. Interview the narrator. Ask one brief question at a time. Give
the narrator time to consider your question and answer it. 9. Ask clarifying questions. Ask for examples. Give encouragement.
Allow the narrator to tell his or her story without interruption. 10. After the interview, transcribe the interview tape and prepare a
written transcript (some digital programs can immediately produce a written transcript).
11. Carefully compare the written transcript with the narrator’s recorded interview. It may be appropriate to have the narrator review and edit the written transcript.
12. If you have made written arrangements with the narrator, place the oral history audio and transcripts in an appropriate archive or library (highly recommended).
Keep In Mind: Oral history is a type of nursing research. Please consider that oral history interviews may require formal consent by the interviewee or narrator before the interview, as well as prior approval of the research from an institutional review board.
Consult the Literature: An example of oral history is presented in an article on the Michigan Oral History Project (Gates et al, 1994).
NEW RESOURCES AND NEW COMMUNITIES: THE 1960s AND NURSING Beginning in earnest in the late 1940s but on the basis of advo- cacy begun in the late 1910s, policymakers and social welfare representatives sought to establish national health insurance. In 1965 Congress amended the Social Security Act to include health insurance benefits for older adults (Medicare) and increased care for the poor (Medicaid). Unfortunately, the revised Social Security Act did not include coverage for preven- tive services, and home health care was reimbursed only when ordered by a physician. Nevertheless, this latter coverage prompted the rapid proliferation of home health care agencies, with for-profit agencies responding to new financial opportuni- ties. Many local and state health departments rapidly changed their policies to include reimbursable home health care as bedside nursing. This could result in reduced health promotion and disease prevention activities, as funding for these activities was less stable. From 1960 to 1968, the number of official agen- cies providing home care services grew from 250 to 1328, and the number of for-profit agencies continued to grow (Kalisch and Kalisch, 2004).
COMMUNITY ORGANIZATION AND PROFESSIONAL CHANGE Social changes during the 1960s and 1970s influenced both nursing and public health. “The emerging civil rights move- ment shifted the paradigm from a charitable obligation to a political commitment to achieving equality and compensation for racial injustices of the past” (Scutchfield and Keck, 1997, p. 328). New programs addressed economic and racial differences in health care services and delivery. Funding was increased for maternal and child health, mental health, mental retardation, and community health training. Beginning in 1964, the federal Economic Opportunity Act provided funds for neighborhood health centers, Head Start, and other community action pro- grams. Neighborhood health centers increased community access for health care, especially for maternal and child care. The work of Nancy Milio in Detroit, Michigan, is an example of this commitment to action with the community. Milio built a dynamic decision-making process that included neighborhood residents, politicians, the Visiting Nurse Association and its board, civil rights activists, and church leaders. The Mom and Tots Center emerged as a neighborhood-centered service to provide maternal and child health services and a day-care center. Milio (1971) recorded this story in her book, 9226
37CHAPTER 2 History of Public Health and Public and Community Health Nursing
encouraged, and the use of nurse practitioners increased. Home health care weathered several threats to adequate reimburse- ment and, by the end of the decade, had secured favorable legal decisions that increased its impact on the care of the sick at home. Individuals and families assumed more responsibility for their own health because health education, always a part of nursing, became increasingly popular. Advocacy groups repre- senting both consumers and professionals urged the passage of laws to prohibit unhealthy practices in public such as smoking and driving under the influence of alcohol. Sophisticated media campaigns contributed to changing health behaviors and improving health status. As federal and state funds grew scarce, fewer nurses were employed by official public health agencies. Committed and determined to improve the health care of Americans, nurses continued to press for greater involvement in official and voluntary agencies (Roberts and Heinrich, 1985; Kalisch and Kalisch, 2004).
The National Center for Nursing Research (NCNR), estab- lished in 1985 within the federal National Institutes of Health near Washington, DC, had a major impact on promoting the work of nurses. Through research, nurses analyze the scope and quality of care provided by examining the outcomes and cost- effectiveness of nursing interventions. With the concerted efforts of many nurses, the NCNR gained official institute status within the National Institutes of Health in 1993, becoming the National Institute of Nursing Research (NINR).
By the late 1980s, public health as a whole had declined significantly in its effectiveness in accomplishing its mission and in shaping the public’s health. Significant reductions in local and national political support, financing, and outcomes were vividly described in a landmark report by the Institute of Medi- cine, The Future of Public Health (Institute of Medicine [IOM], 1988). The IOM study group found America’s public health system in disarray and concluded that, although there was wide- spread agreement about what the mission of public health should be, there was little consensus on how to translate that mission into action. Not surprisingly, the IOM reported that the mix and level of public health services varied extensively across the United States (Williams, 1995).
The Future of Public Health (IOM, 1988) determined that “contemporary public health is defined less by what public health professionals know how to do than by what the political system in a given area decides is appropriate or feasible” (p. 4). Nurses working in health departments saw underfunding reduce the breadth and depth of their role. When local public health departments provided insufficient care, voluntary agen- cies such as VNAs stepped in to assist vulnerable groups. However, without adequate funding for care of the poor, VNAs and other voluntary home health agencies faced hard economic choices, and some closed their doors.
America’s Healthy People initiative has influenced goals and priority setting in both public health and nursing, beginning in 1979 (U.S. Department of Health, Education, and Welfare, 1979), with the current objectives detailed in Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2010). Evidence-based practice recommendations that complement the Healthy People initiative are detailed
Kercheval: The Storefront That Did Not Burn. As shown in Figure 2-4 visiting nurses provided vital services to families.
New personnel also added to the flexibility of the public health nurse to address the needs of communities. Beginning in 1965 at the University of Colorado, the nurse practitioner movement opened a new era for nursing involvement in primary care that affected the delivery of services in community health clinics. Initially, the nurse practitioner was often a public health nurse with additional skills in the diagnosis and treatment of common illnesses. Although some nurse practitioners chose to practice in other clinical areas, those who continued in public health settings made sustained contributions to improving access and providing primary care to people in rural areas, inner cities, and other medically underserved areas (Roberts and Heinrich, 1985). As evidence of the effectiveness of their ser- vices grew, nurse practitioners became increasingly accepted as cost-effective providers of a variety of primary care services.
PUBLIC HEALTH NURSING FROM THE 1970s INTO THE TWENTY-FIRST CENTURY During the 1970s, nursing was viewed as a powerful force for improving the health care of communities. Nurses made signifi- cant contributions to the hospice movement, the development of birthing centers, day care for older adult and disabled persons, drug abuse programs, and rehabilitation services in long-term care. Federal evaluation of the effectiveness of care was empha- sized (Roberts and Heinrich, 1985).
By the 1980s, concern grew about the high costs of health care in the United States. Programs for health promotion and disease prevention received less priority as funding was shifted to meet the escalating costs of acute hospital care, medical pro- cedures, and institutional long-term care. The use of ambula- tory services including health maintenance organizations was
FIG 2-4 A Visiting Nurse Association nurse demonstrates proper infant care and bathing techniques to the parents. (Images from the History of Medicine, National Library of Medi- cine, Image ID 144048.)
38 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
for health promotion, disease prevention, and screening in primary care through the clinical guidelines from the U.S. Pre- ventive Services Task Force, Guide to Clinical Preventive Services (2014), and for groups and communities, through The Guide to Community Preventive Services, now known also as The Com- munity Guide (Community Preventive Services Task Force, 2014). Implementation of these strategies has influenced the work of public health nurses through their employment in health agencies and through participation in state or local health coalitions. See the Healthy People box that follows and that traces the development of this important series of documents.
The health care debate in the 1990s focused on cost, quality, and access to direct care services. Despite considerable interest in health care reform and securing universal health insurance coverage, the core economic debate—who will pay for what— emphasized reform of medical care rather than comprehensive changes in health promotion, disease prevention, and health care. In 1993, the American Health Security Act received insuf- ficient Congressional support. Reflecting the weakness of public health, the aims of public health were never clearly considered in the proposed program. Proposals to reform existing services also failed to apply the lesson learned from the Healthy People initiative—that health promotion and disease prevention appear to yield reductions in costs and illness/injury incidence while increasing years of healthy life.
In 1991 the ANA, the American Association of Colleges of Nursing, the National League for Nursing, and more than 60 other specialty nursing organizations joined to support health care reform. The coalition of nursing organizations empha- sized key health care issues of access, quality, and cost, and proposed a range of interventions designed to build a healthy nation through improved primary care and public health efforts. Professional nursing’s continued support for improved health care access and reduced cost was rewarded in 2010 with the passage of the federal Patient Protection and Affordable Care Act. These successes emphasize that public health nursing must continue to advocate for extension of public health services to prevent illness, promote health, and protect the public.
The Quad Council of Public Health Nursing Organizations was founded in the early 1980s, and is composed of representa- tives from four organizations that include public health nurses: The Association of State and Territorial Directors of Nursing (ASTDN, established in 1935), known since 2012 as the Asso- ciation of Public Health Nurses (APHN); the Association of Community Health Nursing Educators (ACHNE, established in 1977); the Public Health Nursing Section of the American Public Health Association (PHN-APHA; the Section was formed in 1923); and the American Nurses Association Council on Nursing Practice and Economics (ANA).
HEALTHY PEOPLE 2020
In 1979 the groundbreaking Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention asserted that “the health of the Ameri- can people has never been better” (U.S. Department of Health, Education, and Welfare [USDHEW], 1979, p. 3). But this was only the prologue to deep criticism of the status of American health care delivery. Between 1960 and 1978, health care spending increased 700%—without related improvements in mortality or morbidity. During the 1950s and 1960s, evidence had accumulated about chronic disease risk factors, particularly cigarette smoking, alcohol and drug use, occu- pational risks, and injuries. But these new research findings were not systemati- cally applied to health planning and to improving population health.
In 1974 the Government of Canada published A New Perspective on the Health of Canadians (Lalonde, 1974), which found death and disease to have four contributing factors: inadequacies in the existing health care system, behavioral factors, environmental hazards, and human biological factors. Applying the Canadian approach, in 1976 U.S. experts analyzed the 10 leading causes of U.S. mortality and found that 50% of American deaths were the result of unhealthy behaviors, and only 10% were the result of inadequacies in health care. Rather than just spending more to improve hospital care, clearly prevention was the key to saving lives, improving the quality of life, and saving health care dollars.
A multidisciplinary group of analysts conducted a comprehensive review of prevention activities. They verified that the health of Americans could be signifi- cantly improved through “actions individuals can take for themselves” and through actions that public and private decision makers could take to “promote a safer and healthier environment” (p. 9). Similar to Canada’s New Perspectives,
America’s Healthy People (USDHEW, 1979) identified priorities and measurable goals. Healthy People grouped 15 key priorities into three categories: key pre- ventive services that could be delivered to individuals by health providers, such as timely prenatal care; measures that could be used by governmental and other agencies, as well as industry, to protect people from harm, such as reduced exposure to toxic agents; and activities that individuals and communities could use to promote healthy lifestyles, such as improved nutrition.
In the late 1980s, success in addressing these priorities and goals was evalu- ated, new scientific findings were analyzed, and new goals and objectives were set for the period from 1990 to 2000 through Healthy People 2000: National Health Promotion and Disease Prevention Objectives (U.S. Department of Health and Human Services [USDHHS], 1991). This process was repeated 10 years later to develop goals and objectives for the period 2000 to 2010 (USDHHS, 2000), and for the current decade of 2010 to 2020—Healthy People 2020: Improving the Health of Americans (USDHHS, 2010). Recognizing the continuing challenge to using emerging scientific research to encourage modification of health behav- iors and practices, Healthy People 2020 addresses health equity, elimination of disparities, and improved health for all groups across the life span through disease prevention, improved social and physical environments, and healthy development and health behaviors.
Just as the public health nurse in the early twentieth century spread the “gospel of public health” to reduce communicable diseases, today’s population-centered nurse uses Healthy People to reduce chronic and infectious diseases and injuries through health education, environmental modification, and policy development.
History of the Development of Healthy People
Lalonde M: A New Perspective on the Health of Canadians. Ottawa, Canada, 1974, Information Canada; U.S. Department of Health and Human Services: Healthy People 2010: Understanding and Improving Health, ed 2. Washington, DC, 2000, U.S. Government Printing Office; U.S. Depart- ment of Health and Human Services: Healthy People 2020: The Road Ahead. Available at: http://www.healthypeople.gov/hp2020/. Accessed December 2, 2010; U.S. Department of Health, Education, and Welfare: Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. DHEW Publication No. 79-55071, Washington, DC, 1979, U.S. Government Printing Office; U.S. Public Health Service: Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC, 1991, U.S. Government Printing Office.
39CHAPTER 2 History of Public Health and Public and Community Health Nursing
PUBLIC HEALTH NURSING TODAY In the last decades, new and continuing challenges have trig- gered growth and change in nursing. Where existing organiza- tions have been unable to meet community and neighborhood needs, nurse-managed health centers provide a diversity of nursing services, including health promotion and disease/injury prevention. New populations in communities continue to chal- lenge schools of nursing, health departments, rural health clinics, and migrant health services to provide the range of services to meet specific needs, including the needs of new immigrants. Transfer of official health services to private control has sometimes reduced professional flexibility and service deliv- ery. Nurses also make the difficult choice to leave public health nursing to work in acute care, where the salaries are often higher. This is even more prominent in times of a nursing short- age. The Association of Community Health Nurse Educators calls for increased graduate programs to educate public health nurse leaders, educators, and researchers. Natural disasters (such as floods, hurricanes, and tornados) and human-made disasters (including explosions, building collapses, and airplane crashes) require innovative and time-consuming responses. Preparation for future disasters and potential bioterrorism demands the presence of well-prepared nurses. Many of these stories are detailed in the chapters that follow.
Some states have heard renewed persuasion to deploy school nurses in every school; a new recognition of the link between
During the 1990s and 2000s the Quad Council of Public Health Nursing Organizations supported the efforts of its orga- nizational members and public health organizations to establish mechanisms to improve quality of care and to advance the public health nursing profession in the twenty-first century. For example, the certification of public health nurses with graduate degrees was reinforced through collaborative agreements with the American Nurses Credentialing Center (ANCC). The Quad Council also revised its Competencies for Public Health Nurses in 2011. The competencies are separated into three tiers: Tier 1 for generalist public health nurses who conduct clinical, home visiting and population-based services; Tier 2 for public health nurses with management and/or supervisory responsibilities; and Tier 3 for public health nurses at executive, senior manage- ment, or leadership levels in public health nursing organiza- tions. Under Domain #6, a public health nurse “Describes the historical foundation of public health and public health nursing” (Quad Council, 2011, p. 17).
In addition to the actions of the Quad Council itself, the four constituent members of the Council have also worked in their areas of expertise to link content to the practice of public health nursing through their development of standards and compe- tencies that influence practice in various ways.
The Association of Community Health Nursing Educators developed important position papers, including Graduation Education for Advanced Practice Public Health Nursing (ACHNE, 2007) and Academic Faculty Qualifications for Community/ Public Health Nursing (ACHNE, 2009). The Association of State and Territorial Directors of Nursing asserted the importance of public health nurses within public health systems through the publication of Every State Health Department Needs a Public Health Nurse Leader (ASTDN, 2008). And the Association of Public Health Nurses revised the ASTDN position paper on The Role of the Public Health Nurse in Disaster Preparedness, Response, and Recovery (APHN, 2014).
The Council on Linkages between Academia and Public Health Practice provides exchanges and collaborations among all public health disciplines, including public health nursing. The Council’s Core Competencies for Public Health Professionals (2014) features a core competency under the domain of public health sciences skills: “Identifies prominent events in the history of the public health profession” (p. 17).
The American Nurses Association’s Scope and Standards of Public Health Nursing Practice (ANA, 2013) is a key guide for the practice of public health nursing. Periodically revised, the Scope and Standards is developed by a group of public health nursing leaders representing the major public health nursing organiza- tions and reflects the central ideas of public health nursing. As there is substantial agreement about the characteristics and goals of public health nursing across organizations, it is not surprising that the ANA Scope and Standards and the Quad Council’s Public Health Nursing Competencies both includes the processes of assessment, analysis, and planning. Each also incorporates the importance of communication, cultural competency, policy, and public health skills in their recommendations for effective public health nurse practice. The Linking Content to Practice box describes how historically public health nursing journals have preserved the history of public health nursing.
LINKING CONTENT TO PRACTICE
Public Health Nursing, a major journal in the field of public health nursing, publishes articles that very broadly reflect contemporary research, practice, education, and public policy for population-based nurses. Begun in 1984, Public Health Nursing (PHN) was published quarterly through 1993, and has been a bimonthly journal since 1994. Marilyn G. King, DNSc, RN, is the historical editor and Patricia J. Kelly, PhD, MPH, APRN, is the journal’s current editor (2014).
More than any other journal, PHN has assumed responsibility for preserving the history of public health nursing and for publishing new historical research on the field. The contemporary Public Health Nursing shares its name with the official journal of the National Organization for Public Health Nursing in the period 1931 to 1952 (earlier names were used for the official journal from 1913 to 1931, which built on the Visiting Nurse Quarterly, published 1909 to 1913).
The contemporary Public Health Nursing presents a wide variety of articles, including both new historical research and reprints of classic journal articles that deserve to be read and reapplied by modern public health nurses. One historical article reprinted in PHN addressed a nurse’s 1931 work on county drought relief that underscores continuing professional themes of case- finding, collaboration, and partnership (Wharton, 1999). Another historical reprint recalled the important 1984 dialogue between two public health nurse leaders, Virginia A. Henderson and Sherry L. Shamansky, with an added contextual introduction from Sarah Abrams (Abrams, 2007). Original historical research presented in PHN is extremely varied, from public health nursing education, to public health nurse practice in Alaska’s Yukon, to excerpts from the oral histories of public health nurses.
Contemporary nurses find inspiration and possibilities for modern innova- tions in reading the history of public health nursing in the pages of PHN.
Abrams SE: Nursing the community, a look back at the 1984 dialogue between Virginia A. Henderson and Sherry L. Shamansky. PHN 24:382, 2007; reprinted from PHN 1:193, 1984; Wharton AL: County drought relief: a public health nurse’s problem. PHN 16(4):307–308, 1999; reprinted from PHN 23, 1931.
40 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
look to their history for inspiration, explanation, and predic- tion. Information and advocacy are used to promote a compre- hensive approach to address the multiple needs of the diverse populations served. In the twenty-first century, public health nursing both reflects the past and builds on and beyond it.
Nurses will seek to learn from the past and to avoid known pitfalls, even as they seek successful strategies to meet the complex needs of today’s vulnerable populations. As plans for the future are made, and as the public health challenges that remain unmet are acknowledged, it is this vision of what nursing can accomplish that sustains these nurses. In public health nursing as in all other specialty areas, quality and safety are key issues. The box below outlines the six Quality and Safety in Nursing Education (QSEN) competences and describes the development of these competences.
school success and health is again making the school nurse essential. Evidence from cost-benefit research on school nursing services underscores modern financial advantages for families and communities (Wang et al, 2014). Renewed evidence is also available from research on the use of nurses for prenatal and infant/toddler home visits to reduce “all-cause mortality among mothers and preventable-cause mortality in their first-born children living in highly disadvantaged settings” (Olds et al, 2014, p. E1). Even though both of these research inquiries have related precedents in the history of nursing, contemporary public health nurses must seek research approaches to demon- strate the outcomes of this work.
Today, public health nurses’ past contributions ground twenty-first century public health nurses in a narrative that explains and gives importance to contemporary work. Nurses
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Although the scope and responsibilities of public health nurses have changed over time, the commitment to quality and safety has remained constant. Since the beginning of population-centered nursing in the United States, the nurses who worked in this specialty have been committed to preserving health and preventing disease. They have focused on environmental conditions such as sanitation and control of communicable diseases, education for health, preven- tion of disease and disability, and at times care of the sick and aged in their homes. This long-standing commitment to quality and safety is consistent with the work of Quality and Safety Education for Nurses (QSEN), a national initiative designed to transform nursing education by including in the curriculum content and experiences related to building knowledge, skills and attitudes for six quality and safety initiatives (Cronenwett, Sherwood, and Gelmon, 2009). The QSEN work, led by Drs. Linda Cronenwett and Gwen Sherwood at the University of North Carolina, has made great progress in bridging the gap between quality and safety work in both practice and academic settings (Brown, Feller, and Benedict, 2010). The six QSEN competencies for Nursing are: 1. Patient-centered care: Recognizes the client or designee as the source of
control and as a full partner in providing compassionate and coordinated care that is based on the preferences, values, and needs of the client.
2. Teamwork and collaboration: Refers to the ability to function effectively with nursing and interprofessional teams and to foster open communication, mutual respect, and shared decision making to provide quality client care.
3. Evidence-based practice: Integrates the best current clinical evidence with client and family preferences and values to provide optimal client care.
4. Quality improvement: Uses data to monitor the outcomes of the care pro- cesses and uses improvement methods to design and test changes to continu- ally improve quality and safety of health care systems.
5. Safety: Minimizes the risk for harm to clients and provides through both system effectiveness and individual performance.
6. Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making (Brown et al, 2010, p. 116).
Of the six QSEN competencies, all but safety were derived from the Institute of Medicine report, Health Professions Education (2003). The QSEN team added safety because this competency is central to the work of nurses. Articles have been published to teach educators about QSEN, and national forums have been held. Also the American Association of Colleges of Nursing (AACN) has held faculty development institutes for faculty and academic administrators using a train-the-trainer model, and safety and quality objectives have been built in the
AACN essentials for nursing education. Similarly, the National League for Nursing has incorporated the “NLN Educational Competencies Model” into their educational summits. The six QSEN competencies will be integrated in the chapters throughout the text to emphasize the importance of quality and safety in public health nursing today. NOTE: The terms patient and care will be changed to client and intervention to reflect a public health nursing approach.
Specifically related to the history of nursing, the following targeted compe- tency can be applied: • Targeted Competency: Safety—Minimizes risk for harm to clients and
providers through both system effectiveness and individual performance. Important aspects of safety include: • Knowledge: Discuss potential and actual impact of national client safety
resources initiatives and regulations • Skills: Participate in analyzing errors and designing system
improvements • Attitudes: Value vigilance and monitoring by clients, families, and other
members of the health care team
Safety Question Updated definitions around client safety include addressing safety at the indi- vidual level and at the systems level. The history of public health nursing demonstrates the myriad ways that public health nurses have addressed client safety in their evolving practice. Public health nurses support safety through caring for individuals and providing care for communities and groups. Histori- cally, how have public health nurses addressed safety at the individual client level? How have public health nurses addressed client safety at the systems level? How have public health nurses been involved in system improvements?
Answer: Individual level: A rich part of public health nursing’s history has been the development of home visitation, in which clients are cared for in their own environment. Similarly, public health nurses have improved client outcomes by pioneering new models of interventions for maternal–child health and indi- viduals in rural communities.
Systems level: Through their work with communities, public health nurses were an integral part of reducing the incidence of communicable diseases by the mid-twentieth century. More recently, public health nursing has contributed to health care system improvements through the development of the hospice movement, birthing centers, day care for elderly and disabled persons, and drug-abuse and rehabilitation services. These initiatives have updated the health care system to provide targeted care for previously overlooked populations.
41CHAPTER 2 History of Public Health and Public and Community Health Nursing
P R A C T I C E A P P L I C A T I O N Mary Lipsky has worked for the county health department in a major urban area for almost 2 years. Her nursing responsibili- ties include a variety of services, including consultations at a senior center, maternal/newborn home visits, and well-child clinics. As she leaves work each evening and returns to her own home, she keeps thinking about her clients. Why was it so dif- ficult today to qualify a new mother and her baby to receive WIC (Women, Infants, and Children) nutrition services? Why must she limit the number of children screened for high lead levels, when last year the health department screened twice as many children? Several children last month seemed asymptom- atic, but the laboratory found lead levels that were high enough
to cause damage. One of the mothers Ms. Lipsky is acquainted with is having a difficult time emotionally. Why is it so difficult to find a behavioral health provider for her? And the health department still cannot find a new staff dentist! And families on welfare cannot find a private dentist to care for their children. A. Why might it be difficult to solve these problems at the indi-
vidual level, on a case-by-case basis? B. What information would you need to build an understand-
ing of the policy background for each of these various populations? Answers can be found on the Evolve site.
K E Y P O I N T S • A historical approach can be used to increase understanding
of public health nursing in the past, as well as its current dilemmas and future challenges.
• The history of public health nursing can be characterized by change in specific focus of the specialty but continuity in approach and style of the practice.
• Public health nursing, referred to in this text as population- centered nursing, is a product of various social, economic, and political forces; it incorporates public health science in addition to nursing science and practice.
• Federal responsibility for health care was limited until the 1930s, when the economic challenges of the Depression per- mitted reexamination of local responsibility for care.
• Florence Nightingale designed and implemented the first program of trained nursing, and her contemporary, William Rathbone, founded the first district nursing association in England.
• Urbanization, industrialization, and immigration in the United States increased the need for trained nurses, espe- cially in public health nursing.
• Increasing acceptance of public roles for women permitted public health nursing employment for nurses, as well as public leadership roles for their wealthy supporters.
• In 1887 the Women’s Board of the New York City Mission hired Frances Root, a trained nurse, to provide care to sick persons at home.
• The first visiting nurses’ associations were founded in 1885 and 1886 in Buffalo, Philadelphia, and Boston.
• Lillian Wald established the Henry Street Settlement, which became the Visiting Nurse Service of New York City, in 1893. She played a key role in innovations that shaped public health nursing in its first decades, including school nursing, insurance payment for nursing, national organization for public health nurses, and the United States Children’s Bureau.
• Founded in 1902 with the vision and support of Lillian Wald, school nursing sought to keep children in school so that they could learn.
• The Metropolitan Life Insurance Company established the first insurance-based program in 1909 to support commu- nity health nursing services.
• The National Organization for Public Health Nursing (founded in 1912) provided essential leadership and coordi- nation of diverse public health nursing efforts; the organiza- tion merged into the National League for Nursing in 1952.
• Official health agencies slowly grew in numbers between 1900 and 1940, accompanied by a steady increase in public health nursing positions.
• The innovative Sheppard-Towner Act of 1921 expanded community health nursing roles for maternal and child health during the 1920s.
• Mary Breckinridge established the Frontier Nursing Service in 1925, which influenced provision of rural health care.
• African-American nurses seeking to work in public health nursing faced many challenges, but ultimately had signifi- cant impact on the communities they served.
• Tension between the nursing role of caring for the sick and the role of providing preventive care, and the related tension between intervening for individuals and intervening for groups, have characterized the specialty since at least the 1910s.
• As the Social Security Act attempted to remedy some of the setbacks of the Depression, it established a context in which public health nursing services expanded.
• The challenges of World War II sometimes resulted in exten- sion of nursing care and sometimes in retrenchment and decreased public health nursing services.
• By the mid-twentieth century, the reduced prevalence of communicable diseases and the increased prevalence of chronic illness, accompanied by large increases in the popu- lation more than 65 years of age, led to examination of the goals and organization of public health nursing services.
• Between the 1930s and 1965, organized nursing and com- munity health nursing agencies sought to establish health insurance reimbursement for nursing care at home.
• Implementation of Medicare and Medicaid programs in 1966 established new possibilities for supporting community- based nursing care but encouraged agencies to focus on ser- vices provided after acute care rather than on prevention.
• Efforts to reform health care organization, pushed by increased health care costs during the last 40 years, have
42 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
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• The 1988 Institute of Medicine report documented the reduced political support, financing, and impact that increas- ingly limited public health services at national, state, and local levels.
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C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Interview nurses at your clinical placement about the changes
they have seen during their years in a population-centered nursing practice. How do these changes relate to the chang- ing needs of the community or the population?
2. Identify the visible record of nursing agencies in your com- munity. Note the buildings, plaques, and display cases that document the past provision of nursing care in community settings. What forces have influenced these agencies over time? Which factors do they wish to make known publicly, and which factors are less apparent?
3. Secure a copy of your clinical agency’s recent annual report. How is the history of the agency presented? How does this agency’s history fit in with the points made in this chapter? What are your conclusions about how this agency’s past influences its present?
4. Interview older relatives for their memories of public health nursing care received by them, their families, and their
friends. When they were younger, how was the public health nurse perceived in their community? What interventions were used by the public health nurse? How was the public health nurse dressed? How has the position of the public health or community health nurse changed?
5. Of what element or aspect of the history of public health nursing would you like to learn more? At your nursing library, review a period of 10 years of one journal from the past to identify trends in how this element or aspect was addressed. What conclusions do you reach?
6. The work and impact of several nursing leaders is reviewed or noted in this chapter. Of these leaders, which one strikes you as most interesting? Why? Locate and read further arti- cles or books about this leader. What personal strengths do you note that supported this nurse’s leadership?
43CHAPTER 2 History of Public Health and Public and Community Health Nursing
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44
3 The Changing U.S. Health and Public Health Care Systems
Marcia Stanhope, PhD, RN, FAAN Dr. Marcia Stanhope is currently an Associate of the Tufts and Associates Search Firm, Chicago, Ill. She is also a consultant for the nursing program at Berea College, Kentucky. She has practiced community and home health nursing, has served as an administrator and consultant in home health, and has been involved in the development of two nurse-managed centers. At one time in her career, she held a public policy fellowship and worked in the office of a U.S. Senator. She has taught community health, public health, epidemiology, policy, primary care nursing, and administration courses. Dr. Stanhope formerly directed the Division of Community Health Nursing and Administration and served as Associate Dean of the College of Nursing at the University of Kentucky. She has been responsible for both undergraduate and graduate courses in population-centered nursing. She has also taught at the University of Virginia and the University of Alabama, Birmingham. During her career at the University of Kentucky she was appointed to the Good Samaritan Foundation Chair and Professorship in Community Health Nursing, and was honored with the University Provost’s Public Scholar award. Her presentations and publications have been in the areas of home health, community health and community-focused nursing practice, as well as primary care nursing.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Describe the events and trends that influence the status of
the health care system. 2. Discuss key aspects of the private health care system. 3. Compare the public health system to primary care.
4. Explain the model of primary health care. 5. Assess the effects of health care and insurance reform on
health care delivery. 6. Evaluate the changes needed in public health and primary
care to have an integrated health care delivery system.
K E Y T E R M S advanced practice nursing (APN), p. 47 Affordable Care Act, p. 48 community participation, p. 54 Declaration of Alma-Ata, p. 45 disease prevention, p. 45 electronic health record (EHR), p. 47 health, p. 45 health promotion, p. 45
managed care, p. 50 primary care, p. 50 primary health care (PHC), p. 54 public health, p. 50 U.S. Department of Health and Human Services (USDHHS),
p. 50 —See Glossary for definitions
C H A P T E R O U T L I N E Health Care in the United States Forces Stimulating Change in the Demand for
Health Care Demographic Trends Social and Economic Trends Health Workforce Trends Technological Trends
Current Health Care System in the United States Cost Access Quality
Organization of the Health Care System Primary Care System Public Health System
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• NCLEX Review Questions • Case Study, with questions and answers • Community Assessment Applied • Healthy People 2020
Appendixes • Appendix A.3: Declaration of Alma-Ata • Appendix E.3: The Health Insurance Portability and
Accountability Act (HIPAA): What Does It Mean for Public Health Nurses?
A special thanks to Bonnie Jerome-D-Emilia for the many contributions to this chapter in edition 8 of the text.
45CHAPTER 3 The Changing U.S. Health and Public Health Care Systems
HEALTH CARE IN THE UNITED STATES Despite the fact that health care costs in the United States are the highest in the world and comprise the greatest percentage of the gross domestic product, the indicators of what consti- tutes good health do not document that Americans are really getting their money’s worth. In the first decade of the twenty- first century there have been massive and unexpected changes to health, economic, and social conditions as a result of terrorist attacks, hurricanes, fires, floods, infectious diseases, and an eco- nomic turndown in 2008. New systems have been developed to prevent and/or deal with the onslaught of these horrendous events. Not all of the systems have worked, and many are regu- larly criticized for their inefficiency and costliness. Simultane- ously, new, nearly miraculous advances have been made in treating health-related conditions. Organs and joints are being replaced and medicines are keeping people alive who only a few years ago would have suffered and died. These advances and “wonder drugs” save and prolong lives, and a number of deadly and debilitating diseases have been eliminated through effective immunizations and treatments. In addition, sanitation, water supplies, and nutrition have been improved, and animal cloning has begun.
However, attention to all of these advances may overshadow the lack of attention to public health and prevention. Several of the most destructive health conditions can be prevented either through changes in lifestyle or interventions such as immuniza- tions. The increasing rates of obesity, especially among children; substance use; lack of exercise; violence; and accidents are alarmingly expensive, particularly when they lead to disrup- tions in health.
This chapter describes a health care system in transition as it struggles to meet evolving global and domestic challenges. The overall health care and public health systems in the United States are described and differentiated, and the changing priori- ties are identified. Nurses play a pivotal role in meeting these needs, and the role of the nurse is described.
FORCES STIMULATING CHANGE IN THE DEMAND FOR HEALTH CARE In recent years, enormous changes have occurred in society, both in the United States and most other countries of the world. The extent of interaction among countries is stronger than ever, and the economy of each country depends on the stability of other countries. The United States has felt the effects of rising
As is known, the U.S. government began providing public health services in the 1700s, and public health nursing was first recognized 125 years ago (see Chapter 2). Although there were physicians in England in the 1600s and 1700s and in the United States since the 1700s, official recognition of the general prac- titioner (GP) occurred in England only in 1844. In the 1950s and 1960s in the United States, discussions were held to elevate the GP to a specialty practice in medicine. Thus family practice medicine became a reality in the 1960s (ABFM, 2005). After this development in medicine the first nurse practitioner program was begun in 1965 (Medscape, 2000). Then, in September 1978, an international conference was held in the city of Alma-Ata, which at that time was the capital of the Soviet Republic of Kazakhstan. During this conference, the Declaration of Alma- Ata and the primary health care model emerged (Appendix A.3). This declaration states that health is a human right and that the health of its people should be the primary goal of every government. One of the main themes of this declaration was the involvement of community health workers and traditional healers in a new health system (World Health Organization [WHO], 1978).
It was through this conference that the concept of primary health care (PHC) was introduced, defined, and described. In 2008, the WHO renewed its call for health care improvements and reemphasized the need for public policymakers, public health officials, primary care providers, and leadership within countries to improve health care delivery. The WHO said: “Glo- balization is putting the social cohesion of many countries under stress, and health systems … are clearly not performing as well as they could and should. People are increasingly impa- tient with the inability of health services to deliver. … Few would disagree that health systems need to respond better—and faster—to the challenges of a changing world. PHC can do that” (WHO, 2008; and see Chapter 4).
As defined by the WHO, PHC reflects and evolves from the economic conditions and sociocultural and political character- istics of the country and its communities, and is based on the application of social, biomedical, and health services research and public health experience. It addresses the main health problems in the community, providing for health promotion, disease prevention, and curative and rehabilitative services (WHO, 1978).
Defined differently than primary care or public health, PHC promotes the integration of all health care systems within a community to come together to improve the health of the com- munity, including primary care and public health.
C H A P T E R O U T L I N E — cont’d The Federal System The State System The Local System
Forces Influencing Changes in the Health Care System Integration of Public Health and the Primary Care Systems Potential Barriers to Integration
Primary Health Care Promoting Health/Preventing Disease: Year 2020 Objectives
for the Nation Health Care Delivery Reform Efforts—United States
46 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
United States (Office of National Statistics [ONS], 2014). The nation’s foreign-born population is growing, and it is projected that from now until 2050 the largest population growth will be due to immigrants and their children. States with the largest percentage of foreign-born populations are California, New York, Hawaii, Florida, and New Jersey. The states with the fastest-growing immigrant populations in 2012 were Nevada, Texas, Maryland, Illinois, and Arizona (Migration Policy Institute, 2014; Pew Research Center, 2012).
The composition of the U.S. household is also changing (see Chapter 25 for changes in families). From 1935 to 2010, mortal- ity for both genders in all age groups and races declined (Hoyert, 2012) as a result of progress in public health initiatives, such as antismoking campaigns, AIDS prevention programs, and cancer screening programs. The leading causes of death have changed from infectious diseases to chronic and degenerative diseases (NCHS, 2014). New infectious diseases are emerging, such as Ebola virus, which affected the United States in 2014 with the first case in Dallas, Texas (CDC, 2014a). New treatments for infectious diseases have resulted in steady declines in mortality among children, as long as parents participate in immunization programs. A recent measles outbreak in Orange County, Cali- fornia shows that continuous focus on control of infectious diseases is essential (Orange County Health Care Agency, 2014). The mortality for older Americans has also declined. However, people 50 years of age and older have higher rates of chronic and degenerative illness and they use a larger portion of health care services than other age groups.
Social and Economic Trends In addition to the size and changing age distribution of the population, other factors also affect the health care system. Several social trends that influence health care include changing lifestyles, a growing appreciation of the quality of life, the changing composition of families and living patterns, changing household incomes, and a revised definition of quality health care.
Americans spend considerable money on health care, nutri- tion, and fitness (Bureau of Labor Statistics, 2012), because health is seen as an irreplaceable commodity. To be healthy, people must take care of themselves. Many people combine traditional medical and health care practices with complemen- tary and alternative therapies to achieve the highest level of health. Complementary therapies are those that are used in addition to traditional health care, and alternative therapies are those used instead of traditional care. Examples include acu- puncture, herbal medications, and more (National Center for Complementary and Alternative Medicine, 2014). People often spend a considerable amount of their own money for these types of therapies because few are covered by insurance. In recent years, some insurance plans have recognized the value of complementary therapies and have reimbursed for them. State offices of insurance are good sources to determine whether these services are covered and by which health insurance plans.
About 65 years ago, income was distributed in such a way that a relatively small portion of households earned high incomes; families in the middle-income range made up a
labor costs as many companies have shifted their production to other countries with lower labor costs. It is often less expensive to assemble clothes, automobile parts, and appliances and to have call distribution centers and call service centers in a less industrialized country and pay the shipping and other charges involved than to have the items fully assembled in the United States. In recent years the vacillating cost of fuel has affected almost every area of the economy, leading to both higher costs of products and layoffs as some industries have struggled to stay solvent. This has affected the employment rate in the United States. The economic downturn of 2008 left many people unemployed, and many lost their homes because they could not pay their mortgages. When the unemployment rate is high, more people lack comprehensive insurance coverage, since in the United States this has been typically provided by employers. In late November 2008, the U.S. unemployment rate was 6.7%. This represented an increase from 4.6% in 2007. In July 2012 the unemployment rate had increased to 8.2%, close to double the rate in 2007. In recent years the economy has begun to recover. In 2014, for example, the unemployment rate decreased to 6.1%—down by 2.1 percentage points from 2012 (Bureau of Labor Statistics [BLS], 2014a). Also, health care services and the ways in which they are financed are changing, with the continu- ing implementation of the Patient Protection and Affordable Care Act (ACA, enacted in 2010).
Demographic Trends The population of the world is growing as a result of increased fertility and decreased mortality rates. The greatest growth is occurring in underdeveloped countries, and this is accompa- nied by decreased growth in the United States and other devel- oped countries. The year 2000, however, marked the first time in more than 30 years that the total fertility rate in the United States was above the replacement level. Replacement means that for every person who dies, another is born (Hamilton et al, 2010). Both the size and the characteristics of the population contribute to the changing demography.
Seventy-seven million babies were born between the years of 1946 and 1963, giving rise to the often discussed baby boomer generation (Office of National Statistics, 2014) The oldest of these boomers reached 65 years of age in 2011, and they are expected to live longer than people born in earlier times (see Chapter 5). The impact on the federal government’s insurance program for people 65 years of age and older, Medicare, is expected to be enormous, and this population is expected to double between the years 2000 and 2030, representing 20% of the total population (CDC, 2013a).
In 2014, the U.S. population was 318,804 million people, representing the third most populated country in the world. From 1990 to 2012, the U.S. foreign-born immigrant popula- tion grew from about 19 million to about 41 million and is continuing to increase every year (US Census Bureau, 2014).
At the time of the 1990 census, African Americans were the largest minority group in the United States (U.S. Census Bureau, 1996). However, in 2014, the U.S. Census Bureau announced that Hispanic persons outnumbered African Americans, with non-Hispanic whites being the largest single ethnic group in the
47CHAPTER 3 The Changing U.S. Health and Public Health Care Systems
care teams (see Chapter 39). Although there is a shortage of primary care physicians, nurse practitioners may or may not be able to fill the gap because of state nurse practice acts and medical practice acts, which influence the practice of both groups.
In terms of the nursing workforce, increasing the number of minority nurses remains a priority and a strategy for addressing the current nursing shortage. In 2013 minority nurses repre- sented about 22% of the registered nurse population. It is thought that increasing the minority population will help close the health disparity gap for minority populations (AACN, 2014). For example, persons from minority groups, especially when language is a barrier, often are more comfortable with and more likely to access care from a provider from their own minority group.
Technological Trends The development and refinement of new technologies such as telehealth have opened up new clinical opportunities for nurses and their clients, especially in the areas of managing chronic conditions, assisting persons who live in rural areas, and in providing home health care, rehabilitation, and long-term care. On the positive side, technological advances promise improved health care services, reduced costs, and more convenience in terms of time and travel for consumers (see Chapter 5). Reduced costs result from a more efficient means of delivering care and from replacement of people with machines. It also reduces paperwork, gets accurate information to providers and clients and agencies, assists with care coordination and safety, and provides direct access to health records between agencies and to clients (HealthIT.gov, 2013). Contradictory as it may seem, cost is also the most significant negative aspect of advanced health care technology. The more high-technology equipment and computer programs become available, the more they are used. High-technology equipment is expensive, quickly becomes outdated when newer developments occur, and often requires highly trained personnel. There are other drawbacks to new technology, particularly in the area of home health care. These include increased legal liability, the potential for decreased privacy, too much reliance on technological advances, and the inconsistent quality of resources available on the Internet and other places (Palma, 2014).
Advances in health care technology will continue. One example of an effective use of technology is the funding pro- vided by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) to health centers so they can adopt and implement electronic health records (EHRs) and other health information technol- ogy (HRSA, 2008). HRSA’s Office of Health Information Tech- nology (HIT) was created in 2005 to promote the effective use of HIT as a mechanism for responding to the needs of the uninsured, underinsured, and special-needs populations (HRSA, 2014). Specifically, in December 2012, an award of $18 plus million through the Affordable Care Act was announced to expand health information technology in 600 health centers (HRSA, 2012). One innovative use of the EHR in public health is to embed reminders or guidelines into the system. For
somewhat larger proportion and households at the lower end of the income scale made up the largest proportion. By the 1970s, household income had risen, and income was more evenly distributed, largely as a result of dual-income families.
Since 1970 and to 2008, two trends in income distribution have emerged. The first is that the average per-person income in America has increased. Income of households in the top 1% of earners grew by 275%, compared with 65% for the next 19%, just under 40% for the next 60%, and 18% for the bottom fifth of households (Congressional Budget Office [CBO], 2011). However, as a result of what is being called the Great Recession, which began in 2008, and in recent years with layoffs, outsourc- ing, and other economic forces, many families are seeing decreases in wages. The second trend is that the gap between the richest 25% and the poorest 25% is widening because of the percent wage increase in the higher income levels (CBO, 2011). Chapter 5 provides a detailed discussion of the economics of health care and how financial constraints influence decisions about public health services.
Health Workforce Trends The health care workforce ebbs and flows. The early years of the twenty-first century saw the beginning of what is expected to be a long-term and sizable nursing shortage. Similarly, most other health professionals are documenting current and future shortages. Historically, nursing care has been provided in a variety of settings, primarily in the hospital. Approximately 56% of all registered nurses (RNs) continue to be employed in hospitals (American Nurses Association, 2012). A few years ago hospitals began reducing their bed capacity as care became more community based. Now they are expanding, including building for both acute and longer term chronic care. This growth is due to the factors previously discussed: the ability to treat and perhaps cure more diseases, the complexity of the care and the need for inpatient services, and the growth of the older age group.
The nursing shortage has been discussed in recent years, yet new graduates often have difficulty finding positions on gradu- ation (American Association of Colleges of Nursing [AACN], 2014). Participating in a nurse internship program and being a bachelor of science in nursing (BSN) graduate or higher pro- vides more opportunities for the new graduate. By 2016 there are expected to be 527,000 new nursing positions (BLS, 2014b). In addition, 55% of nurses reported in a recent survey that they intended to retire between 2011 and 2020, which will open positions for others (Fears, 2010).
There tend to be periodic shortages, especially in the primary care workforce in the United States, as providers choose to be specialists in fields such as medicine and nursing. Primary care providers include generalists who are skilled in diagnostic, pre- ventive, and emergency services. The health care personnel trained as primary care generalists include family physicians, general internists, general pediatricians, nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants, and certified nurse-midwives (CNMs) (Steinwald, 2008).
NPs, CNSs, and CNMs, considered advanced practice nursing (APN) specialties, are vital members of the primary
48 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
Cost Beginning in 2008, a historic weakening of the national and global economy—the “Great Recession”—led to the loss of 7 million jobs in the United States (Economic Report, 2010). Even as the gross domestic product (GDP), an indicator of the eco- nomic health of a country, declined in 2009, health care spend- ing continued to grow and reached $2.5 trillion in the same year (Truffer et al, 2010). In the years between 2010 and 2019, national health spending is expected to grow at an average annual rate of 6.1%, reaching $4.5 trillion by 2019, for a share of approximately 19.3% of the GDP. This translates into a pro- jected increase in per capita spending (see Chapter 5).
In Chapter 5, additional discussion illustrates how health care dollars are spent. The largest share of health care expendi- tures goes to pay for hospital care, with physician services being the next largest item. The amount of money that has gone to pay for public health services is much lower than for the other categories of expenditures. Other significant drivers of the increasingly high cost of health care include prescription drugs, technology, and chronic and degenerative disease.
Following the “Great Recession,” the economic rebound will likely coincide with the burgeoning Medicare enrollment of the aging baby boomer population. It was projected that these new Medicare enrollees will increase Medicare expenditures for the foreseeable future. Medicaid recipients can be expected to decline as jobs are added to the economy, and the percentage of workers covered by employer-sponsored insurance should rise to reflect that growth. Although workers’ salaries have not kept pace, employer-sponsored insurance premiums have grown 119% since 1999 (Kaiser Family Foundation, 2009a), and the inability of workers to pay this increased cost has led to a rise in the percentage of working families who are uninsured. It is essential to read about the changes in the above facts as the American Affordable Care Act is implemented.
Access Another significant problem is poor access to health care (case study in Box 3-1). The American health care system is described as a two-class system: private and public. People with insurance or those who can personally pay for health care are viewed as receiving superior care; those who receive lower quality care are
example, the CDC published health guidelines that contain clinical recommendations for screening, prevention, diagnosis, and treatment. To find and keep current on these guidelines, clinicians must visit the CDC website. The availability of an EHR system allows the embedding of reminders so that the clinician can have access to practice guidelines at the very point of care. Some additional benefits in public health (and these are some of the uses health centers make of such records) include the following: • 24-hour availability of records with downloaded laboratory
results and up-to-date assessments • Coordination of referrals and facilitation of interprofes-
sional care in chronic disease management • Incorporation of protocol reminders for prevention, screen-
ing, and management of chronic disease • Improvement of quality measurement and monitoring • Increased client safety and decline in medication errors
Two federal programs, Medicaid and the State Children’s Health Insurance Program (SCHIP), have effectively used health information technology (HIT) in several key functions including outreach and enrollment, service delivery, and care management, as well as communications with families and the broader goals of program planning and improvement. In early 2009, the surgeon general’s office reopened a web site that had been tried first in 2004, and then closed: an electronic family tree for your health (National Institutes of Health [NIH], 2010). This is described as an easy-to-use computer application for people to keep a personal record of their family health history (https://familyhistory.hhs.gov/FHH/html/index.html). Before the initiative described above, the CDC began a family history public health initiative through the Office of Public Health Genomics to increase awareness of family history as an impor- tant risk factor for common chronic diseases. This initiative had four main activities: 1. Research to define, measure, and assess family history in
populations and individuals 2. Development and evaluation of tools for collecting family
history 3. Evaluation of how family history-based strategies work 4. Promotion of evidence-based applications of family history
to health professionals and the public (CDC, 2013b).
CURRENT HEALTH CARE SYSTEM IN THE UNITED STATES Despite the many advances and the sophistication of the U.S. health care system, the system has been plagued with problems related to cost, access, and quality (see more discussion in Chapters 5, 21, and 26). These problems are different for each person and have been affected by the ability of individuals to obtain health insurance. Most industrialized countries want the same things from their health care system. Several give their government a greater role in health care delivery and eliminate or reduce the use of market forces to control cost, access, and quality. Seemingly, there is no one perfect health care system in the world.
Created by Deborah C. Conway, Assistant Professor, University of Virginia School of Nursing.
Public health nurses who worked with local Head Start programs noted that many children had untreated dental caries. Despite qualifying for Medicaid, only two dentists in the area would accept appointments from Medicaid patients. Dentists asserted that Medicaid patients frequently did not show up for their appointments and that reimbursement was too low compared with other third-party payers. They also said the children’s behavior made it difficult to work with them. So the waiting list for local dental care was approximately 6 years long. Although some nurses found ways to transport clients to dentists in a city 70 miles away, it was very time consuming and was feasible for only a small fraction of the clients. When decayed teeth abscessed, it was possible to get extractions from the local medical center. The health department dentist also saw children, but he, too, was booked for years.
BOX 3-1 Case Study
49CHAPTER 3 The Changing U.S. Health and Public Health Care Systems
Although the IOM report made it clear that the majority of medical errors today were not produced by provider negligence, lack of education, or lack of training, questions were raised about the nurse’s role and workload and its effect on client safety. In a follow-up report, Keeping Patients Safe: Transforming the Work Environment of Nurses, the IOM (2003) stated that nurses’ long work hours pose a serious threat to patient safety, because fatigue slows reaction time, saps energy, and diminishes attention to detail. The group called for state regulators to pass laws barring nurses from working more than 12 hours a day and 60 hours a week—even if by choice (IOM, 2003). Although this information is largely related to acute care, many of the patients who survive medical errors are later cared for in the community.
The culture of quality improvement and safety has made pro- viders and consumers more conscious of safety, but medical errors and untoward events continue to occur. As a means to improve consumer awareness of hospital quality, the Centers for Medicare and Medicaid Services (CMS) began publishing a data- base of hospital quality measures, Hospital Compare, in 2005. Hospital Compare, a consumer-oriented website that provides information on how well hospitals provide recommended care in such areas as heart attack, heart failure, and pneumonia, is avail- able through the CMS website (www.cms.gov). In a further effort, the CMS, in 2008, announced that it will no longer reimburse hospitals, under Medicare guidelines, for care provided for “pre- ventable complications” such as hospital-acquired infections. This reimbursement policy was extended to Medicaid reimburse- ment in 2011 (Galewitz, 2011; CMS, 2009).
The accreditation process for public health is new and the impact of quality and safety monitoring has not yet been deter- mined. The ability of a public health agency or a community to respond to community disasters is one event that will be moni- tored. In December 2014, 60 of 303 local, tribal, and state centralized integration systems, and multijurisdictional health departments, have received accreditation in this new process. The accredited health departments served a 111 million popula- tion base. The purpose of this process is to • Assist and identify quality health departments to improve
performance and quality, and to develop leadership • Improve management • Improve community relationships (Public Health Accredita-
tion Board [PHAB], 2014)
ORGANIZATION OF THE HEALTH CARE SYSTEM An enormous number and range of facilities and providers make up the health care system. These include physicians’ and dentists’ offices, hospitals, nursing homes, mental health facili- ties, ambulatory care centers, freestanding clinics and clinics inside stores such as drugstores, as well as free clinics, public health, and home health agencies. Providers include nurses, advanced practice nurses, physicians and physician assistants, dentists and dental hygienists, pharmacists, and a wide array of essential allied health providers such as physical, occupational, and recreational therapists; nutritionists; social workers; and a range of technicians. In general, however, the American health
(1) those whose only source of care depends on public funds or (2) the working poor, who do not qualify for public funds either because they make too much money to qualify or because they are illegal immigrants. Employment-provided health care is tied to both the economy and to changes in health insurance premi- ums. By 2009, 61% of the nonelderly population continued to obtain health insurance through their employer as a benefit; however, employment did not guarantee insurance (Rowland et al, 2009). This became clear when considering that 9 in 10 (91%) of the middle-class uninsured came from families with at least one full-time worker in jobs that did not offer health insur- ance or where coverage was unaffordable (Rowland et al, 2009).
In 2012, the total number of uninsured persons in the United States was 48 million. As discussed, there was a strong relationship between health insurance coverage and access to health care ser- vices. Insurance status determines the amount and kind of health care people are able to afford, as well as where they can receive care. During this same year 15% of the total population was unin- sured and 48% were covered by employer health insurance. All but 5% of the remaining, or 32%, were covered by government insurance programs (Kaiser Health News 2012; Kaiser Family Foundation, 2014).
The uninsured receive less preventive care, are diagnosed at more advanced disease states, and once diagnosed tend to receive less therapeutic care in terms of surgery and treatment options. There is a safety net for the uninsured or underinsured. As dis- cussed later in this chapter, there are more than 1300 federally funded community health centers throughout the country. Feder- ally funded community health centers provide a broad range of health and social services, using nurse practitioners and RNs, phy- sician assistants, physicians, social workers, and dentists. Commu- nity health centers serve primarily in medically underserved areas, which can be rural or urban. These centers serve people of all ages, races, and ethnicities, with or without health insurance.
Quality The quality of health care leaped to the forefront of concern following the 1999 release of the Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System (IOM, 2000). As indicated in this groundbreaking report, as many as 98,000 deaths a year could be attributed to preventable medical errors. Some of the untoward events categorized in this report included adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint- related injuries or death, falls, burns, pressure ulcers, and mis- taken client identities. It was further determined that high rates of errors with serious consequences were most likely to occur in intensive care units, operating rooms, and emergency departments. Beyond the cost in human lives, preventable medical errors result in the loss of several billions of dollars annually in hospitals nationwide. Categories of error include diagnostic, treatment, and prevention errors as well as failure of communication, equipment failure, and other system fail- ures. Significant to nurses, the IOM estimated the number of lives lost to preventable errors in medication alone represented more than 7000 deaths annually, with a cost of about $2 billion nationwide.
50 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
care system is divided into the following two, somewhat dis- tinct, components: a private or personal care component and a public health component, with some overlap, as discussed in the following sections. It is important to discuss primary health care and examine the interest in developing such a system.
Primary Care System Primary care, the first level of the private health care system, is delivered in a variety of community settings, such as physicians’ offices, urgent care centers, in-store clinics, community health centers, and community nursing centers. Near the end of the past century, in an attempt to contain costs, managed care orga- nizations grew. Managed care is defined as a system in which care is delivered by a specific network of providers who agree to comply with the care approaches established through a case management approach. The key factors are a specified network of providers and the use of a gatekeeper to control access to providers and services. This form of care has not become as prominent as the original concept outlined.
The government tried to reap the benefits of cost savings by introducing the managed care model into Medicare and Med- icaid, with varying levels of success. The traditional Medicare plan involves Parts A and B. Part C, the Medicare Advantage program, incorporates private insurance plans into the Medi- care program including HMO (health maintenance organiza- tion) and PPO (preferred provider organization) managed care models and private fee-for-service plans. In addition, Medicare Part D has been added to cover prescriptions (see Chapter 5).
Public Health System The public health system is mandated through laws that are developed at the national, state, or local level. Examples of public health laws instituted to protect the health of the com- munity include a law mandating immunizations for all children entering kindergarten and a law requiring constant monitoring of the local water supply. The public health system is organized into many levels in the federal, state, and local systems. At the local level, health departments provide care that is mandated by state and federal regulations.
The Federal System The U.S. Department of Health and Human Services (USDHHS; or simply HHS) is the agency most heavily involved with the health and welfare concerns of U.S. citizens. The orga- nizational chart of the HHS (Figure 3-1) shows the office of the secretary, 11 agencies, and a program support center (USDHHS, 2014a). Ten regional offices are maintained to provide more direct assistance to the states. Their locations are shown in Table 3-1. The HHS is charged with regulating health care and over- seeing the health status of Americans. See Box 3-2 for the goals and objectives of the HHS strategic plan for fiscal years 2010- 2015. Newer areas in the HHS are the Office of Public Health Preparedness, the Center for Faith-Based and Neighborhood Partnerships and the Office of Global Affairs. The Office of Public Health Preparedness was added to assist the nation and states to prepare for bioterrorism after September 11, 2001. The Faith-Based Initiative Center was developed by President George W. Bush to allow faith communities to compete for
U.S. Department of Health and Human Services: HHS Regional Offices. Retrieved December 2014 from http://www.hhs.gov/about/regions/
Region Location Territory
1 Boston Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont
2 New York New Jersey, New York, Puerto Rico, Virgin Islands
3 Philadelphia Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia
4 Atlanta Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
5 Chicago Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin
6 Dallas Arkansas, Louisiana, New Mexico, Oklahoma, Texas
7 Kansas City Iowa, Kansas, Missouri, Nebraska 8 Denver Colorado, Montana, North Dakota, South
Dakota, Utah, Wyoming 9 San Francisco Arizona, California, Hawaii, Nevada,
American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Republic of the Marshall Islands, Republic of Palau
10 Seattle Alaska, Idaho, Oregon, Washington
TABLE 3-1 Regional Offices of the U.S. Department of Health and Human Services
federal money to support their community activities. The goal of the Office of Global Affairs is to promote global health by coordinating HHS strategies and programs with other govern- ments and international organizations (USDHHS, 2014a).
The U.S. Public Health Service (USPHS; or simply PHS) is a major component of the Department of Health and Human Services. The PHS consists of eight agencies: Agency for Health- care Research and Quality, Agency for Toxic Substances and Dis- eases Registry, Centers for Disease Control and Prevention, Food and Drug Administration, Health Resources and Services Admin- istration, Indian Health Service, National Institutes of Health, and Substance Abuse and Mental Health Services Administra- tion. Each has a specific purpose (see Chapter 8 for relevancy of the agencies to policy and providing health care). The PHS also has a Commissioned Corps, which is a uniformed service of more than 6500 health professionals who serve in many HHS and other federal agencies. The surgeon general is head of the Commis- sioned Corps. The corps fills essential services for public health, clinic and provides leadership within the federal government departments and agencies to support the care of the underserved and vulnerable populations (USPHS, 2014).
An important agency and a recent addition to the federal government, the U.S. Department of Homeland Security (USDHS, or simply DHS), was created in 2003 (USDHS, 2014). The mission of the DHS is to prevent and deter terrorist attacks and protect against and respond to threats and hazards to the nation. The goals for the department include awareness, pre- vention, protection, response, and recovery. The DHS works with first responders throughout the United States, and through the development of programs such as the Community
51CHAPTER 3 The Changing U.S. Health and Public Health Care Systems
FIG 3-1 Organization of the U.S. Department of Health and Human Services. (From U.S. Depart- ment of Health and Human Services; Available at http://www.hhs.gov/about/orgchart/.)
Office of Intergovernmental
and External Affairs (IEA)
Office of the Assistant Secretary
for Legislation (ASL)
Office of the Assistant Secretary for Administration
(ASA)
Office of the Assistant Secretary
for Financial Resources (ASFR)
Office of The Assistant Secretary
for Public Affairs (ASPA)
Office of the Assistant Secretary for Planning
and Evaluation (ASPE)
Office of the Assistant Secretary for Preparedness
and Response∗
(ASPR)
Office of Minority Health (OMH)#
Office of Health Reform
(OHR)
The Executive Secretariat
Secretary Deputy Secretary
Chief of Staff
Program Support Center (PSC)
Office of the Assistant Secretary
for Health∗
(OASH)
Office of Inspector General (OIG)
Center for Faith-based & Neighborhood
Partnerships (CFBNP)
Departmental Appeals Board
(DAB)
Office of Medicare Hearings and
Appeals (OMHA)
Office of the National Coordinator for Health
Information Technology (ONC)
Office of Global Affairs∗
(OGA)
Office for Civil Rights (OCR)
Office of the General Counsel
(OGC)
Administration for Children and
Families (ACF)
Agency for Healthcare
Research and Quality∗
(AHRQ)
Centers for Disease Control and Prevention∗
(CDC)
Substance Abuse & Mental Health Services
Administration∗
(SAMHSA)
∗Designates a component of the U.S. Public Health Service.
#Administratively supported by the Office of the Assistant Secretary for Health
Administration for Community Living
(ACL)
Agency for Toxic Substances &
Disease Registry∗
(ATSDR)
Centers for Medicare &
Medicaid Services (CMS)
Health Resources and Services
Administration∗
(HRSA)
National Institutes of Health∗
(NIH)
Food and Drug Ddministration∗
(FDA)
Indian Health Services∗
(IHS)
52 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
important functions, such as health care financing and admin- istration for programs such as Medicaid, providing mental health and professional education, establishing health codes, licensing facilities and personnel, and regulating the insurance industry. State systems also have an important role in direct assistance to local health departments, including ongoing assessment of health needs (see Chapter 46).
Emergency Response Team (CERT) program trains people to be better prepared to respond to emergency situations in their communities. Nurses working in state and local public health departments as well as those employed in hospitals and other health facilities may be called on to respond to acts of terrorism or natural disaster in the course of their careers, and the DHS, along with the Food and Drug Administration (FDA) and CDC, is developing programs to ready nurses and other health care providers for an uncertain future (USDHS, 2014).
The State System When the United States faced a pandemic flu outbreak in 2009, the federal government and the public health community quickly prepared to meet the challenge of educating the public and health professionals about the H1N1 flu and making vac- cinations available. In 2014 public health within the states was responding to an enterovirus affecting large numbers of chil- dren with systems of upper respiratory disease and weakness in arms and legs. The virus was considered life-threatening (CDC, 2014b). In addition to standing ready for disaster prevention or response, state health departments have other equally
*In process of being updated for 2014-2018. From the U.S. Department of Health and Human Services, 2014. Retrieved July 2, 2014, from http://www.hhs.gov/secretary/about/priorities.html.
GOAL 1: Strengthen Health Care Objective A Make coverage more secure for those who have insurance, and extend affordable coverage to the uninsured. Objective B Improve health care quality and patient safety. Objective C Emphasize primary and preventive care linked with community prevention services. Objective D Reduce the growth of health care costs while promoting high-value, effective care. Objective E Ensure access to quality, culturally competent care for vulnerable populations. Objective F Promote the adoption and meaningful use of health information technology.
GOAL 2: Advance Scientific Knowledge and Innovation Objective A Accelerate the process of scientific discovery to improve patient care. Objective B Foster innovation to create shared solutions. Objective C Invest in the regulatory sciences to improve food and medical product safety. Objective D Increase our understanding of what works in public health and human service practice.
GOAL 3: Advance the Health, Safety, and Well-Being of the American People Objective A Promote the safety, well-being, resilience, and healthy development of children and youth. Objective B Promote economic and social well-being for individuals, families, and communities. Objective C Improve the accessibility and quality of supportive services for people with disabilities and older adults. Objective D Promote prevention and wellness. Objective E Reduce the occurrence of infectious diseases. Objective F Protect Americans’ health and safety during emergencies, and foster resilience in response to emergencies.
GOAL 4: Increase Efficiency, Transparency, Accountability and Effectiveness of HHS Programs Objective A Ensure program integrity and responsible stewardship of resources. Objective B Fight fraud and work to eliminate improper payments. Objective C Use HHS data to improve the health and well-being of the American people. Objective D Improve HHS environmental, energy, and economic performance to promote sustainability.
GOAL 5: Strengthen the Nation’s Health and Human Service Infrastructure and Workforce Objective A Invest in the HHS workforce to meet America’s health and human service needs today and tomorrow. Objective B Ensure that the Nation’s health care workforce can meet increased demands. Objective C Enhance the ability of the public health workforce to improve public health at home and abroad. Objective D Strengthen the Nation’s human service workforce. Objective E Improve national, state, local, and tribal surveillance and epidemiology capacity.
BOX 3-2 USDHHS Strategic Plan Goals and Objectives—Fiscal Years 2010-2015*
LEVELS OF PREVENTION
Primary Prevention Implement a community-level program such as walking for exercise to assist citizens in improving health behaviors related to lifestyle.
Secondary Prevention Implement a family-planning program to prevent unintended pregnancies for young couples who attend the local community health center.
Tertiary Prevention Provide a self-management asthma program for children with chronic asthma to reduce their need for hospitalization.
Related to the Public Health Care System
53CHAPTER 3 The Changing U.S. Health and Public Health Care Systems
company stocks are now traded by major stock exchanges, direc- tors receive benefits when profits are high, and the locus of control had shifted from the provider to the payer. Many compet- ing forces have influenced the changing design of the health care system, some of which are consumers, employers (purchasers), care delivery systems, and state and federal legislation.
First, consumers want lower costs and high-quality health care without limits and with an improved ability to choose the providers of their choice. Second, employers (purchasers of health care) want to be able to obtain basic health care plans at reasonable costs for their employees. Many employers have seen their profits diminish as they put more money into providing adequate health care coverage for employees. Third, health care systems want a better balance between consumer and purchaser demands. Thus they continually watch their own budget and expenses. To maintain a profit while providing quality care, many health care delivery groups have downsized and created alliances, mergers, and other joint ventures. Finally, legislation, especially concerning access and quality, continues to be enacted, thus creating one more force helping shape a health care system. The goal of “evidence-based care” is to ensure quality.
Many have said that solving the health care crisis requires the institution of a rational health care system that balances equity, cost, and quality. The fact that millions of people have been uninsured, that wide disparities have existed in access, and that a large proportion of deaths each year seem attributable to prevent- able causes (errors as well as tobacco, alcohol abuse, preventable injuries, and obesity) has indicated that the American system is currently not serving the best interests of the American popula- tion. The WHO has suggested that integrating primary care and public health into a primary health care system will be the basis for better health for all world citizens (WHO, 1986a).
Integration of Public Health and the Primary Care Systems Although primary care and public health share a goal of pro- moting the health and well-being of all people, these two disci- plines historically have operated independently of one another. Problems that stem from this separation have long been recog- nized, but new opportunities are emerging for bringing these systems together to promote lasting improvements in the health of individuals, communities, and populations (IOM, 2012).
In recognition of this potential, the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA), both agencies of the Depart- ment of Health and Human Services (HHS), asked the Institute of Medicine (IOM) to convene a committee of experts, includ- ing input from nursing, to examine the integration of primary care and public health (IOM, 2012).
To recognize the differences in these two systems, definitions were used to guide the work of the experts. Primary care was defined as “the providing of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, while developing partnerships with patients and practicing in the context of family and community” (IOM, 1996, p. 1). Public health was defined as “fulfilling society’s interest in assuring conditions in
Nurses serve in many capacities in state health departments; they are consultants, direct service providers, researchers, teach- ers, and supervisors. They also participate in program develop- ment, planning, and the evaluation of health programs.
The Local System The local health department has direct responsibility to the citi- zens in its community or jurisdiction. Services and programs offered by local health departments vary depending on the state and local health codes that must be followed, the needs of the community, and available funding and other resources. For example, one health department might be more involved with public health education programs and environmental issues, whereas another health department might emphasize direct client care. Local health departments vary in providing sick care or even primary care (see Chapter 46). More often than at other levels of government, public health nurses at the local level provide population level or direct services. Some of these nurses deliver special or selected services, such as follow-up of contacts in cases of tuberculosis or venereal disease or providing child immunization clinics. Others provide more general care, deliver- ing services to families in certain geographic areas. This method of delivery of nursing services involves broader needs and a wider variety of nursing interventions. The local level often provides an opportunity for nurses to take on significant leadership roles, with many nurses serving as directors or managers.
Since the tragedy of September 11, 2001, state and local health departments have increasingly focused on emergency preparedness and response. In case of an event, state and local health departments in the affected area will be expected to collect data and accurately report the situation, to respond appropriately to any type of emergency, and to ensure the safety of the residents of the immediate area, while protecting those just outside the danger zone. This level of knowledge—to enable public health agencies to anticipate, prepare for, recognize, and respond to terrorist threats or natural disasters such as hurri- canes or floods—has required a level of interstate and federal- local planning and cooperation that is unprecedented for these agencies. Whether participating in disaster drills or preparing a local high school for use as a shelter, nurses play a major role in meeting the challenge of an uncertain future.
FORCES INFLUENCING CHANGES IN THE HEALTH CARE SYSTEM Although most people are personally satisfied with their own physicians or nurse practitioners, at present few people are satis- fied with the health care system in general. Costs have been high and have continued to rise while quality and access have been uneven across the country and within communities, depending on the ability to pay. What, then, were some of the factors that might influence health care to change? First, as a nation, citizens must decide what has to be provided for all people, who will be in charge of the system, and who will pay for what. In recent years, federal and state services have been reduced and more responsibility for health care delivery has been moved to the private sector. Health care has become big business. Health care
54 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
help in defining health problems and in developing approaches to address the problems. The setting for primary health care is within all communities of a country and involves all aspects of society (WHO, 1978).
The primary health care movement officially began in 1977 when the 30th World Health Organization (WHO) Health Assembly adopted a resolution accepting the goal of attaining a level of health that permitted all citizens of the world to live socially and economically productive lives. At the international conference in 1978 in Alma-Ata, in the former Soviet Union (Russia), it was determined that this goal was to be met through PHC. This resolution, the Declaration of Alma-Ata, became known by the slogan “Health for All (HFA) by the Year 2000,” which captured the official health target for all the member nations of the WHO. In 1998 the program was adapted to meet the needs of the new century and was deemed “Health for All in the 21st Century.”
In 1981 the WHO established global indicators for monitor- ing and evaluating the achievement of HFA. In the World Health Statistics Annual (WHO, 1986b), these indicators are grouped into the following four categories: health policies, social and economic development, provision of health care, and health status. The indicators suggest that health improvements are a result of efforts in many areas, including agriculture, industry, education, housing, communications, and health care. Because PHC is as much a political statement as a system of care, each United Nations member country interprets PHC according to its own culture, health needs, resources, and system of govern- ment. Clearly, the goal of PHC has not been met in most coun- tries including the United States.
Promoting Health/Preventing Disease: Year 2020 Objectives for the Nation As a WHO member nation, the United States has endorsed primary health care as a strategy for achieving the goal of “Health for All in the 21st Century.” However, the PHC empha- sis on broad strategies, community participation, self-reliance, and a multidisciplinary health care delivery team is not the primary strategy for improving the health of the American people. The national health plan for the United States identifies disease prevention and health promotion as the areas of most concern in the nation. Each decade since the 1980s has been measured and tracked according to health objectives set at the beginning of the decade. The U.S. Public Health Service of the HHS publishes the objectives after gathering data from health professionals and organizations throughout the country.
Healthy People 2020, which was officially launched in Decem- ber 2010 (USDHHS, 2010a), is composed of a large number of objectives related to 42 topic areas. These objectives are designed to serve as a road map for improving the health of all people in the United States during the second decade of the twenty-first century. These objectives are described by four main goals (USDHHS, 2010b): • Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death • Achieve health equity, eliminate disparities, and improve the
health of all groups
which people can be healthy” (IOM, 1988, p. 140). The purpose of the integration is to achieve the WHO goal of primary health care.
Potential Barriers to Integration Contrasting the two systems, primary care, which can be either a public or a private entity, is person focused, provides a point of first contact for individuals to address health problems, and is considered comprehensive and provides coordination of indi- vidual care; public health can also be delivered through public and private entities to contribute to the health of society, but government plays a major role in public health. Health depart- ments are legally bound to provide essential public health ser- vices, and to work with the total community and multiple stakeholders to address community-level health problems. Public health also has specific functions of assurance, assess- ment, and policy development to address community-level health issues and has a charge to create healthy communities (see Chapter 1).
In addition to differing roles and functions and issues related to funding, different clients and different foci will need to be addressed to form a solid foundation for a partnership. Primary care is largely funded through individual client payments, health insurance, and sometimes through federal grants. Public health is largely funded through tax dollars, federal and state grants, and sometimes health insurance payments through Medicare and Medicaid. Primary care serves the individuals who present to the practice while public health serves to assess the health problems of the population. Both focus on meeting the most prevalent health needs of the population. Primary care focuses more on the curative aspect of care while public health focuses more on the prevention of health problems (Levesque et al, 2013).
The common goal of public health and primary care, although these systems operate independently, is to ensure a healthier population. Integration of these two systems has the potential to produce a greater impact on the health of popula- tions than either could have working alone, said the committee of experts convened by the IOM (2012).
The Healthy People initiatives, beginning with the U.S. surgeon general’s 1979 report, indicate the long-standing desire to improve population health in the United States.
Primary Health Care Primary health care (PHC), the goal of the integration of public health and primary care, includes a comprehensive range of services including public health and preventive, diagnostic, therapeutic, and rehabilitative services. This system is com- posed of public health agencies, community-based agencies and primary care clinics, and health care providers. From a concep- tual point of view, PHC is essential care made universally acces- sible to individuals, families, and the community. Health care is made available to them with their full participation and is pro- vided at a cost that the community and country can afford. This care is not uniformly available and accessible to all people in many countries including the United States. Full community participation means that individuals within the community
55CHAPTER 3 The Changing U.S. Health and Public Health Care Systems
• Create social and physical environments that promote good health for all
• Promote quality of life, healthy development, and healthy behaviors across all life stages These goals provide the framework with which measurable
health indicators can be tracked. The emphasis on the social and physical environment moves Healthy People 2020 from the traditional disease-specific focus to a more holistic view of health consistent with a public health frame of reference (Healthy People 2020, 2012). This in turn will encourage public health nurses to broaden their scope to all aspects of their clients’ lives that may need assessment and intervention, includ- ing where they live, the condition of their home, and how the
appropriateness of their environment may change as the client ages. The Healthy People 2020 box presents indicators of Healthy People 2020 related to the strengthening of the public health infrastructure. These objectives will assist nurses in having data to show that their assessments and interventions are changing practice.
HEALTH CARE DELIVERY REFORM EFFORTS—UNITED STATES Over the centuries, both health insurance and health care reform have been the focus of numerous discussions and politi- cal battles. As can be seen in Chapter 2, the first health insurance plan, established in about 1798 in the United States, was for the Merchant Marines to assist in treating infectious diseases and protecting the ports of entry into the United States. The United States has discussed national health care reform since the 1900s (see Chapter 5). In 1912 Theodore Roosevelt campaigned on a health insurance proposal for industry. Then in 1915 the “pro- gressive reformers” campaigned for a state-based system of compulsory health insurance. In the 1920s, the Committee on the Costs of Medical Care suggested group medicine and vol- untary insurance, and this movement was labeled as promoting “socialized medicine.” Since the 1930s, through surveys, Ameri- cans have generally shown support of the goals of guaranteed access to health care and health insurance, and a governmental role in financing of care. Some strides were made in improving access and defining the role of government financing through
Dorn S, Hill I, Hogan S: The secrets of Massachusetts’success: why 97 percent of state residents have health coverage: state health access reform evaluation, Rommneycare-The truth about Massachusetts health care. 2014, accessed at mittromneycentral.com/resources/romneycare. 9/25/20142009, Robert Wood Johnson Foundation. Available at http://www.urban.org/uploadedpdf/411987_massachusetts_success_brief.pdf. Accessed September 19, 2012.
It is often said that the states are the laboratories of democracy. One state, Massachusetts, began an experiment in health reform in 2006. Two years after health reform legislation became effective, only 2.6% of Massachusetts resi- dents were uninsured, the lowest percentage ever recorded in any state (Dorn et al, 2009). However, the program became one of the most successful and a model for the Affordable Care Act. After 5 years approximately 98% to 99% of all of the commonwealth’s citizens were covered by the plan.
Although other states have experimented with various programs to decrease the number of uninsured, the Massachusetts plan has had the most success. The health reform plan rests on an individual mandate that requires everyone who can afford insurance to purchase coverage. Those unable to afford insur- ance receive subsidies that allow low-income individuals and families to pur- chase coverage. A new state-run program, Commonwealth Care (CommCare), provides benefits to adults who are not eligible for Medicaid but whose incomes fall below 300% of the federal poverty level.
To understand how the state was so successful in this effort toward universal coverage, a group of evaluators met with 15 key informants representing hospitals, community health centers, insurance companies, Medicaid, and CommCare. Several factors, it was found, have contributed to the historic level of coverage seen in the state. Rather than requiring consumers to complete separate applica- tions for programs such as Medicaid, the Children’s Health Insurance Program (CHIP), or CommCare, a single application system provides entry to all the state programs. If an uninsured client was admitted to a hospital or visited a community
health center, his or her eligibility was automatically evaluated and, if eligible, the client would be automatically converted to CommCare coverage, even without completing an application. A “Virtual Gateway” has been developed through which staff of community-based organizations have been trained to complete online applications on behalf of consumers, and to provide education and counseling about insurance options to underserved communities. By holding back reimburse- ment to providers who do not help consumers sign up for one of the available insurance options, hospitals and health centers are motivated to dedicate staff to provide education and counseling to the formerly uninsured. The result is that at least half of the new enrollees in Medicaid and CommCare have been enrolled without filling out any forms on their own. In addition to these efforts, shortly after the reform legislation was enacted, the state financed a massive public education effort to inform consumers about their new options.
Nurse Use As health reform begins on the national level, nurses can play a crucial role in driving down the number of uninsured. Nurses should educate themselves so that they can encourage clients to apply and take advantage of all available coverage options. Taking an active role in consumer educational programs is a natural extension of a nurse’s role as a client advocate. Nurses can promote legislation to simplify enrollment processes and encourage the development of shared databases for community health care providers, thus preventing consum- ers from falling through the cracks in our fragmented health care system.
EVIDENCE-BASED PRACTICE
HEALTHY PEOPLE 2020
• PHI-7 (Developmental): Increase the proportion of population-based Healthy People 2020 objectives for which national data are available for all major population groups.
• PHI-8: Increase the proportion of Healthy People 2020 objectives that are tracked regularly at the national level.
Selected Objectives That Pertain to Strengthening the Public Health Infrastructure
From U. S. Department of Health and Human Services. Healthy People 2020. Available at http://www.healthypeople.gov/2020topics objectives2020/default.aspx. Accessed December 27, 2010.
56 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
the passing of Medicare in 1965, with Medicaid as a part of the proposal for social security amendments, and the Children’s Health Insurance Program bill passed in 1996. Many proposals have been put forward over the decades for health care reform, as well as health insurance reform. Beginning in the 1970s Senator Ted Kennedy, President Richard Nixon, President Gerald Ford, and President Jimmy Carter all made health- related proposals, all followed by the Health Security Act of President Bill Clinton. None were accepted by Congress (Kaiser Family Foundation, 2009b).
Nurses and the American Nurses Association have been involved in the debates about health care reform over time. In its 2005 Healthcare System Reform Agenda, the American Nurses Association (American Nurses Association, 2008) pro- moted a blueprint for reform that includes the following: • Health care is a basic human right, and so a restructured
health care system with universal access to a standard package of essential health care services for all citizens and residents must be assured.
• The development and implementation of health policies that reflect the aims put forth by the Institute of Medicine (safe, effective, patient centered, timely, efficient, equitable) and are based on outcomes research will ultimately save money.
• The overuse of expensive, technology-driven, acute, hospital- based services must give way to a balance between high-tech treatment and community-based and preventive services, with emphasis on the latter.
• A single-payer mechanism is the most desirable option for financing a reformed health care system. In 2010 the Affordable Care Act (ACA) was passed, after
introduction by the Obama team and after much debate. This act reflects many of the tenets offered by the ANA in its Health System Reform Agenda and puts into place comprehensive health insurance reforms that are to be implemented by 2014 and beyond. The act was passed to improve quality and lower health care costs, provide access to care, and provide for con- sumer protection. Table 3-2 provides an overview of the key features of the act by year. The ACA has a major focus on pre- vention. This focus is designed to improve the health of Ameri- cans, but also help to reduce health care costs and improve quality of care. Through the Prevention and Public Health Fund, the ACA will address factors that influence health— housing, education, transportation, the availability of quality affordable food, and conditions in the workplace and the envi- ronment. By concentrating on the causes of chronic disease, the ACA will move the nation from a focus on sickness and disease to one based on wellness and prevention.
To improve the health of Americans, ways to make the healthy choice in each community an easy and affordable choice must be found. In addition, within the law there are specific benefits for women, young adults, and families. It strengthens Medicare and holds insurance companies account- able (USDHHS, 2014b).
Since the close of the first enrollment period for the ACA in early 2014, the numbers of uninsured have declined (see Chapter 1). Because of a lag in data, the effects of the health care reform will not be known until 2015.
Discussions and debates will continue about the impact of the ACA, and the IOM’s discussions of integrating public health and primary care, reducing cost, increasing quality, and access for all Americans. It is important not to lose sight of the goal: to protect and improve the health of all populations. After spending 18 months in a public policy fellowship and working with the Ways and Means Committee in Congress, Nancy Rid- enour, PhD, RN and dean of the College of Nursing at the University of New Mexico, described her opportunity to work with others as the ACA was being developed. At a board of nursing celebration in Kentucky in the summer of 2014, Dr. Ridenour explained to the audience that it would be important for nurses to be involved in the implementation of the ACA to promote the success of the health care changes proposed. It is all about the influence of nurses and the nursing profession! (Kentucky Board of Nursing, 2014).
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES Targeted Competency: Informatics—Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.
Important aspects of Informatics include the following: Knowledge: Identify essential information that must be available in a
common database to support interventions in the health care system. Skills: Use information management tools to monitor outcomes of interven-
tion processes. Attitudes: Value technologies that support decision making, error preven-
tion, and case coordination. Informatics Question: Updated informatics definitions focus on having
access to the necessary client and system information at the right time, to make the best clinical decision. In the U.S. Department of Health and Human Services (USDHHS) Strategic Plan for 2010 to 2015, there are five overarching goals.
Goal 1, Objective C focuses on “Emphasizing primary and preventive care linked with community prevention services.” Which community data would a public health nurse assess to determine the work that needs to be done in a community related to this USDHHS strategic goal?
Answer: To assess future work that could be done to effectively address Goal 1, Objective C, public health nurses might gather data in the following areas: • How informed are members of the community about existing community
services that support health promotion (e.g., exercise classes, educational classes, self-management training, and nutrition counseling)?
• How relevant are the services offered by health centers to the needs of a community?
• Do payment or insurance barriers exist for individuals to access preventive health services?
• How accessible is entry to care for vulnerable populations such as pregnant women and infants?
• What community-based prevention programs exist for individuals with and at risk for chronic diseases and conditions?
• How available are substance abuse screening and intervention programs?
• How linked are primary care and health promotions and wellness programs in a community?
57CHAPTER 3 The Changing U.S. Health and Public Health Care Systems
2010 New Consumer Protections • Putting information for consumers online. • Prohibiting denying coverage of children based on pre-existing conditions. • Prohibiting insurance companies from rescinding coverage. • Eliminating lifetime limits on insurance coverage. • Regulating annual limits on insurance coverage. • Establishing consumer assistance programs in the states.
Improving Quality and Lowering Costs • Providing small business health insurance tax credits. • Offering relief for 4 million seniors who hit the Medicare prescription drug
“donut hole.” • Providing free preventive care. • Preventing disease and illness. • Cracking down on health care fraud.
Increasing Access to Affordable Care • Providing access to insurance for uninsured Americans with pre-existing
conditions. • Extending coverage for young adults. • Expanding coverage for early retirees. • Rebuilding the primary care workforce. • Holding insurance companies accountable for unreasonable rate hikes. • Allowing states to cover more people on Medicaid. • Increasing payments for rural health care providers. • Strengthening community health centers.
2011 Improving Quality and Lowering Costs • Offering prescription drug discounts. • Providing free preventive care for seniors. • Improving health care quality and efficiency. • Improving care for seniors after they leave the hospital. • Introducing new innovations to bring down costs.
Increasing Access to Affordable Care • Increasing access to services at home and in the community.
Holding Insurance Companies Accountable • Bringing down health care premiums. • Addressing overpayments to big insurance companies and strengthening
Medicare Advantage.
TABLE 3-2 Overview of Key Features of the Affordable Care Act by Year
For more detail about each of the bulleted statements please refer to HHS.gov/HealthCare (Key Features of the Affordable Care Act, 2014: http://www.hhs.gov/healthcare/facts/timeline/).
2012 Improving Quality and Lowering Costs • Linking payment to quality outcomes. • Encouraging integrated health systems. • Reducing paperwork and administrative costs. • Understanding and fighting health disparities.
Increasing Access to Affordable Care • Providing new, voluntary options for long-term care insurance.
2013 Improving Quality and Lowering Costs • Improving preventive health coverage. • Expanding authority to bundle payments.
Increasing Access to Affordable Care • Increasing Medicaid payments for primary care doctors. • Open enrollment in the health insurance marketplace begins.
2014 New Consumer Protections • Prohibiting discrimination due to pre-existing conditions or gender. • Eliminating annual limits on insurance coverage. • Ensuring coverage for individuals participating in clinical trials.
Improving Quality and Lowering Costs • Making care more affordable. • Establishing the health insurance marketplace. • Increasing the small business tax credit.
Increasing Access to Affordable Care • Increasing access to Medicaid. • Promoting individual responsibility.
2015 Improving Quality and Lowering Costs • Paying physicians based on value, not volume.
P R A C T I C E A P P L I C A T I O N During a well-child clinic visit, Jenna Wells, RN, met Sandra Farr and her 24-month-old daughter, Jessica. The Farrs had recently moved to the community. Mrs. Farr stated that she knew that Jessica needed the last in a series of immunizations and because they did not have health insurance, she brought her daughter to the public health clinic. On initial assessment, Mrs. Farr told the nurse that her husband would soon be employed, but the family had no health care coverage for the next 30 days. The Farrs also needed to decide which health care package they wanted. Mr. Farr’s company offers a preferred provider organi- zation (PPO), a health maintenance organization (HMO), and
a community nursing clinic plan to all employees. Neither Mr. nor Mrs. Farr has ever used an HMO or a community nursing clinic, and they are not sure what services are provided.
Mrs. Farr asks Nurse Wells what she should do. Nurse Wells should do which of the following?
A. Encourage Mrs. Farr to choose the HMO because it will pay more attention to the family’s preventive needs, and direct Mrs. Farr to other sources of health care should the family need to see a provider while they are uninsured.
B. Encourage Mrs. Farr to choose the PPO because it will have a greater number of qualified providers from which to
58 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
P R A C T I C E A P P L I C A T I O N — cont’d choose, and direct Mrs. Farr to other sources of health care should the family need to see a provider while they are uninsured.
C. Encourage Mrs. Farr to choose the local community nursing center because it is staffed with nurse practitioners who are well qualified to provide comprehensive health care with an emphasis on health education, and direct Mrs. Farr to other sources of health care should the family need to see a pro- vider while they are uninsured.
D. Explain the differences between a PPO, HMO, and commu- nity nursing clinic and encourage Mrs. Farr to discuss the options with her husband about signing up for a health insurance plan under the ACA plans, and direct Mrs. Farr to other sources of health care should the family need to see a provider while they are uninsured. Answers can be found on the Evolve site.
K E Y P O I N T S • Health care in the United States is made up of a personal
care system and a public health system, with overlap between the two systems.
• Primary care is a personal health care system that provides for first contact and continuous, comprehensive, and coor- dinated care.
• Primary health care is essential care made universally acces- sible to individuals and families in a community. Health care is made available to them through their full participation and is provided at a cost that the community and country can afford.
• Primary care and the public health systems are part of primary health care.
• Public health refers to organized community efforts designed to prevent disease and promote health.
• Important trends that affect the health care system include demographic, social, economic, political, and technological trends.
• More than 48 million people in the United States were unin- sured in 2012, and many more simply lacked access to ade- quate health care.
• With the implementation of the Affordable Care Act (ACA), by 2014 the numbers of uninsured dropped by 8%.
• Many federal agencies are involved in government health care functions. The agency most directly involved with the health and welfare of Americans is the U.S. Department of Health and Human Services (USDHHS).
• Most state and local jurisdictions have government activities that affect the health care field.
• Health care and insurance reform measures seek to make changes in the cost and quality of and access to the present system, such as the ACA passed in 2010.
• To achieve the specific health goals of programs such as Healthy People 2020, primary care and public health must work within the community for community-based care.
• The most sustainable individual and system changes come when people who live in the community have actively participated.
• Nurses are more than able to fill the gap between personal care and public health because they have skills in assessment, health promotion, and disease and injury prevention; knowl- edge of community resources; and the ability to develop relationships with community members and leaders.
• Nurses are important to the success of the ACA.
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Compare local and state services. How have they been
affected by the implementation of the ACA? What changes would you recommend to your local health department to improve public health and primary care?
2. Debate the following with a classmate. The major problem with the health care system is (choose one of the following topics): a. Escalating costs (including those from increased
technology) b. Fragmentation of services c. Limited access to care d. Quality of care
Explain your choice and give examples of reasons for the choice.
3. Visit your local health department and determine how its services fit into a primary care, public health, community- based health care system. Illustrate what you mean by your answer with examples.
4. Determine whether there is a federally funded health center in your community. If yes, learn what services are provided. Are there services that are needed in the community that are not being provided? If so, what are they?
59CHAPTER 3 The Changing U.S. Health and Public Health Care Systems
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4
Perspectives in Global Health Care
Anita Hunter, PhD, APRN-CPNP Dr. Anita Hunter, a pediatric nurse practitioner since 1975, has worked with vulnerable populations of children and families living in poor urban and rural communities. Her work with culturally diverse populations expanded to the international arena in 1994 when she began taking students and faculty on clinical immersion experiences into Northern Ireland, Ghana, Mexico, the Dominican Republic, and Uganda; each trip evolved into sustain- able health initiatives within the country. Dr. Hunter serves as an Executive Board Member for the Holy Innocents Children’s Hospital Uganda NGO (nongovernmental organization) that oversees the development and management of the Holy Innocents Children’s Hospital in Uganda. Dr. Hunter holds the BSN from Elms College; the PNP from Northeastern University; an MSN-CNS from the University of Massachusetts and the PhD from the University of Connecticut. Currently, Dr. Hunter is Professor and Co-Coordinator of the FNP track at Washington State University, Vancouver, WA.
O B J E C T I V E S After reading this chapter, the student should be able to do the following:
1. Identify the major aims and goals for global health that have been presented by the Millennium Global Developmental Goals: 2013 Report
2. Identify the health priorities of Health for All in the 21st Century (HFA21) and Healthy People 2020.
3. Analyze the role of nursing in global health. 4. Explain the role and focus of a population-based
approach for global health. 5. Discuss the many causes of global health problems.
6. Identify some solutions for at least one of these global health problems.
7. Describe how global health is related to economic, industrial, environmental, and technological development.
8. Compare and contrast the health care system in a developed country with one in a less developed country.
9. Define burden of disease. 10. Explain how countries can prepare for natural and
manmade disasters and the role of nurses in these efforts. 11. Describe at least five organizations that are involved in
global health.
K E Y T E R M S bilateral organization, p. 69 bioterrorism, p. 86 chemical emergency, p. 86 determinants, p. 66 developed country, p. 63 disability-adjusted life-years, p. 75 environmental sanitation, p. 77 genocide, p. 86 global burden of disease, p. 75 global health diplomacy, p. 72 health commodification, p. 71 Health for All in the 21st Century (HFA21), p. 63 less developed country, p. 63 man-made disasters, p. 86 Millennium Development Goals, p. 64
multilateral organizations, p. 69 natural disasters, p. 85 nongovernmental organizations (NGOs), p. 69 Pan American Health Organization (PAHO), p. 70 philanthropic organizations, p. 71 population health, p. 66 primary health care, p. 67 private voluntary organizations (PVOs), p. 69 radiation poisoning, p. 86 religious organizations, p. 71 United Nations Children’s Fund (UNICEF), p. 70 World Bank, p. 70 World Health Organization (WHO), p. 69 —See Glossary for definitions
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz • Case Studies
• Glossary • Answers to Practice Application • Resource Tool
• Resource Tool 4.A: Millennium Development Goals Report 2013
62 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
Alexander and Blackburn (2013) did a historical analysis surveying data (2006- 2009) to examine the temporal pattern of recurrent diarrheal outbreaks in Chobe District in Botswana in patients less than 5 years of age; as well as had patients of all ages presenting with diarrheal disease and medical staff complete a questionnaire survey tool during two diarrheal outbreaks (2011- 2012). Cluster analysis and classification and regression trees (CART) were used to evaluate patient attributes by outbreak. Results showed that peak outbreaks appeared to coincide with major hydrological phenomena (rainfall/ flood recession), water shortages, and water quality deficiencies. Public health strategy should be directed at securing improved water service and correcting water quality deficiencies. Public health education should include increased emphasis on sanitation practices when providing care to household members with diarrhea.
Nurse Use Being culturally sensitive and responsive means that nurses need to under- stand where patients come from, what barriers exist that contribute to the public health problems they develop, and what can reasonably be done to reduce the health consequences of poverty and access deprivation. Given this research study, how could you as a nurse help reduce the incidence of diarrhea contamination in a family and across the village? One example might be to gather all the women together who have sick children and teach them how to improve sanitation and provide clean water; then have them go and teach the remainder of the village and expand that teaching to other villages. What might be other examples?
EVIDENCE-BASED PRACTICEThis chapter presents an overview of the major public health problems of the world, along with a description of the role and involvement of nurses in global and community health care settings. It describes health care delivery from a global and population health perspective, illustrates how health systems operate in different countries, presents examples of organiza- tions that address global health, and explains how economic development relates to health care throughout the world.
OVERVIEW AND HISTORICAL PERSPECTIVE OF GLOBAL HEALTH Global warming and the melting of the polar ice caps; world- wide droughts and the natural disasters of blizzards, hurricanes, tornadoes, volcanoes, typhoons, and earthquakes; war; growing populations and the impoverished, destitute populations of the world make it imperative that nurses know about global health. Recent movements in the global arena identify the need for nurses to practice global health diplomacy, expanding beyond the tenets of health care and education we once provided (Hunter et al, 2013). Evidence indicates that contamination of water sources by heavy metals such as arsenic, copper, cadmium, mercury, and lead, to name a few, arising from the earth’s crust appears to be increasing around the globe because of the chang- ing environmental conditions (Fernández-Luqueño et al, 2013; Bolender et al, 2012, 2013; World Health Organization. Heavy metals in children, 2011). What once were the unique health challenges of people in less developed countries, such as loss of human rights; and lack of access to food, housing, safety, and health care, are now common problems of people all over the world. Contamination of the water sources in many countries, abject poverty, increasing global violence, the declining global economy, and the depletion of food supplies all contribute to the current global health crisis. See the Evidence-Based Practice box to learn how diarrheal outbreaks in Botswana correlate with poor water quality.
Preventable conditions such as malaria, malnutrition, com- municable diseases, chronic health problems, and conditions related to environmental pollution are taxing the health care systems of many nations. Immigrants from developing nations often bring these conditions with them because of lack of access to health care services that could successfully diagnose or treat these issues in their home country. Understanding global health
and factors that contribute to the immigrant’s health problems better prepares the nurse to develop interventions that are cul- turally congruent, culturally responsive, and culturally accept- able to the people for whom interventions are planned. It is well known that nurses provide more than 90% of all the health care services for people around the globe (Bryar et al, 2012), and the vision of the International Council of Nurses (ICN)’s Leader- ship for Change program is that nursing is to take a leadership role in helping achieve better health for all. Yet, in sub-Saharan Africa, reported to have 25% of the world’s disease burden, the patients are cared for by only 1.3% of the world’s trained health workforce, most of those being nurses (Bryar et al, 2012).
In 1977 attendees at the annual meeting of the World Health Assembly stated that all citizens of the world should enjoy a level of health that would permit them to lead a socially and economically productive life. This goal was to have been
C H A P T E R O U T L I N E Overview and Historical Perspective of Global Health The Role of Population Health Primary Health Care Nursing and Global Health Major Global Health Organizations Global Health and Global Development Health Care Systems
The Netherlands Mexico Uganda
Ecuador The United Kingdom China
Major Global Health Problems and the Burden of Disease
Communicable Diseases Diarrheal Disease Maternal and Women’s Health Nutrition and World Health Natural and Man-Made Disasters
63CHAPTER 4 Perspectives in Global Health Care
69% of the people living with HIV worldwide (WHO Fact Sheet on Global HIV/AIDS, 2012a), which relates to objective HIV-1. Last, the leading causes of death in under-five children are pneumonia, preterm birth complications, birth asphyxia, diar- rhea, and malaria (about 45% of all child deaths are linked to malnutrition). Children in sub-Saharan Africa are about 16 times more likely to die before the age of five than children in developed regions (WHO Child Deaths Fact Sheet, 2013b); this relates to objective MICH-3. See the Quality and Safety in Nursing Education box for suggestions for how to deal with malaria through a team approach.
achieved by the year 2000; however, man-made and natural disasters, political corruption, lack of infrastructure in less developed nations, and unforeseen obstacles have inhibited this goal from being achieved. The goals of Health for All by the Year 2000 (HFA2000) were extended into the next century with the document Health for All in the 21st Century (HFA21: http:// w w w. eu ro. w h o. i n t / en / p u bl i c a t i on s / p o l i c y - do c u m en t s / health21-health-for-all-in-the-21st-century). The four main HFA21 strategies for action to ensure that scientific, economic, social and political sustainability were those designed as follows: 1. To tackle the determinants of health, taking into account
physical, economic, social, cultural, and gender perspectives, and ensuring the use of health impact assessment
2. As health-outcome-driven programs and investments for health development and clinical care
3. For integrated family- and community-oriented primary health care, supported by a flexible and responsive hospital system
4. As a participatory health development process that involves relevant partners for health at home, school, and work and at local community and country levels, and that promotes joint decision making, implementation and accountability HFA laid the foundation for the Healthy People agendas of
Healthy People 2020.
HEALTHY PEOPLE 2020 Selected Objectives That Apply to Global Health Care
• EH-4 Increase the proportion of persons served by community water systems who receive a supply of drinking water that meets the regulations of the Safe Drinking Water Act.
• EH-5: Reduce waterborne disease outbreaks arising from water intended for drinking among persons served by community water systems.
• FP-1: Increase the proportion of pregnancies that are intended. • GH-1: Reduce the number of cases of malaria reported in the United States. • HIV-1: Reduce the number of new HIV diagnoses among adolescents and
adults. • MICH-3: Reduce the rate of child deaths.
From U.S. Department of Health and Human Services: Healthy People: 2020 Topics and Objectives. Retrieved December 2014 from http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx. Accessed January 1, 2011.
EH, Environmental Health; FP, Family Planning; GH, Global Health; HIV, Human Immunodeficiency Virus; MICH, Maternal, Infant, and Child Health.
Each of the previous goals has relevance to the global arena. The millions of deaths related to unsafe water and poor hygiene is most pronounced in Africa and Southeast Asia. This relates to objectives EH-4 and EH-5 (see the Healthy People 2020 Box). Six in ten pregnancies in developing nations are unintended and relate to objective FP-1 (Kott, 2011). Malaria caused an estimated 627,000 deaths, mostly among African children (World Health Organization [WHO] Malaria Fact Sheet, 2013a), which relates to objective GH-1. Sub-Saharan Africa remains most severely affected with HIV/AIDS, with nearly 1 in every 20 adults (4.9%) living with HIV and accounting for
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES As described in earlier chapters of the text, including Chapter 2, there are six QSEN competencies for nursing. Because of the complex and multifaceted nature of providing public health nursing care in countries around the world, competency number two, teamwork and collaboration, is emphasized here.
Teamwork and collaboration refer to the ability to function effectively with nursing and interprofessional teams and to foster open communication, mutual respect, and shared decision making in order to best provide safe and quality care. One of the United Nations Millennium Development Goals is to combat HIV/AIDS, malaria, and other diseases (see Box 4-1).
The quality and safety question is as follows: How would nurses working in a country that is plagued by malaria develop a team to help control this mosquito-borne disease?
Answer: The spread of malaria can be interrupted by prevention, treatment, and control measures such as using insecticide-treated bed nets and spraying in and near where people live, work, and go to school. Nurses would develop a team including representatives from funding agencies, environmental health, NGOs, medical practitioners, and local governments to locate funds and develop, implement, and evaluate prevention, control, and treatment measures.
Because of the ease of global travel, contagious and prevent- able health conditions are not endemic in just an isolated country; they are prevalent around the world. Health profes- sionals and world leaders want to be enlightened about these health issues and want answers on how to address them, which becomes problematic in the countries most afflicted but without the technological infrastructure to help their people.
Many terms are used to describe nations that have achieved a high level of industrial and technological advancement (along with a stable market economy) and those that have not. For the purposes of this chapter, the term developed country refers to those countries with a stable economy and a wide range of industrial and technological development, low child mortality, high gross national income, and a high human asset index (e.g., the United States, Canada, Japan, the United Kingdom, Sweden, France, and Australia). A country that does not meet these criteria is referred to as a less developed country (e.g., Congo, Bangladesh, Somalia, Haiti, Guatemala, most countries in sub- Saharan Africa, and the island nation of Indonesia). Both devel- oped and lesser-developed countries are found in all parts of the world and in all geographic and climatic zones (UN Depart- ment of Economic and Social Affairs [DESA], 2013c).
64 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
Haiti, Chile, and Indonesia. These environments are unsanitary, unsafe, and a breeding ground for TB, dysentery, malnutrition, abuse of women and children, and mosquito and other insect or animal-borne diseases.
Nations plagued by civil war and political corruption are faced with chronic poverty, unstable leadership, and lack of economic development. The effects of war and conflict also have devastating effects on a country and the health of its popu- lation. The wars in Afghanistan, Iraq, and the West Bank of Palestine, to name a few, have had devastating mental and phys- ical health consequences, leaving each country and its people with few health care services or other resources to sustain life. A recent research study about the long-term effects of children exposed to war (Asia, 2009) supports the negative health consequences of such exposure. For example, changes in bio- markers can lead to future chronic health conditions such as cardiovascular disease, autoimmune conditions, cancer, and mental health problems.
As countries promote the objectives of HFA21, they realize that they need to improve their economies and infrastructures. They often seek funds and technological expertise from the wealthier and more-developed countries (World Bank, Conces- sional Finance and Global Partnership Report, 2013a). Accord- ing to the WHO (2013c), HFA21 is not a single, finite goal but a strategic process that can lead to progressive improvement in the health of people. In essence, it is a call for social justice and solidarity. Unfortunately, the lesser-developed nations still lack the infrastructure necessary to achieve health promotion and living conditions, as many of these countries continue to dete- riorate for the poor, and environments that breed infections are the norm (Figure 4-2).
The UN Millennium Development Goals (MDGs) were first agreed on by world leaders at the Millennium Summit in 2000 (see Resource Tool 4.A on the book’s Evolve site). The MDGs were developed to relieve poor health conditions around the world and to establish positive steps to improve living con- ditions by the year 2015 (UN, 2013a; see goals in Box 4-1).
Health problems exist throughout the world, but the lesser- developed countries often have more unusual health care prob- lems. There are more than 6000 rare diseases (Forman et al, 2012) and in developing countries such conditions as Buruli ulcers, leishmaniasis, river blindness, schistosomiasis, brucel- losis, typhus, yellow fever, scurvy, and malaria are often unknown entities in the world of Western medicine (Molyneux and Sayioli, 2013). Ongoing health problems needing control in lesser-developed countries include measles, mumps, rubella, and polio; the current health concerns of the more-developed countries are problems such as hepatitis, infectious diseases, and new viral strains such as hantavirus, SARS (severe acute respiratory syndrome), H1N1, and avian flu. Chronic health problems such as hypertension, diabetes, cardiovascular disease, obesity, cancer, the resurgence of human immunodefi- ciency virus/acquired immunodeficiency syndrome (HIV/ AIDS) among adolescents and young adults, drug-resistant tuberculosis (TB); and the larger social, yet health-related, issues such as terrorism, warfare, violence, and substance abuse are now global issues (Shah, 2014). World travelers may expose themselves to diseases and environmental health hazards that are unknown or rare in their home country, and may serve as hosts to various types of disease agents. Two recent examples of diseases that were once fairly isolated and rare but are now widespread throughout the world are AIDS and drug-resistant TB (Institute of Medicine [IOM], 2010b; U.N. Global Health Report, 2013d) (Figure 4-1).
In addition to direct health problems, increasing popula- tions, migration within countries, political corruption, lack of natural resources, and natural disasters affect the health and well-being of populations. Dr. Paul Farmer in his book Patholo- gies of Power (2005) talks about the war on the poor; how many migrate to the city to find employment, where limited employ- ment opportunities exist. Such migration leads to the develop- ment of shanty towns often built on the outskirts of cities, on unstable ground, and in areas vulnerable to natural disasters such as hurricanes, tsunamis, and earthquakes such as those in
FIG 4-1 Open market in Uganda, where preventable diseases are rampant. (Courtesy A. Hunter.)
FIG 4-2 The streets of a typical town in Uganda. (Courtesy A. Hunter.)
65CHAPTER 4 Perspectives in Global Health Care
the policies and actions of HFA21. The WHO (2013c) continues to develop new and holistic health policies that are based on the concepts of equity and solidarity, with an emphasis on the individual’s, family’s, and community’s responsibility for health. Strategies for achieving the continuing goals of HFA21 include building on past accomplishments and the identifica- tion of global priorities and targets for the first 20 years of the new century.
Nurses need to be informed about global health. Many of the world’s health problems directly affect the health of indi- viduals who live in the United States. For example, the One Hundred Third U.S. Congress passed the North American Free Trade Agreement (NAFTA), which opened trade borders between the United States, Canada, and Mexico in 1994 and allowed increased movement of products and people. Along the United States–Mexico border, an influx of undocumented immigrants in recent years has raised concerns for the health of people who live in this area. For example, many immigrants have settled on unincorporated land, known as colonias, outside the major metropolitan areas in California, Arizona, New Mexico, and Texas. These colonies may have no developed roads, transportation, water, or electrical services (U.S. Geologi- cal Survey [USGS]: U.S.–Mexico Border Environmental Health Report, 2011) (Figures 4-3 and 4-4).
Conditions in these settlements have led to an increase in disease conditions such as amebiasis and respiratory and diar- rheal diseases. Environmental health hazards in the colonias are associated with poverty, poor sanitation, and overcrowded conditions (USGS: U.S.–Mexico Border Environmental Health Report, 2011). On a more positive note, NAFTA has provided an impetus and framework for the government of Mexico to modernize their medical system so that they can compete and respond to the demands of more global competition. Although some improvements have been made, there is still an overriding concern that environmental and health regulations in Mexico have not kept up with the pace of increased border trade (California Department of Public Health, Office of Binational
From United Nations: UN millennium development goals (MDGs). 2005. Available at http://www.un.org/millenniumgoals/. Accessed August 25, 2014.
MDG 1: Eradicate extreme poverty and hunger. MDG 2: Achieve universal primary education. MDG 3: Promote gender equality and empower women. MDG 4: Reduce child mortality. MDG 5: Improve maternal health. MDG 6: Combat HIV/AIDS, malaria, and other diseases. MDG 7: Ensure environmental sustainability. MDG 8: Develop a global partnership for development.
BOX 4-1 Millennium Goals Millennium Development Goals
These goals have continued to evolve as natural disasters and internal strife continue to affect the poor and the vulnerable. The Millennium Report (UN Millennium Development Report, 2013a) describes the developed nations’ responsibility to the betterment of those in lesser-developed nations. The revised goals highlight the global responsibility to eradicate poverty and hunger; achieve universal primary education for all children; promote gender equality and empower women; reduce child mortality; improve maternal health; combat HIV/AIDS, malaria, and other diseases; ensure environmental sustainability; and develop a global partnership for development. Unfortunately, the 2013 report indicated that one in eight people worldwide remains hungry; death in childbirth is still a major problem; more than 2.5 billion people still lack improved sanitation facil- ities; and climate change has caused the loss of forests, species and fish stocks. The United States supports the Millennium Development Goals in its Global Health Initiatives (www.ghi.gov Accessed December 20, 2014) as has the ICN. Continued work to develop economic agreements between countries so as to remove financial and political barriers has stimulated growth and development; but, is it enough?
Despite efforts by individual governments and international organizations to improve the general economy and welfare of all countries, many health problems continue to exist, especially among poorer people. Many countries lack both political com- mitment to health care and recognition of basic human rights. They may fail to achieve equity in access to primary health care, demonstrate inappropriate use and allocation of resources for high-cost technology, and maintain a low status of women. At present, the lesser-developed countries experience high infant and child death rates (http://gamapserver.who.int/gho/ interactive_charts/MDG4/atlas.html), with diarrheal and respi- ratory diseases as major contributory factors (under-five and infant mortality rates, by WHO region; WHO, 2013d).
Other major worldwide health problems include nutritional deficiencies in all age groups, women’s health and fertility prob- lems, sexually transmitted infections (STIs), and illnesses related to the human immunodeficiency virus (HIV), malaria, drug- resistant TB, neonatal tetanus, leprosy, occupational and envi- ronmental health hazards, and abuses of tobacco, alcohol, and drugs. Because of these continuing problems, the director general of the WHO has made a commitment to renew all of
FIG 4-3 A community living in a dump in Miacatlán, Mexico. (Courtesy A. Hunter.)
66 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
assessing emerging diseases and other health risks to a com- munity (IOM, 2010a). A population can be defined by a geo- graphic boundary, by the common characteristics shared by a group of people such as ethnicity or religion, or by the epide- miologic and social conditions of a community.
The factors and conditions that are important consider- ations in population health are called determinants. Population health determinants may include income and social factors, social support networks, education, employment, working and living conditions, physical environments, social environments, biology and genetic endowment, personal health practices, coping skills, healthy child development, health services, sex, and culture (WHO, Health Impact Assessment, 2014a). The determinants do not work independently of each other but form a complex system of interactions.
Canada is a leader in promoting the population health approach. Canada has been implementing programs using this framework since the mid-1990s and builds on a tradition of public health and health promotion. Box 4-2 presents the devel- opment of the Healthy Cities movement in Toronto. This suc- cessful project has been adopted by the WHO and is being implemented in several countries around the world—most spe- cifically Europe, Southeast Asia, Africa, and the Western Pacific
Border Health, Border Health Status Report, 2011). The Mexican National Academy of Medicine continues to make health and environmental recommendations to the government, which illustrates the beneficial interactions that are occurring between Mexico, Canada, and the United States as part of this trade agreement. Nurses play a significant role in obtaining health for the indigent and undocumented persons who live along the border regions in Texas, New Mexico, Arizona, and California. Nurses supported by private foundations and by local and state public health departments often provide the only reliable health care in these areas.
Interestingly, Canadian worker groups were concerned that NAFTA would eventually lead to worsened working conditions as manufacturing plants move to the lower-wage and largely non-unionized southern United States and Mexico; however, reports indicate that trade, standard of living, and employment opportunities have risen (Ibbitson, 2012).
THE ROLE OF POPULATION HEALTH Population health refers to the health outcomes of a group of individuals, including the distribution of such outcomes within the group, and includes health outcomes, patterns of health determinants, and policies and interventions that link these two. It is an approach and perspective that focuses on the broad range of factors and conditions that have a strong influence on the health of populations (environment, genetics, ethnicity, pollu- tion, and physical and mental stressors affecting a community). Using epidemiologic trends, population health emphasizes health for groups at the population level rather than at the individual level and focuses on reducing inequities, improving health in these groups to reduce morbidity and mortality, and
FIG 4-4 Diseases in the colonias. (From PBS Online, The Forgotten Americans. Available at http://www.pbs.org/klru/ forgottenamericans/focus/health.htm and http://abcnews.go .com/US/hidden-america-forgotten-struggle-survive-texas -barren-colonias/story?id=16213828 and http://www.cinelasa mericas.org/special-events/1060-the-forgotten-americans-a -film-by-hector-galan (Accessed March 20, 2014).)
16
Salmonellosis
Shigellosis
Tuberculosis
Hepatitis A
13.4 21.3
11 12.6
18
17.5
14.6
28.1
12.2
18.2
50.3
USA
Colonias
Texas
From Flynn B, Ivanov L: Health promotion through healthy communities and cities. In Community & Public Health Nursing, ed 6, St. Louis, 2004, Mosby, pp 396–411.
Toronto, Ontario, Canada was one of the first cities in North America to become involved in the Healthy Cities movement. Toronto began with a stra- tegic planning committee to develop an overall strategy for health promotion. The committee conducted vision workshops in the community and a compre- hensive environmental scan to help identify health needs in Toronto. The outcome was a final report outlining major issues, and it included a strategic mission, priorities, and recommendations for action. The Toronto Healthy City program involved a number of projects. One of them, the Healthiest Babies Possible project, was an intensive antenatal education and nutritional supple- ment program for pregnant women who were identified by health and social agencies as being at high risk. The program included intensive contact and follow-up of women, along with food supplements. It has been successful in decreasing the incidence of low-birth-weight infants.
Another example is Chengdu, China. Chengdu is located on the upper parts of the Yangtze River. It is surrounded on four sides by the Fu and Nan Rivers and was one of the most polluted cities in southwestern China. The pollution created severe environmental problems as a result of industrial waste, raw sewage, and the intensive use of fresh water. The proliferation of slum and squatter settlements exacerbated the social, economic, and environmental problems of the city. The Fu and Nan Rivers Comprehensive Revitalization Plan was started in 1993 as a Healthy Community and City initiative to deal with the growing environmental problems. The principles of participatory planning and partnership were used to raise awareness of the problem among the general public and to mobilize major stakeholders to invest in a sustainable future for Chengdu and its inhabitants. The plan resulted in providing 30,000 households living in the slum and squatter settlements with decent and afford- able housing, and with projects to deal with sewage and industrial waste. In addition, the plan was able to improve parks and gardens, turning Chengdu into a clean and green city within the natural flow of its rivers.
BOX 4-2 Examples of the Healthy Cities Movement
67CHAPTER 4 Perspectives in Global Health Care
• Initiation of preventive programs that are specifically aimed at local endemic problems such as malaria and schistosomia- sis in tropical regions
• Accessibility and affordability of services for the treatment of common diseases and injuries
• Availability of chemotherapeutic agents for the treatment of acute, chronic, and communicable diseases
• Development of nutrition programs • Promotion and acceptance of traditional medicine
Global leaders have recognized the need to get nations com- mitted to the health care agenda. An important effort is needed at the level of recruitment, education, and retention of primary health care workers, including primary care nurses, family phy- sicians, and mid-level care workers. Professional organizations, clinical agencies, universities, and other institutions for higher education should continue to demonstrate their “social account- ability” by training appropriate providers.
It is well documented that PHC practiced in high-income countries exerts a positive influence on health costs, appropri- ateness of care, and outcomes for most of the major health indicators. They also have more equitable health outcomes than systems oriented toward specialty care. In low and middle income countries the research studies did find consistent evi- dence of the impact of PHC on improved health outcomes; however, there were problems with the research rigor and valid- ity of instrumentation to make any further statement than that health outcomes did improve.
NURSING AND GLOBAL HEALTH Nurses play a leadership role in health care throughout the world. Those with public health experience provide knowledge and skill in countries where nursing is not an organized profession, and they give guidance to the nurses as well as to the auxiliary person- nel who are part of the primary health care team (Bryar et al, 2012). In many areas in the developed world, nurses provide direct client care and help meet the education and health promo- tion needs of the community. They are viewed as strong advo- cates for primary health care, through social commitment to equality of health care and support of the concepts that are con- tained in the Declaration of Alma-Ata (Bryar et al, 2012).
Unfortunately, in the lesser-developed countries, the role of the nurse is defined poorly, if at all, and care often depends on and is directed by physicians. I have seen health care systems in Africa, Mexico, and the Dominican Republic in which nursing is not valued and the ability of nurses to contribute to improv- ing an individual’s health, much less a community’s health, is minimal. Much work is needed to raise the bar in the education of nurses in these countries so they have the skills necessary to make a difference; however, overcoming some of the cultural and gender-role barriers makes this process labori- ous (Figure 4-5).
Nurses have led in care delivery after the devastating tsunami in South Asia, and more recently after the earthquakes in Haiti and Chile in 2010. Other health interventions have been the interprofessional work of nursing and science to build and open a dedicated children’s hospital in Uganda (Bolender and Hunter,
(WHO, Healthy Cities, 2014b). A key to the success of this project has been the identification and definition of health issues and of the investment decisions within a population that were guided by evidence about what keeps people healthy. Therefore a population health approach directs investments that have the greatest potential to influence the health of that population in a positive manner. A Healthy City aims to create a health-supportive environment, achieve a good quality of life, provide basic sanitation and hygiene needs, and supply access to health care. The most successful Healthy Cities programs have a commitment of local community members, a clear vision, ownership of policies, a wide array of stakeholders, and a process for institutionalizing the program.
Integration of health determinants into public policies is apparent on the global stage. At the 2009 Nairobi Global Confer- ence on Health Promotion, more than 600 participants repre- senting 100 countries adopted a Call to Action on addressing population health and finding ways to promote health at the global level. Health and development today face unprecedented threats by the financial crisis, global warming and climate change, and security threats. Since 1986, with the development of the first Global Conference, until 2009, a large body of evi- dence and experience has accumulated about the importance of health promotion as an integrative, cost-effective strategy, and as an essential component of health systems primed to respond adequately to emerging concerns (WHO, 2010a, 2014c).
As nurses work with immigrants from global arenas or become active participants in health care around the world, understanding such concepts as population health and the determinants of health for a population becomes more impor- tant than the most advanced acute care skills. These skills, though important, are intended to help an individual; popula- tion health skill sets can help the world.
PRIMARY HEALTH CARE The ultimate goal of primary health care (PHC) is to achieve better health for all. WHO (2014c) has identified five key ele- ments to achieving that goal: 1. Reducing exclusion and social disparities in health 2. Organizing health services around people’s needs and
expectations 3. Integrating health into all sectors 4. Pursuing collaborative models of policy dialogue 5. Increasing stakeholder participation These aims continue to be reinforced and modified and were recently updated to incorporate MDGs (WHO, 2014c). Such services included the following: • An organized approach to health education that involves
professional health care providers and trained community representatives
• Aggressive attention to environmental sanitation, especially food and water sources
• Involvement and training of community and village health workers in all plans and intervention programs
• Development of maternal and child health programs that include immunization and family planning
68 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
Chile, nurses have set up successful and cost-effective clinics to deliver quality primary care services. However, the nurses often are being threatened by physicians who want to remove the nurses and replace them with the more costly services of physi- cians (Organization for Economic Cooperation and Develop- ment [OECD], Health at a Glance, 2011). Box 4-3 describes nursing and health care efforts in Zambia.
Several nursing initiatives from the United States have been developed to help address some of these global health problems. According to Sheila Davis, ANP-BC, FAAN, Director of Global Nursing, Partners in Health, the Dana Farber Cancer Institute has supported the creation of a nursing oncology partnership with Inshuti Mu Buzima (IMB) in Rwanda. Four experienced oncology nurses have committed to working alongside local nurses and physicians at IMB for 3-month rotations, to help Rwandan nurses develop the specialized skills and experience needed to raise the quality of oncology care. Another is Regis College in Massachusetts, which has partnered with the Haitian Ministry of Health to tackle the nursing education shortage in Haiti by developing a comprehensive 3-year master’s program for 12 Haitian nursing faculty members. Another is out of the University of San Diego, in collaboration with the Holy Inno- cents Children’s Hospital in Uganda. Nurses and physicians have been actively involved in building the first children’s hos- pital in the country and training the staff in pediatric care. A new entry into this global nursing arena is the development of the Global Nurse Initiative, a nonprofit organization that links health professionals with opportunities to volunteer in under- privileged areas (Global Nurse Initiative, 2013).
MAJOR GLOBAL HEALTH ORGANIZATIONS Many international organizations have an ongoing interest in global health. Despite the presence of these well-meaning
2010; Bolender, McDonald and Hunter, 2013), the nurse- developed Ghana Health Mission (Hunter and McKenry, 2005; https://ghanahealthmission.wordpress.com/), a nurse-led chronic illness management program in Thailand (Sindhu et al, 2010), and a nurse-led mental health program for Chinese patients (Chien et al, 2012) are just a few examples of nurse- initiated health programs around the globe.
The role of nursing in China and Taiwan is noteworthy. Nursing in China is undergoing a dramatic change, largely because of an evolving political and economic environment. In the past, nursing was viewed as a trade, and the acquisition of nursing skills and knowledge took place in the equivalent of a middle school or junior high school in the United States. Increasing pressure on the health care system in China is pro- viding an impetus for education at the university level. The Chinese government has sent many nurses to the United States, Europe, and Australia to receive university-level education in nursing at the undergraduate and graduate levels in hopes that these individuals will return to China to provide the nursing and nursing education needed there; but very few do, and a recent poll in China indicated that if the nurses could leave China to practice elsewhere, they would (Global Times, 2011). I, in conjunction with a colleague (Dr. Mary Jo Clark), have consulted in Taiwan, helping them establish their nurse practi- tioner programs and to implement their doctoral programs in nursing. Part of that consultation involved the use of standard- ized clients as a component for certification and license to prac- tice as a nurse practitioner. The United States has entertained this idea.
In some countries, such as Chile, the physician-to- population ratio is higher than the nurse-to-population ratio. In these cases, physicians influence nursing practice and place economic and political pressure on local, regional, and national governments to control the services that nurses provide. In
FIG 4-5 Uganda hospital information for nurses assisting in labor and delivery. (Courtesy A. Hunter.)
69CHAPTER 4 Perspectives in Global Health Care
Courtesy Prudencia Mweemba, University of Zambia, School of Medicine, Department of Post Basic Nursing, Lusaka, Zambia, 2006.
The Ministry of Health, Churches Health Association, the private Medical Prac- titioners, and the Traditional Healer Services provide health care in Zambia. By 1995 there were 86 hospitals and 1345 health centers in the country. About 60% of the bed capacity is provided by the government hospitals and health centers, 26% by mission hospitals, and 13% by the Zambia Consolidated Copper Mines. At the time of independence, the population of Zambia was sparsely distributed, especially in the rural area, and there were inadequate health facilities. Health facilities were concentrated along the line of rail, and the provision of care was poor. This prompted the government to review the health care provision system after independence in 1964. The government then declared that health care services would be free for all, with the main health care services being curative rather than preventive. This policy was detrimental to Zambia, whose population was increasing.
In 1991 the government of the Republic of Zambia, under the leadership of the Movement for Multiparty Democracy, introduced the concept of National Health Reforms, the vision being to provide equitable access to high-quality, cost-effective health care intervention as close to the family as possible. Health reforms stress the need for families and communities to be self-reliant and to participate in their own health care provision and development. The major component of the health policy reform is the restructured primary health care (PHC) program. This has been defined as the essential health care made univer- sally accessible to individuals and families by means acceptable to them through their full participation and at a cost that the community and country can afford. The principles of PHC include community participation and intersectoral collabo- ration. Families are considered a unit of service, as most health care provision starts with the family setting. The Zambian government is committed to the fundamental and humane principle in the development of the health care system to provide Zambians with the equity of access to cost-effective quality health care as close to the family as possible.
The National Health Reforms decentralized power to districts, and home-based care (HBC) was introduced. HBC was adopted and implemented in all districts as a way of cost sharing between the government, families, and community. HBC led to reduced congestion in hospitals, and government resources were not overstrained as families also took part in supplying the needed resources, time, and personnel (caregivers) when the clients were cared for at home.
Nurses provide about 75% of the health force in Zambia. The community health nursing component is one of the major components of the nursing cur- riculum at all levels of training. Basically, every general nurse is taught to operate as a community health nurse. However, to be registered as a public health nurse by the General Nursing Council of Zambia, one must undergo the following levels of training. The individual undergoes 3 years of training as a registered nurse followed by 1 year of training as a midwife. In the past they would then undergo 2 years of training at the University of Zambia to obtain a diploma in public health nursing. This was phased out when the bachelor of science in nursing degree was initiated. At present, the individual pursues the bachelor of science in nursing degree and majors in community health nursing in the final year.
The main role of the community health nurse includes competence and skill in the care of individuals, families, and communities in the following ways: 1. Critically explore and analyze current developments in community health as
they relate to different populations at different levels of care. 2. Apply health promotion models and theories to community health nursing
practice. 3. Design, implement, and manage community-based projects, programs, and
services. 4. Integrate community-based agents into the health care system. 5. Use epidemiology concepts in the management of communicable and non-
communicable diseases.
BOX 4-3 Community Health Nursing in Zambia
organizations, it is estimated that the less developed countries still bear most of the cost for their own health care and that contributions from major international organizations actually provide for less than 5% of needed costs. Recent reports indi- cate that the majority of funds raised by international organiza- tions are used for food relief, worker training, and disaster relief (Shah, 2012; World Food Program, 2014). Shah (2012) reports that aid is often wasted by requiring recipients to use overpriced goods and services from donor countries; most aid does not go to the country in greatest need as aid is often used in order for the richer country to get their foot in the door of the poorer country to access its resources; and graft is still a major problem in developing countries—promised monies are funneled into the pockets of the local politicians who were chosen to help the people.
International health organizations are classified as multilat- eral organizations, bilateral organizations, or nongovernmen- tal organizations (NGOs) or private voluntary organizations (PVOs) (including philanthropic organizations). Multilateral organizations are those that receive funding from multiple gov- ernment and nongovernment sources. The major organizations are part of the United Nations (UN), and they include the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the Pan American Health Organi- zation (PAHO), and the World Bank. A bilateral organization
is a single government agency that provides aid to less devel- oped countries, such as the U.S. Agency for International Development (USAID). NGOs or PVOs, including the philan- thropic organizations, are represented by such agencies as Oxfam, Project Hope, the International Red Cross, various professional and trade organizations, Catholic Relief Services (CRS), church-sponsored health care missionaries, and many other private groups.
Specifically, the World Health Organization (WHO) is a separate, autonomous organization that, by special agreement, works with the United Nations through its Economic and Social Council. The idea for this worldwide health organization devel- oped from the First International Sanitary Conference in 1902, a precursor to the WHO. The WHO was created in 1946 as an outgrowth of the League of Nations and the UN charter that provided for the formation of a special health agency to address the wide scope and nature of the world’s health problems. The WHO, headed by a director general and five assistant generals, has three major divisions: (1) the World Health Assembly approves the budget and makes decisions about health policies, (2) the executive board serves as the liaison between the assem- bly and the secretariat, and (3) the secretariat carries out the day-to-day activities of the WHO. The principal work of the WHO is to direct and coordinate international health activities and to provide technical medical assistance to countries in need.
70 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
system infrastructure in the poorer Latin American countries. PAHO collaborates with individual countries and actively pro- motes multinational efforts as well. Recently, PAHO has exam- ined the effects of health care reform on nurses and midwifery in the Latin American countries and found that the reform changed the work environments, the scope of practice, and the relationship of nurses with other health care workers and pro- viders. The role of PAHO in the development of healthy com- munities is discussed in Chapter 20.
The World Bank (http://www.worldbank.org) is another multilateral agency that is related to the United Nations. Although the major aim of the World Bank is to lend money to the less developed countries so that they might use it to improve the health status of their people, it has collaborated with the field offices of the WHO for various health-related projects such as the control and eradication of the tropical disease onchocer- ciasis in West Africa, as well as programs aimed at providing safe drinking water and affordable housing, developing sanita- tion systems, and encouraging family planning and childhood immunizations. The World Bank also sponsors programs to protect the environment, as reflected by the $30 million project in Brazil to protect the Amazon ecosystem and reduce the effects on the ozone layer; to support people in less developed countries to pursue careers in health care; and to improve internal infrastructure, including communication systems, roads, and electricity, all of which ultimately affect health care delivery.
Bilateral agencies operate within a single country and focus on providing direct aid to less developed countries. The U.S. Agency for International Development (USAID) (http:// www.usaid.gov) is the largest of these and supports long-term and equitable economic growth and advances U.S. foreign policy objectives by supporting economic growth, agriculture, and trade; global health; and democracy, conflict prevention, and humanitarian assistance. It provides assistance in five regions of the world: sub-Saharan Africa, Asia, Latin America and the Caribbean, Europe and Eurasia, and the Middle East. All bilateral organizations are influenced by political and his- torical agendas that determine which countries receive aid. Incentives for engaging in formal arrangements may include economic enhancements for the benefit of both countries, national defense of one or both countries, or the enhancement and protection of private investments made by individuals in these nations. Something similar is present in other developed nations around the globe. For example, the Japanese govern- ment currently has an active collaborative arrangement with Indonesia to study ways to control the spread of yellow fever and malaria. France gives most of its aid to its former colonies.
Nongovernmental organizations (NGOs) or private volun- tary organizations (PVOs), as well as philanthropic organiza- tions, provide almost 20% of all external aid to less developed countries. NGOs and PVOs are represented by many different kinds of religious and secular groups. Representatives of these independent citizen organizations are increasingly active in policymaking at the United Nations. These organizations are often the most effective voices for the concerns of ordinary
More than 1000 health-related projects are ongoing within the WHO at any one time. Requests for assistance may be made directly to the WHO by a country for a project, or the project may be part of a larger collaborative endeavor involving many countries. Examples of current collaborative, multinational projects include comprehensive family planning programs in Indonesia, Malaysia, and Thailand; applied research on com- municable disease and immunization in several East African nations; and projects that investigate the viability of administer- ing AIDS vaccines to pregnant women in South Africa and Namibia. For further information about the WHO, visit http:// www.who and find the tab such as publications, countries, pro- grammes, or health topics that meets your need. The WHO has supported the development of multiple health training pro- grams for professionals in developing nations. An example of one is the Tanzania Nurse Initiative, which has been successful in strengthening nursing education in Tanzania by educating 415 nurses in HIV/AIDS prevention, care, and treatment; pro- viding technical assistance and support on curriculum develop- ment and revision; and providing support to Tanzanian nursing schools (Global Health Workforce Alliance, 2014).
Another multilateral agency is the United Nations Chil- dren’s Fund (UNICEF) (http://www.unicef.org). Formed shortly after World War II (WWII) to assist children in the war- ravaged countries of Europe, it is a subsidiary agency to the UN Economic and Social Council. After WWII, many social agen- cies realized that the world’s children needed medical and other kinds of support. With financial assistance from the newly formed UN General Assembly, post-WWII programs were developed to control yaws, leprosy, and TB in children. Since then, UNICEF has worked closely with the WHO as an advocate for the health needs of women and children under the age of 5. In particular, there have been multinational programs aimed at the provision of safe drinking water, sanitation, education, and maternal and child health.
The Pan American Health Organization (PAHO) is one of the oldest continuously functioning multilateral agencies, founded in 1902, and predates the WHO. At present, PAHO serves as a regional field office for the WHO in Latin America, with a focused effort to improve the health and living standards of the Latin American countries. PAHO distributes epidemio- logic information, provides technical assistance over a wide range of health and environmental issues, supports health care fellowships, and promotes health and environmentally related research, along with professional education. Focusing primarily on reaching people through their communities, PAHO works with a variety of governmental and nongovernmental entities to address the health issues of the people of the Americas. At present, a primary concern of PAHO is the prevention and control of AIDS and other sexually transmitted diseases amongst the most vulnerable: mothers and children, workers, the poor, older adults, refugees, and displaced persons. With the earth- quakes in Haiti and Chile, and the drought and starvation in Guatemala, PAHO’s attentions are being directed toward crisis intervention (http://www.paho.org). Other focused efforts include the provision of public information, the control and eradication of tropical diseases, and the development of health
71CHAPTER 4 Perspectives in Global Health Care
orphanages, and leprosy treatment centers. For example, the Maryknoll Missionaries, sponsored by the Roman Catholic Church, carry out health service projects around the world. The missionaries comprise a large group of religious as well as lay people trained and educated in a variety of educational and health care professions. The Catholic Relief Services (CRS) (http://crs.org) is the official international humanitarian agency of the Catholic community in the United States. CRS alleviates suffering and provides assistance to people in need who are affected by war, starvation, famine, drought, and natural disas- ters, in more than 100 countries, without regard to race, reli- gion, or nationality. Many Protestant and evangelical groups throughout the world function both as separate entities and as part of the Church World Service, which works jointly with secular organizations to improve health care, community devel- opment, and other needed projects. Other private and volun- tary groups that assist with the worldwide health effort include CARE (http://www.care.org), Oxfam (www.oxfam.org.uk), and Third World First. Several of these organizations receive addi- tional funding from developed countries including the United States, the United Kingdom, Sweden, Canada, and countries in Western Europe.
Philanthropic organizations receive funding from private endowment funds. A few of the more active philanthropic orga- nizations that are involved in world health care include the W. K. Kellogg Foundation, the Milbank Memorial Fund, the Pathfinder Fund, the Hewlett Foundation, the Ford Foundation, the Rockefeller Foundation, the Carnegie Foundation, and the Gates Foundation. The purpose and programmatic goals of each organization differ widely with respect to funding, and their purposes often change as their governing boards change. Some of the worldwide health care activities that have been sponsored in the past include projects in public and preventive health; vital statistics; medical, nursing, and dental education; family planning programs; economic planning and develop- ment; and the formation of laboratories to investigate com- municable diseases.
Many private and commercial organizations such as Nestlé and the Johnson & Johnson Company provide financial and technical backing for investment, employment, and access to market economies and to health care. Although these organiza- tions have been present throughout the world for more than 30 years, they have come under criticism for the promotion and marketing of infant formulas, pharmaceuticals, and medical supplies, especially to lesser-developed countries. The intense marketing that is done in these countries is known as commodi- fication, turning health care into a business with clients as con- sumers and health care professionals from altruistic healers to business technicians. Breast cancer awareness is the best known of these practices in the United States (http://www.theguardian .com/commentisfree/2012/oct/03/pinkification-breast-cancer -awareness-commodified).
There is global controversy as to the legitimacy of commodi- fication. For example, in the sentinel article by Segal, Demos, and Kronenfeld (2003) the health commodification of phar- maceuticals in southern India was a concern because the companies gave little consideration to the cultural and social
people in the international arena. NGOs include the most out- spoken advocates of human rights, the environment, social programs, women’s rights, and more (Kaiser Family Founda- tion, 2010). An example of an NGO is the Holy Innocents Children’s Hospital in Mbarara, Uganda (http://www.holyinno centsuganda.com) (the result of a nurse-led initiative and a U.S.-based NGO that acquired the funds, built the hospital, trained the staff, and then turned it over to the Ugandans to operate and expand) is a 50-bed dedicated children’s hospital that since its opening in 2009 has cared for more than 100,000 children. Its mortality rate is one quarter that of the local gov- ernment hospital because the goal of the hospital was to save lives and to have available the necessary supplies to achieve this goal. The administrative and professional staff training has helped this hospital be self-sustaining with minimal continued assistance from the U.S.-based NGO and its donors.
The International Red Cross (http://www.icrc.org) is one of the best-known NGOs. Although the Red Cross is most often associated with disaster relief and emergency aid, it lays the groundwork for health intervention as a result of a country’s emergency. It is a volunteer organization that consists of approximately 160 individual Red Cross societies around the world, and it prides itself on its neutrality and impartiality with respect to politics and history. Therefore, it seeks permission from the country in which the disaster occurs before services are rendered.
Another NGO that provides health services and aid to countries experiencing warfare or disaster is Médecins sans Frontières (MSF) (http://www.msf.org), also home of Doctors without Borders. It is an international, independent, medical humanitarian organization that delivers emergency aid to people affected by armed conflicts, epidemics, health care exclu- sion, and natural or man-made disasters. Unlike the Red Cross, MSF does not seek government approval to enter a country and provide aid and it often speaks out against observed human rights abuses in the country it serves. MSF was the recipient of the Nobel Peace Prize in 1999 and the Conrad Hilton Prize in 1998. In Uganda, Doctors without Borders is involved with the local medical school in Mbarara to help develop an intensive malaria intervention approach to help improve the survival rate of children affected by cerebral malaria (personal communica- tion with Dr. Bitariho Deogratias, Professor of Orthopedics at Mbarara Science and Technology University School of Medicine, January 2013).
The professional and trade organizations are PVOs that are found mostly in the more developed and industrialized coun- tries. One of the most famous of the professional and technical organizations is the Institut Pasteur (http://www.pasteur.fr/ip/ easysite/pasteur/en/institut-pasteur), which began in the 1880s. Its laboratories have facilitated the development of sera and vaccines for countries in need, disseminated current health information, and trained and provided fellowships for medical training and study in France. They have facilities in Africa, South and Central America, and Southeast Asia.
Religious organizations, reflecting several denominations and religious interests, support many health care programs, including hospitals in rural and urban areas, refugee centers,
72 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
quality issues affecting public health; and assessing and making recommendations for business ventures that could help support the fiscal sustainability of the hospital and improve the eco- nomics of the community. It is hoped that future projects will include faculty and students from the school of peace studies to help the community learn how to deal with conflict and social justice issues and the school of education to help support the teacher training that might better serve the education of the children (Bolender and Hunter, 2010).
Access to services and the removal of financial barriers alone do not account for the public’s use of health services. In fact, the introduction of health care technology from developed countries to less developed countries has led to less-than- satisfactory results. For example, equipment donated to the Holy Innocents Children’s Hospital (HICH) in 2009-2012 has not been as usable as the donors had hoped because of the significant difference in power voltage necessary to run the machines; power outages in Uganda with secondary power surges, which have burnt out the equipment’s power compo- nents; and power outages requiring the use of a gas generator, which may or may not produce enough power to effectively run the machines (personal communication with John Baptist Mujuni, HICH administrator, January 2012). The World Bank reported that during the 1980s in an eastern Mediterranean country, two thirds of the high-output x-ray machines were not in use because of a lack of qualified and trained individuals to carry out routine maintenance and repairs. Even in Uganda, there are minimal qualified technicians to repair broken x-ray units, rebreathing units for the neonatal intensive care unit (NICU) area, and EKG machines for monitoring the critically ill children (personal communication with John Baptist Mujuni, HICH administrator, January 2012).
Countries devastated by war have lost their total infrastruc- ture for food, trade, social justice, health, water, and public security as evident today in Afghanistan, the West Bank, Gaza, Darfur, Syria, and other war-torn countries. When implement- ing services for less developed nations, it is essential to conduct needs assessments to learn what a community has, what a com- munity wants, and what it can sustain. Quite simply, well- intended projects can fail because first, the project served the purpose of the donors and not the needs of the people; second, because no assessment was done to ascertain what resources the country had and what services the country could sustain.
When projects are developed that pay attention to the intent of global health diplomacy, then there is improvement in the overall health status of a population, which secondarily can contribute to the economic growth of a country in several ways (WHO, 2013c): • Reduction in production loss caused by workers who are
absent from work because of illness • Increase in the use of natural resources that, because of the
presence of disease entities, might have been inaccessible • Increase in the number of children who can attend school and
eventually participate in their country’s economic growth • Increase in monetary resources, formerly spent on treating
disease and illness, now available for the economic develop- ment of the country
structure of the country, thus interfering with the long-standing traditional Indian medical system. In southern India, good health and prosperity are related to certain social parameters bestowed to families and communities as a result of their con- formity to the socio-moral order that was established by their ancestors, gods, and patron spirits. The taking of pharmaceuti- cal agents thus disrupts the social and cultural order of things that have been traditionally addressed by cultural practices.
Information about volunteering for many NGOs and PVOs can be obtained from the Internet web sites included in the text. Nurses have developed global initiatives, participate in global health projects, and lead global health organizations such as Doctors without Borders. Becoming a global citizen is the responsibility of all (http://www.globalnurseinitiative.org/).
GLOBAL HEALTH AND GLOBAL DEVELOPMENT Global health is not just a global public health agenda; it does not begin and end with the individual; it must consider all factors within a country that affect health, such as environment, educa- tion, national and local policies, health care and access to health care, economics (importing and exporting of goods, industry, technology), war, and public safety. This paradigm shift is called global health diplomacy, which refers to multilevel and multi- factor negotiation processes involving environment, health, emerging diseases, and human safety. It is now recognized that to solve global health problems, one must build capacity for global health diplomacy by training public health professionals and diplomats, respectively, to prevent the imbalances that emerge between foreign policy and public health experts and the imbalances that exist in negotiating power and capacity between developed and developing nations (Hunter et al, 2013). The cutting edge of global health diplomacy raises certain cautions regarding health’s role in trade and foreign policies. Unfortu- nately, securing health’s fullest participation in foreign policy does not ensure health for all, but it supports the principle that foreign policy achievements by any country in promoting and protecting health will be of value to all (Hunter et al, 2013).
Nurses cannot think in isolation about health for the global population; they must think more broadly to achieve their goals through a multidisciplinary, multilevel approach involving such dimensions as economic, industrial, and technological develop- ment. An example of this global health diplomacy approach, developed by the author and her colleagues, is the Uganda Project. What began as a simple request to help a community in Uganda save the lives of children dying unnecessarily from preventable diseases has turned into a sustainable community development project. Serving as consultants to an NGO, led by the school of nursing at the University of San Diego, and working collaboratively with the departments of environmental science and business, students and faculty have provided vol- unteer service and consultation to the people of Mbarara, Uganda on the building, implementation, and sustainability of a children’s hospital in their community. Such consultation involved addressing the training of health care professionals on pediatric care and lay health educators to help improve the health of the community; assessing and intervening on water
73CHAPTER 4 Perspectives in Global Health Care
provides larger subsidies to insurers for participants who are sicker, are elderly, or have preexisting conditions. Tax credits are given to low-income clients to help them purchase insurance. People under age 18 are insured at no cost. There is a separate universal national social insurance program for long-term care, known as the AWBZ, or Exceptional Medical Expenses Act. Insurers offer a choice of policies at a range of costs. In some of the plans, the insurer negotiates and contracts with the health provider, whereas more costly plans allow clients to choose their health provider and be reimbursed by the insurer. The insured also pay a flat-rate premium to their insurer for a policy. Every- one with the same policy pays the same premium, and lower- income residents receive a health care allowance from the government to help make payments (Daley and Gubb, 2013).
Mexico Mexico has a fractionalized system with a variety of public programs. There is no universal coverage, but a social security– administered system does cover those who are employed. The private insurance market is used mostly by wealthy residents. The Seguro Popular program, created in 2003, has been set up to help cover more of the uninsured population. Poor families can participate in Seguro Popular for free, and people who do not participate in the insurance program can still access services through the Ministry of Health, although sometimes with some difficulty. The different public set-ups and private insurers all use different systems of medical facilities and providers, with a wide range of quality reported in those services. The social security system provides broad coverage for medical services, including primary care, acute care, ambulatory and hospital care, pregnancy and childbirth, as well as prescription medica- tions. The Seguro Popular system provides access to an estab- lished set of essential medical services and the needed drugs for those conditions, as well as 17 high-cost interventions such as breast cancer treatment. The services are provided through gov- ernment, usually state-run, facilities. Out-of-pocket payments by clients represent over half of financing for the Mexican health care system, whereas the public schemes are financed through general taxes and payment from the employer and employee, determined by salary. The Seguro Popular is also funded by taxes, contributions from the state and federal gov- ernment, and payments by the families, as a percentage of income. Participants in Seguro Popular pay nothing at the time of delivery of the service (Puig et al, 2009).
Uganda Uganda’s health care system is a national service, meaning that health care is supposed to be free and accessible to all. There are five clinic and hospital facilities that patients can access (if they are staffed, if the staff workers are not extorting money from the people, and if they have supplies). These clinics and hospi- tals work on a referral basis; if a level I or II facility cannot handle a case, it refers it to a unit the next level up. Often units do not have the essential drugs, meaning the patients have to buy them from pharmacies or other drug sellers. Level I clinics do health counseling; level II can take care of common diseases such as malaria and antenatal care; level III clinics are where
Because the economics of international development are complex, it is often difficult to convince governments to direct their resources away from perceived needs such as military and technology and, instead, place resources in health and educa- tional programs. Ideally, the role of the more-developed coun- tries is to assist less developed countries to identify internal needs and to support cost-efficient measures and share their technology and industrial expertise. It is important that nurses who work in international communities acknowledge the importance of global health diplomacy and its various param- eters: culture, politics, economics, technology, public health, social justice, foreign policy, and public safety. Provision of health services alone will not ease a country’s health care plight (Figure 4-6).
HEALTH CARE SYSTEMS The countries of the world present many different kinds of health care systems. Most consist of the population to be served, health care providers, third-party payers, health care facilities, and those who control access and usability of the system (Shakarishvili et al, 2010). Understanding some of these principles is highlighted when one compares the health care systems in the Netherlands, Mexico, Uganda, Ecuador, the United Kingdom, and China. For more information on the lists of countries and the per capita expenditures on health care, please see the report at http://dpeaflcio.org/the-u-s-health-care -system-an-international-perspective/.
The Netherlands In the Netherlands, under a health policy reform movement in 2006, residents are required to purchase health insurance, which is provided by private health insurers (for-profit or nonprofit) that compete for business. Everyone must be insured and the insurers are required to accept every resident in their coverage area, regardless of preexisting conditions. The government
FIG 4-6 “NICU” in a local Ugandan community hospital: one oxygen concentrator and one suction machine. (Courtesy A. Hunter.)
74 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
Although the British system has come under criticism in past years, individual citizens still maintain a high level of support for government funding and control of their health services. Clients, especially the elderly and new mothers, receive assis- tance from the district nurses (public health nurses). One of the hallmarks of the British system is a reduction in infant mortal- ity, from 14.3 deaths per 1000 births in 1975 to 5.4 in 2002. Overall life expectancy in Great Britain also improved during the same period (77.2 years in 2000). This has been done while holding down gross spending on health care. A 2009 report by Sutherland found that the United Kingdom has seen a signifi- cant fall in mortality rates from the major killers: cancer, coro- nary heart disease, and stroke. Client ratings of quality care are high all across the United Kingdom; however, there is concern about rising health expenditure over the past 10 years (Sutherland, 2009).
China China has made tremendous strides since 1949 in providing access to health care for its citizens. At present, China is a large developing country with many human resources (Yun et al, 2010). Nursing comprises a large segment of the health care workforce, yet there are too few nurses to meet the needs of the population. China, like the United States, is engaged in health care reform. China also has more physicians than nurses, which is different than in most other areas of the world. Nurse density in China is higher in urban than in rural areas, and this poses a problem in a large country in which much of the territory is rural in nature. Like many other countries, China has made public health advances by controlling contagious diseases such as cholera, typhoid, and scarlet fever, and by reducing infant mortality (Yun et al, 2010). These accomplishments in public health were credited to a political system that was and is largely socialistic and features a health care system that is described in socialistic terms as collective. The Chinese collective system emphasized the common good for all people, not individuals or special groups. This system was financed through coopera- tive insurance plans. The collective health care system was owned and controlled by the state and used “barefoot” doctors. Barefoot doctors were medical practitioners trained at the com- munity level and who could provide a minimal level of health care throughout the country. Barefoot doctors combined Western medicine with traditional techniques such as acupunc- ture and herbal remedies. The government focused on improv- ing the quality of water supplies and disease prevention, and implemented massive public health campaigns against sanita- tion problems, such as flies, mosquitoes, and the snails that spread schistosomiasis. Box 4-2 describes a Healthy Cities ini- tiative that took place in Chengdu, China.
Today, health care in China is managed by the Ministry of Public Health, which sets national health policy. The current Chinese government continues to make health care a priority and has set goals to provide medical care to all of its citizens. The Chinese government published its health care reform plan in 2009. In developing this plan the government took into account recommendations from the WHO and the World Bank. Among the aims of the plan are to develop a system of health
outpatients are seen and treated, a maternity ward exists, and minimal (screening) laboratory services are provided; level IV is a mini-hospital with the kind of services found at level III clinics, but with wards for men, women, and children who can be admitted for short stays; and level V is a tertiary hospital for patients who are trauma victims, have major health problems, or are in need of mental health, dentistry, and surgery services. Although this sounds like an excellent system, my years of experience in Uganda can attest to both its strengths and weak- nesses, with the greatest weakness being the lack of health pro- fessionals and the lack of supplies—too many children die because they have no oxygen, no intravenous (IV) fluids, and no antibiotics. Other aspects of the health system in Uganda are the faith-based hospitals; private medical practices/clinics set up by individual doctors or nurses as an income generator for themselves; and the traditional healers who practice herbal therapy, magic, bloodletting, and other nontherapeutic activi- ties that often cause more harm than good (Kamwesiga, 2011; Kelly, 2009).
Ecuador The health system in Ecuador has both a public sector and a private sector, with the public sector providing health care ser- vices to the whole working and uninsured populations. Private insurance is for the middle and high-income group, which includes about 3% of the population. In addition, there are about 10,000 private physicians’ offices, generally equipped with basic infrastructure and technology, located in major cities, and the population tends to make direct payments out of pocket at the time they receive care. There are special govern- ment programs to provide nutrition for the poor and maternity services to ensure healthy pregnancies and deliveries (Lucio et al, 2011). Recent reports by expatriate visitors to Ecuador indicate that the greatest perk for foreign residents is the high- quality, low-cost health care. There is personal attention from medical practitioners not seen in the United States since the 1960s; and in the bigger cities, one will find hospitals with state- of-the-art equipment, as well as specialists in all fields and phy- sicians with private clinics.
The United Kingdom It is also useful to examine the United Kingdom, with a tax- supported health system that is owned and operated by the government. Services are available to all citizens without cost or for a small fee. Administration of health services is conducted through a system of health authorities (Trusts). Each Trust plans and provides services for 250,000 to 1 million people. The services offered by each Trust are comprehensive, in that health care is available to all who want it and covers all aspects of general medicine, disability and rehabilitation, and surgery. Although physicians are the primary providers in this system, nurses and allied health professionals are also recognized and used. Services are made available through hospitals, private physicians and allied health professional clinics, and health out- reach programs such as hospice, and environmental health ser- vices. Physicians are paid by the number of clients they serve and not by individual visits (Boyle, 2011).
75CHAPTER 4 Perspectives in Global Health Care
that result from disability. Premature death is defined as the difference between the actual age at death and life expectancy at that age in a low-mortality population. People who have debilitating injuries or diseases must be cared for in some way, most often by family members, and thus they no longer can contribute to the family’s or a community’s economic growth. The GBD represents units of disability-adjusted life-years (DALYs) (WHO, 2014e) (Box 4-4). Thirty-five percent of the health factors contributing to the DALY numbers in 2011 were related to communicable diseases, maternal and perinatal conditions, and nutritional deficits; 54% of DALYs were in noncommunicable conditions such as respiratory, cardiac, musculoskeletal, and other conditions; and the rest were related to injuries. Tables 4-1 and 4-2 reflect the conditions with the greatest impact on the 2011 DALYs (WHO, 2014e).
Table 4-1 indicates that in 2011, 88% of the disability- adjusted life-years were the result of the top 10 conditions. Psychiatric disorders, although traditionally not regarded as a major epidemiologic problem, are shown by consideration of disability-adjusted life-years to have a huge impact on popula- tion ranking in the top 10 on the global burden of disease index. From just this table, 2.4 billion DALYs were lost worldwide, which equates to 70 million deaths of newborn children or to 150 million deaths of people who reach age 50. Approximately 2.5 million neonatal deaths occurred and more than 20 million
insurance to help people pay for catastrophic illness, to increase and improve the education for nurses in order to intervene in the growing nursing shortage, and to develop urban health centers. At present, a small percentage of Chinese nurses work in public health, and some authors attribute this to the low pay in these settings. Hospitals and clinics are typically located in urban areas, which means that people in rural areas must travel a great distance for care, and even then, the care may be sub- standard and the wait time to receive care may be long. It is estimated that approximately 200 million people in China lack health insurance. When the State Council published its health care reform plan in April of 2009, a 3-year goal of “covering 90% of the Chinese population by 2011 and achieving universal health care by 2020” was established.
The nursing education system in China has developed rapidly. All college-based nursing education was terminated during the period of the Cultural Revolution and began again only in the mid-1980s. At present the nursing education system includes associate degree, baccalaureate, master’s degree, and doctoral programs. Interestingly, the image of nursing has improved, based on the effectiveness of nurses during recent public health crises and events that claimed international atten- tion. Specifically, nurses played important and effective roles in caring for people during the disasters caused by the SARS virus in 2003 and the Sichuan earthquake in 2008. More recently, nurses were well recognized in China for their considerable work during the 2008 Olympic Games in Beijing (Yun et al, 2010). Unfortunately, pay and working conditions are contrib- uting to the desire of many Chinese nurses to leave the country.
MAJOR GLOBAL HEALTH PROBLEMS AND THE BURDEN OF DISEASE Despite the gains that have been made in improving the health of so many around the globe, the increasing population, decreas- ing food and water sources, and increasing poverty related to a global economic crisis are all contributing to a critical demise in health. The amount of debt incurred by less developed coun- tries has increased steadily over the last 20 years, and money that was once used for health care has been used to pay off growing debt. Communicable diseases that are often prevent- able are still common throughout the world and are more common in less developed countries. Also, both developed and less developed countries are seeking ways to cope with the aging of their populations—a population that presents governments with the burden of providing care for those who become ill with more expensive noncommunicable and chronic forms of dis- eases and disabilities. Illnesses such as AIDS continue to raise concerns, especially in child-bearing women, adolescents, and young adults. Long-standing diseases such as TB, dysentery, and mosquito-borne diseases, especially malaria, still persist and have become drug resistant, adding to the growing burden of overextended health care delivery systems.
Mortality statistics do not adequately describe the outlook of health in the world. The WHO (2014d) has developed an indicator called the global burden of disease (GBD). The GBD combines losses from premature death and losses of healthy life
http://www.cbra.be/publications/Devleesschauwer2014b.pdf
DALYs are composed of years lived with disability (YLDs) and years of life lost due to premature mortality (YLLs). YLDs, the morbidity component of the DALYs, are calculated as follows: YLD = 14 Number of cases x duration till remission or death x disability weight.
Within the DALY calculation are the social weighting factors: 1. Duration of time lost because of a death at each age: Measurement is
based on the potential limit for life, which has been set at 82.5 years for women and 80 years for men.
2. Disability weights: The degree of incapacity associated with various health conditions. Values range from 0 (perfect health) to 1 (death). Four prescribed points between 0 and 1 represent a set of accepted disability classes.
3. Age-weighting function, Cxe−βx, where C = 0.16243 (a constant), β = 0.04 (a constant), e = 2.71 (a constant), and x = age; this function indicates the relative importance of a healthy life at different ages.
4. Discounting function, e−r(x − a), where r = 0.03 (the discount rate), e = 2.71 (a constant), a = age at onset of disease, and x = age; this function indi- cates the value of health gains today compared with the value of health gains in the future.
5. Health is added across individuals: 2 people each losing 10 DALYs are treated as showing the same loss as 1 person losing 20 years.
“In summary, one DALY can be thought of as one lost year of ‘healthy’ life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences” (see http://www/ who.int/healthinfo/global_burden_disease/)
BOX 4-4 Calculating Disability-Adjusted Life-Years
76 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
http://www.who.int/healthinfo/global_burden_disease/estimates_regional/en/index1.html
2011
Rank Broad Cause DALYs (000s) % DALYs DALYs per 100,000 Population
1 Infectious diseases (incl. respiratory infections) 624141 22.7 8996 2 Cardiovascular diseases 378875 13.8 5461 3 Injuries 296836 10.8 4278 4 Neonatal conditions 231581 8.4 3338 5 Cancers 223539 8.1 3222 6 Mental and behavioral disorders 198370 7.2 2859 7 Respiratory diseases 134246 4.9 1935 8 Neurological and sense organ conditions 128613 4.7 1854 9 Musculoskeletal diseases 108401 4.0 1562
10 Endocrine, blood, immune disorders, diabetes mellitus 88211 3.2 1271
TABLE 4-2 Top 10 DALYs in Broad Categories
children under age 5 died during the same year in less developed countries. If these children could face the same risks as those in developed nations, the deaths would decrease by 90%. This example demonstrates the importance of having accessible and affordable disease prevention programs for children around the world (WHO, 2014e). Infections and parasitic diseases remain a threat to the health of the majority of the world and are dis- eases seen in the United States in newly arriving immigrants. Studies demonstrate the continuing need for intervention for infectious and other kinds of communicable diseases. Condi- tions that contribute to one fourth of the GBD throughout the world include diarrheal disease, respiratory tract infections, worm infestations, malaria, and childhood diseases such as measles and polio. Sub-Saharan Africa demonstrated a GBD of 43% DALYs lost, largely because of preventable diseases among children (WHO, 2014e).
According to the U.S. Global Health Policy fact sheet pub- lished by the Kaiser Family Foundation (2010), globally there were 33 million people living with HIV in 2007, up from 29.5 million in 2001, the result of continuing new infections, people living longer with HIV, and general population growth. HIV is a leading cause of death worldwide and the number one cause of death in Africa. An estimated 8 in 10 people infected with HIV do not know it. HIV has led to a resurgence of TB, particu- larly in Africa, and TB is a leading cause of death for people with HIV worldwide. Women represent half of all people living with HIV worldwide, and more than half (60%) in sub-Saharan Africa. Globally, there were 2.5 million children living with HIV in 2009, 370,000 new infections among children, and 260,000 AIDS deaths. There are approximately 16.6 million AIDS orphans today (children who have lost one or both parents to HIV), most of whom live in sub-Saharan Africa (89%).
2011
Rank GHE Code Cause DALYs (000s) % DALYs DALYs per 100,000 Population
1 39 Lower respiratory infections 164804 6.0 2375 2 113 Ischaemic heart disease 159659 5.8 2301 3 114 Stroke 135369 4.9 1951 4 11 Diarrhoeal diseases 118789 4.3 1712 5 50 Preterm birth complications 110688 4.0 1595 6 10 HIV/AIDS 95226 3.5 1372 7 118 Chronic obstructive pulmonary disease 89605 3.3 1291 8 153 Road injury 78792 2.9 1136 9 51 Birth asphyxia and birth trauma 78199 2.8 1127
10 83 Unipolar depressive disorders 75002 2.7 1081 11 140 Congenital anomalies 57697 2.1 832 12 80 Diabetes mellitus 56402 2.1 813 13 22 Malaria 55414 2.0 799 14 138 Back and neck pain 52692 1.9 759 15 58 Iron-deficiency anaemia 46244 1.7 667 16 3 Tuberculosis 42240 1.5 609 17 155 Falls 40782 1.5 588 18 161 Self-harm 39787 1.4 573 19 68 Trachea, bronchus, lung cancers 37252 1.4 537 20 123 Cirrhosis of the liver 34925 1.3 503
TABLE 4-1 Top 20 DALY Conditions
From ChildInfo: Monitoring the situation of children and women. Available at http://www.childinfo.org/maternal_mortality.html. Accessed March 20, 2014.
77CHAPTER 4 Perspectives in Global Health Care
The WHO has estimated that if all the vaccines now available against childhood diseases were widely adopted, and if coun- tries could raise vaccine coverage to a global average of 90%, by 2015 an additional 2 million deaths a year could be prevented among children under age 5. This level of vaccination would reduce child deaths by two thirds and achieve one of the MDG goals. It would also greatly reduce the burden of illness and disability from vaccine-preventable diseases and contribute to improving child health and welfare, as well as reducing hospi- talization costs (WHO, Immunizations, 2010b).
As discussed in Chapter 10, environmental sanitation is critical to the well-being of people around the globe. Many of the major health risks relate to interactions between people and their environment. For example, in developing nations, com- munity drinking water sources can be contaminated by agricul- tural runoffs containing toxic pesticides and fertilizers, but they can also be contaminated by naturally occurring elements in the earth such as arsenic and fluoride. This author and her col- leagues have found gross heavy metal (primarily arsenic) con- tamination of the water sources in Uganda including the government filtered water, bottled water from clean water bot- tling companies in Uganda, bore holes (wells), river, swamps, and springs (Bolender et al, 2012, 2013; Jameel et al, 2012). Efforts are underway to assess the extent of this problem across Uganda and to assess the effects on the population. We have already discovered unexplained neurological symptoms in the adults and persistent anemia in the children; which could have its causative origin in the arsenic-contaminated water con- sumed by the people. Long-term absorption of arsenic in humans has been associated with skin cancer, cancer of the bladder and lungs, developmental effects, neurotoxicity, diabe- tes, and cardiovascular disease (Global Poverty Project, 2013; WHO, Fact Sheet on Arsenic, 2012c).
In developing nations, it is not uncommon for hospitals and HIV testing centers to dump waste products into the local rivers that often supply the local household water. Worldwide, envi- ronmental factors play a role in more than 80% of adverse outcomes reported by the WHO, including infectious diseases, injuries, mental retardation, and cancer, to name a few. Global- ization and industrialization in the developing world have increased daily exposure to pollution and a wide array of chem- icals in air, water, and food. At the same time, fecal pollution of drinking water sources caused by a lack of basic sanitation still exists. The effects of environmental risk factors are magni- fied by conditions often prevalent in poorer, undeveloped countries such as poor nutrition, poverty, lack of education about risks, and conflicts. Children are particularly susceptible to environmental risks because their systems are still develop- ing. It is estimated that about one quarter of global disease is caused by avoidable environmental exposures; for young chil- dren in the developing world, causes of environmentally related deaths are acute respiratory infections, related to poor air quality; and diarrhea, related to poor drinking water quality. Annually, about 3 million children under the age of 5 die of environment-related diseases. There are projects that train and give technical assistance, data collection and analysis, laboratory analyses, research, surveillance, and emergency responses to
Uganda’s emphasis on ameliorating HIV/AIDS is a model for all African nations; however, there are still too many Ugandan children under 5 years old who are AIDS orphans. Unfortu- nately, despite the efforts of advocates, donors, and affected countries, there needs to be greater attention given to the long overdue effort to expand access to antiretroviral therapy, which is still available to less than 10% of those who urgently require it.
Determining the total amount of loss, even using the GBD, is difficult because it does not address the many consequences of disease and injury such as post–trauma and infectious physi- cal disabilities. Nor can it measure the short- or long-term effects of familial and marital dysfunction, family violence, or war. The following further elaborates on selected communica- ble diseases that still contribute substantially to the worldwide disease burden (TB, AIDS, and malaria) and other health prob- lems such as maternal and women’s health, diarrheal disease in children, nutrition, natural and man-made disasters.
Communicable Diseases Prevention of communicable diseases is through immunization and improving environmental conditions. One example of the long-term benefits of immunizing children against communi- cable diseases is the successful campaign against smallpox that the WHO conducted during the 1960s and 1970s. Smallpox has been virtually eliminated throughout the world, with only occa- sional and incidental reporting from laboratory accidents and inoculation complications. The systematic and planned small- pox program formed the basis for a series of worldwide efforts that are now being implemented to control and eradicate other infectious and communicable diseases.
In 1974 the WHO formed the Expanded Program on Immu- nization, which sought to reduce morbidity and mortality from diphtheria, pertussis, tetanus, TB, measles, and poliomyelitis throughout the world (WHO, 2010). In the 2010 State of the World Report on immunizations and vaccines, the WHO noted that for the first time in documented history the number of children dying every year had fallen below 10 million. This appears to be the result of improved access to clean water and sanitation, increased immunization coverage, and the inte- grated delivery of essential health interventions. Unfortunately, almost 20% of the children born each year do not get the com- plete routine immunizations scheduled for their first year of life. This is most prevalent in developing countries and for those children born in the very rural communities. In developing countries, more vaccines are available and more lives are being saved; however, death from pertussis in developing countries is 40 per 1000 infants, and 10 per 1000 in older children. It still occurs in industrialized countries but at less than 1 per 1000 cases. Although free vaccination clinics are brought to the people, they are often not used because of lack of knowledge, fear propagated by the traditional healers, and suspicion of anything offered by the government. Reaching these vulnerable children—typically in poorly served remote rural areas, deprived urban settings, fragile states, and strife-torn regions—is essen- tial in order to meet the Millennium Development Goals (MDGs; United Nations, 2013b).
78 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
TB to their families and to the community, further increasing the prevalence of this condition.
The second is the growing multidrug resistance of the TB bacillus to isoniazid and rifampin, the two drugs used to treat it. Resistance to these drugs is already evident around the world, including in the Mexico-Texas border communities. The WHO and other organizations maintain that a high priority should be given to TB control and eradication programs around the world. They advocate a short-term chemotherapy regimen for smear-positive clients as being one of the most cost-effective health interventions available (Forman et al, 2012; WHO, Tuberculosis Fact Sheet, 2012d). The bacille Calmette-Guérin (BCG) vaccine, which has been available since the 1920s, was promoted as an effective vaccine to induce active immunity against TB, especially among children living in TB-endemic or high-risk TB areas that are impoverished and crowded. The BCG vaccine has a documented protective effect against men- ingitis and disseminated TB in children. It does not prevent primary infection and, more importantly, does not prevent reactivation of latent pulmonary infection, the principal source of bacillary spread in the community. The impact of BCG vac- cination on transmission of TB is therefore limited (WHO, 2012d). The standard chemotherapeutic agents used in many countries for TB are isoniazid, thioacetazone, and streptomycin, and they are effective at converting sputum-positive cases to noninfectivity. The drugs and the combinations that are used vary from country to country. To be effective, however, treat- ment must be carried out on a consistent basis, and many less developed countries have difficulty persuading clients to pur- chase the medications and to adhere to any treatment regimen. In 1990 the WHO Global Tuberculosis Program (GTB) pro- moted the revision of national TB programs to focus on short- course chemotherapy (SCC), with directly observed treatment (DOT). DOT programs have been successful in the United States and in several less developed countries, including Malawi, Mozambique, Nicaragua, and Tanzania, producing a cure rate of approximately 80%. The SCC program involves aggressive administration of chemotherapeutic drugs combined with short-term hospitalization. The key to the program lies in a well-managed system with a regular supply of anti-TB drugs to the treatment centers, follow-up care, and rigorous reporting and analysis of client information (IOM, 2011).
Lasting control of AIDS, TB, and/or malaria will depend on strengthening the health, economic, political, education, and other infrastructure necessary to sustain life and promote the well-being of the people. It will require sustained investment in physical infrastructure, drug distribution systems, management at all levels, and, most importantly, human resources such as the training and appropriate use of community health workers to deliver some essential services and education. Unfortunately, the failure of developed countries to fulfill their pledges of more development aid, and the failure of developing countries them- selves to invest in health, are overarching barriers to health systems development. HIV/AIDS, TB, and malaria are only three of the challenges facing poor people. Only stronger, inte- grated health systems can provide a platform to sustain a suc- cessful fight against these diseases while advancing the other
international communities (American Society of Hematology, 2013; WHO, Fact Sheet on Child Deaths, 2013b).
As of 2013, 783 million people still do not have access to clean water, and their water sources are often far away, unclean, and unaffordable; 2.5 billion people or 40% of the world’s popula- tion lack an adequate toilet or latrine. Getting hold of clean water is not good enough if the water is being made dirty because there are no toilets, and toilets are not good enough if there is no hygiene promotion to persuade whole communities to change the habits of generations and use the latrines. Esti- mates by the Joint Monitoring Program of UNICEF and the WHO predict that at the current rate of progress, approximately 2 billion people will still lack access to a clean environment by 2015. In sub-Saharan Africa 50% of people lack this basic human right, and their need may not be met until 2072 if the current rate continues (UNICEF, Water, Sanitation and Hygiene, 2010).
Tuberculosis In 2012, according to the WHO (Tuberculosis Fact Sheet, 2012d) about 8.6 million people fell ill with tuberculosis and 1.3 million died of the disease. Ninety-five percent of TB deaths occur in low to middle income countries, and TB is one of the top three causes of death for women ages 15-44. Children are not immune to this bacterium, as the WHO report indicates that more than 530,000 children diagnosed with the disease and 74,000 HIV-negative children died of TB. It is a leading killer of people with HIV, and up to 80% of TB clients are HIV positive in countries with a high prevalence of HIV. People with HIV are much more likely to develop TB; as are those infected with malaria, especially children, because of the physi- ological damage to the liver, spleen, and hematological systems. A child or adult with any one of the three diseases mentioned is more prone to the other two, and this triad is the new scourge of impoverished nations. The WHO estimates that more than one third of infectious disease deaths are due to this deadly triad of AIDS, TB, and malaria (WHO, Tuberculosis Fact Sheet, 2012d).
It is expected that at least one third of the world’s population, or 1.7 billion people, harbor the TB pathogen Mycobacterium tuberculosis. The Stop TB Partnership, engaging nearly 300 gov- ernments and agencies, has brought consensus on approaches to global control of this disease, galvanized support, and launched new support mechanisms, such as the Global TB Drug Facility, an initiative to increase access to high-quality TB drugs. The Working Group on Tuberculosis recommends seven priori- ties to meet the MDG targets for this disease for 2015. All this effort has resulted in some good news. It has been shown that the number of people falling ill with tuberculosis each year is declining, although very slowly. The world appears to be on track to achieve the Millennium Development Goal to reverse the spread of TB by 2015, especially given that the TB death rate dropped 45% between 1990 and 2010.
Two factors are a threat to TB control and eradication. The first is the AIDS virus. The appearance of HIV has added to the difficulty of treatment programs in both developed and less developed countries. More important, HIV-positive individuals with infectious TB have an increased likelihood of transmitting
79CHAPTER 4 Perspectives in Global Health Care
Worldwide prevention programs are important because failing to control this virulent disease will result in damaging and costly consequences for all countries in the future. Ideally, the goal is primary prevention of HIV. When prevention efforts fail at this level, the next goal is secondary prevention, or early diagnosis and treatment. Aggressive interventions in many African nations have begun to make a difference in the life potential for patients diagnosed with HIV.
Combination ART has contributed to the reduced morbidity and mortality rate since 2001 and in sub-Saharan Africa alone, the number of people receiving ART increased significantly from 50,000 in 2002 to 7.5 million in 2012. In 2012, ART covered 61% of individuals who were eligible for treatment, representing 65% of the 2011 U.N.General Assembly Special Session target of treating 15 million by 2015. New WHO guide- lines recommend starting treatment of HIV earlier in the course of illness. Given these new recommendations, 25.9 million people are now eligible for treatment (Kaiser Family Founda- tion, 2013a). See the levels of prevention box below to learn about prevention of HIV.
health priorities of developing countries, including child and maternal health and chronic disease.
It is important, when conducting a health assessment inter- view, always to ask whether the client has recently traveled out of the United States or to one of the border areas along the United States–Mexico perimeter. People who travel abroad may bring back diseases that are difficult to diagnose. In addition, people often cross the border into Mexico to fill a prescription for medicine because it is often less expensive than in the United States. Unfortunately, many times the medications brought back have been relabeled and are out of date.
Acquired Immunodeficiency Syndrome As discussed in Chapter 14, AIDS remains a major cause of morbidity and mortality throughout the world. More than 70 million people have been infected with HIV since the beginning of the epidemic; approximately 35 million people have died of AIDS. At the end of 2011, 34.0 million people globally were living with HIV with an estimated 0.8% of the adult population aged 15-49 years infected. The burden of the epidemic continues to vary considerably between countries and regions; however, sub-Saharan Africa remains most severely affected, with nearly 1 in every 20 adults (4.9%) living with HIV and accounting for 69% of the global population infected with this virus (IOM, 2012; WHO, HIV/AIDS, 2014f ). For more infor- mation, go to http://www.who.int/gho/hiv/hiv_013.jpg?ua=1 (WHO, Global Health Observatory—HIV/AIDS, 2014f ).
The Kaiser Family Foundation report (2013a) stated that approximately 35.3 million people were living with HIV in 2012, up from 29.4 million in 2001. This rise appears to be the result of continuing new infections (averaging 6300 per day), people living longer with HIV, and general population growth. When comparing the population growth with the HIV inci- dence rates, overall new HIV infections have declined by 33% since 2001. Of interest is that 1.6 million people died of AIDS in 2012, which was a 30% decrease since 2005. Such results appear to be the result of antiretroviral treatment (ART) scale-up.
The majority of new infections are being transmitted hetero- sexually, placing women and children at increased risk for acquiring the infection. Gender inequalities, lack of access to services, and sexual violence against women and children increase their vulnerability to HIV. Women represent about half (52%) of all people living with HIV worldwide and younger women are biologically more susceptible to HIV. Unfortunately, young people often believe the disease can be cured with drugs and thus they can be less cautious; in addition, cultural practices exist whereby older men marry virgins to cure them of AIDS or to prevent them from getting AIDS.
By 2012, there were 3.3 million children globally living with HIV, with 260,000 new infections identified and 210,000 chil- dren who lost their lives to AIDS. Sadly, there are approximately 17.3 million children with AIDS who have lost one or both parents to HIV; most of these children live in sub-Saharan Africa (88%) and will either die from the disease or be treated as social outcasts by the community at large (Kaiser Family Foundation, 2013a).
LEVELS OF PREVENTION
Primary Prevention Teach people how to avoid or change risky behaviors that might lead to contracting human immunodeficiency virus (HIV).
Secondary Prevention Initiate screening programs for HIV.
Tertiary Prevention Manage symptoms of HIV, provide psychosocial support, and teach clients and significant others about care and other forms of symptom management.
Global Health Care
Malaria Malaria affects more than 50% of the world’s population and hits tropical Africa the hardest. However, there have been major global efforts to control and eliminate malaria that have saved an estimated 3.3 million lives since 2000, reducing malaria mor- tality rates by 45% globally and by 49% in Africa, according to the “World Malaria Report 2013” published by the WHO (see http://www.who.int/malaria/publications/world_malaria _report_2013/en/).
The large majority of the 3.3 million lives saved between 2000 and 2012 were in the 10 countries with the highest malaria burden, and among children under 5 years of age, which is the group most affected by the disease. Over the same period, malaria mortality rates among children in Africa were reduced by an estimated 54%. An expansion of prevention and control measures has contributed to a consistent decline in malaria deaths and illness. Unfortunately, the new WHO report notes a slowdown in the expansion of interventions to control mosqui- toes for the second successive year, particularly in providing access to insecticide-treated bed nets, because of lack of funds to procure bed nets. My experience in Uganda still finds that
80 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
Although chemotherapeutic agents can be used for both protection and treatment of the disease, they are expensive and often cause side effects. However, evidence suggests that the Plasmodium sporozoites are becoming resistant to both treat- ment and preventive chemotherapeutic agents, especially chloroquine and its derivatives. Alternative therapies and/or combinations of medications such as sulfadoxine/ pyrimethamine (Fansidar), amodiaquine, artemisinin, arte- mether, and atovaquone/proguanil (Malarone) are somewhat effective in treating malaria. Recent reports indicate that drug manufacturers in these endemic countries are diluting the drugs so that clients, especially children, are not receiving therapeutic levels of the medications. Many children suffer the effects of partially treated malaria, and once hospitalized, IV quinine is the drug of choice. Unfortunately, quinine has significant neu- rotoxic and cardiovascular side effects that need monitoring (CDC, 2013a). Efforts are underway to develop an antimalarial vaccine and one candidate vaccine, known as RTS,S/AS01, has been shown to almost halve the number of malaria cases in young children (aged 5 to 17 months at first vaccination) and to reduce by about one fourth the malaria cases in infants (aged 6 to 12 weeks at first vaccination) (Malaria Vaccine Initiative, 2013). As discussed in Chapter 13, persons who live or travel to Anopheles-infested areas should protect themselves with mos- quito netting, clothing that protects vulnerable parts of the body, repellents for both their bodies and their clothes, and antimalarial medications such as Malarone or doxycycline.
Diarrheal Disease The normal intestinal tract regulates the absorption and secre- tion of electrolytes and water to meet the body’s physiological needs. More than 98% of the 10 L of fluid per day entering the adult intestines is reabsorbed (Ahs et al, 2010; Alexander and Blackburn, 2013). The remaining stool water, related primarily to the indigestible fiber content, determines the consistency of normal feces from dry, hard pellets to mushy, bulky stools, varying from person to person, day to day, and stool to stool. This variation complicates the definition of diarrhea. For adults diarrhea is present when three or more liquid stools are passed in 24 hours. The frequent passage of formed stool is not diar- rhea. Although young nursing infants tend to have five or more bowel movements per day, stools that are liquid without any formation and/or are more than what is normal for the child constitute diarrhea (Ahs et al, 2010; Farthing et al, 2012). Defi- nitions are complicated by the observable presence of blood, mucus, or parasites and the age of the affected person.
Diarrhea, one of the leading causes of illness and death in children less than 5 years of age throughout the world, is most prominent in the less developed countries despite recent initia- tives by the WHO to correct this problem. Each year there are 760,000 diarrhea deaths in children under five; there are 1.7 billion cases of diarrheal disease every year related to unsafe water, sanitation, and hygiene; and it is the leading cause of malnutrition in children under five (WHO, Diarrhea Fact Sheet, 2013f ). Causes of diarrhea are just as varied and diverse as its definitions and perceptions. Some of the causes include (1) viruses such as the rotavirus and Norwalk-like agents, (2)
malaria and its sequelae are the number one cause of death in children less than 8 years of age.
Malaria is caused by the Anopheles mosquito and is the only mosquito-borne disease that can be prevented and cured by pharmacological management (WHO, Malaria Report, 2013e). It is caused by parasitic transmission from the infected female mosquito to its host. There are four parasite species that cause malaria, the most serious being Plasmodium falciparum, which causes microvascular sequestration and obstruction in the brain, kidney, and liver leading to cerebral malaria, anemia, kidney failure, hypoglycemia, disseminated intravascular coag- ulation (DIC), fluid-electrolyte imbalance, and death (CDC, 2013a). Symptoms vary and range from mild to severe physi- ological responses (mild fever and chills to temperatures of 106° F with prolonged chills, seizures, and dehydration).
A range of effective antimalarial interventions exists for the prevention, treatment, and control of malaria. These include the use of insecticide-treated bed nets (ITNs); indoor residual spraying; intermittent presumptive treatment during preg- nancy; early diagnosis and prompt treatment with effective antimalarials; management of the environment to control mos- quitoes; health education; and epidemic forecasting, preven- tion, and response (CDC, 2013a; WHO, 2013e). Methods of vector control vary widely, from using the larvae-eating fish tilapia to the use of insecticidal sprays and oils. Needless to say, the latter poses a potential threat to the environment in tropical areas where a delicate ecosystem is already threatened by other potential hazards such as lumbering and mining.
Countries that do not have strict environmental laws con- tinue to use dichlorodiphenyltrichloroethane (DDT) sprays to control mosquito populations despite the advent of DDT- resistant mosquitoes. The non-DDT insecticide sprays, such as malathion, generally cost more, presenting an extra financial burden to less developed countries. Methods for control and eradication that are being considered by malaria-ridden coun- tries are environmental management, reduction and control of the source, and elimination of the adult mosquito. There are significant global efforts being made to “blanket” endemic com- munities with insecticide-treated mosquito nets. A multitude of NGO projects are distributing ITNs to contribute to this initia- tive: Project Mosquito Net in Kenya (www.projectmosquitonet .org), Nothing But Nets (www.nothingbutnets.net/), Global Giving for Africa (www.globalgiving.org/projects/mosquito- nets-for-africa-families), Angola Mosquito Net Project (https:// angolamosquitonetproject.wordpress.com/) and Holy Inno- cents Children’s Hospital Uganda (www.holyinnocentsuganda .org) are examples of organizations actively engaged in prevent- ing malaria and saving lives.
However, coverage levels are inadequate in endemic coun- tries, especially in poor communities. Without adequate and predictable funding, the progress against malaria is also threat- ened by emerging parasite resistance to artemisinin, the core component of artemisinin-based combination therapies (ACTs), and mosquito resistance to insecticides. Artemisinin resistance has been detected in four countries in Southeast Asia, and insecticide resistance has been found in at least 64 countries.
81CHAPTER 4 Perspectives in Global Health Care
available and affordable medical care increases the problem. Children suffer from an apparently never-ending sequence of infections and rarely receive appropriate preventive care, and too often their parents seek health care only when the children have become severely ill.
Dehydration is an immediate result of diarrhea and leads to a loss of fluid and electrolytes. The loss of up to 10% of the body’s electrolytes can lead to shock, acidosis, stupor, and failure of the body’s major organs (e.g., kidneys, heart). Persis- tent diarrhea often leads to loss of body protein, an increased time-limited inability to digest and absorb dairy products, and increased susceptibility to infection. Every country should have as a major aim the prevention and control of diarrheal disease, especially in infants and children. Many countries have devel- oped diarrhea control programs that improve childhood nutri- tion. These programs instruct in breastfeeding and weaning practices and promote oral rehydration therapy and the use of supplementary feeding programs (Farthing et al, 2012). However, all these programs must be considered in conjunction with improving the social and economic conditions that con- tribute to safe environmental, sanitary, and general living con- ditions of populations around the world. The following How To box provides useful resources for keeping well informed about public health issues including water quality.
bacteria, including Campylobacter jejuni, Clostridium difficile, Escherichia coli, Salmonella, and Shigella, (3) environmental toxins, (4) parasites such as Giardia lamblia and Cryptosporid- ium, and (5) worms. Nutritional deficiencies can also cause diarrhea and are most often a result of infectious agents. Of these, the rotavirus has emerged as a major world concern, hospitalizing 55,000 American children and killing 1 million children in the world each year (Farthing et al, 2012; WHO, Diarrhea Fact Sheet, 2013f ). Three major diarrhea syndromes exist: • Acute watery diarrhea, which results in varying degrees of
dehydration and fluid losses that quickly exceed total plasma and interstitial fluid volumes and is incompatible with life unless fluid therapy can keep up with losses. Such dramatic dehydration is usually due to rotavirus, enterotoxigenic E. coli, or Vibrio cholerae (the cause of cholera), and it is most dangerous in the very young.
• Persistent diarrhea, which lasts 14 days or longer, and is manifested by malabsorption, nutrient losses, and wasting; it is typically associated with malnutrition, either preceding or resulting from the illness itself. Even though persistent diarrhea accounts for a small percentage of the total number of diarrhea episodes, it is associated with a disproportion- ately increased risk of death.
• Bloody diarrhea, which is a sign of the intestinal damage caused by inflammation. Bloody diarrhea, defined as diar- rhea with visible or microscopic blood in the stool, is associ- ated with intestinal damage and nutritional deterioration, often with secondary sepsis. Mild dehydration and fever may be present. Bloody diarrhea should not be confused with dysentery, because dysentery is a syndrome consisting of the frequent passage of characteristic, small-volume, bloody mucoid stools, abdominal cramps, and tenesmus (a severe pain that accompanies straining to pass stool). Agents that cause bloody diarrhea or dysentery can also provoke a form of diarrhea that clinically is not bloody diarrhea, although mucosal damage and inflammation are present microscopi- cally. The release of host-derived cytokines alters host metabolism and leads to the breakdown of body stores of protein, carbohydrate, and fat and the loss of nitrogen and other nutrients. Those losses must be replenished during the expected prolonged convalescence. For these reasons, bloody diarrhea calls for management strategies that are markedly different than those for watery or persistent diarrhea. New bouts of infection that occur before complete restoration of nutrient stores can initiate a downward spiral of nutritional status terminating in fatal protein-energy malnutrition (Farthing et al, 2012). Diarrheal diseases are rampant among the impoverished.
Poverty is associated with poor housing, crowding, dirt floors, lack of access to sufficient clean water or to sanitary disposal of fecal waste, cohabitation with domestic animals and zoonotic transmission of pathogens, and a lack of refrigerated storage for food. Unfortunately, even when the cause of the diarrhea is eliminated, poverty can restrict the ability to provide age- appropriate, nutritionally balanced diets or to modify diets so as to mitigate and repair nutrient losses. The lack of adequate,
HOW TO Stay Current about Global Health One way to stay current with the world’s health problems and advances is by reading the newspaper daily. Examples of newspa- pers that cover international health on an ongoing basis include the Wall Street Journal, USA Today, the Washington Post, and the New York Times. The following websites are examples of sources that pertain to international or global health: • U.S. Department of Health and Human Services: http://www
.globalhealth.gov/ • Global Health Council: http://www.globalhealth.org/ • Centers for Disease Control and Prevention: http://www.cdc.gov/
globalhealth/ • World Health Organization: http://www.who.int/en/ • Pan American Health Organization: http://new.paho.org/ • World Bank: http://www.worldbank.org/ • Institute of Medicine: http://www.iom.edu/ • Millennium Development Goals: http://www.undp.org/mdg/
Maternal and Women’s Health Maternal health is central to the health of women, as well as the well-being of their children and families, and the economic productivity of their countries. A woman’s ability to survive pregnancy and childbirth is closely related to how effectively societies invest in and realize the potential of women not only as mothers, but as critical contributors to sustaining families and transforming nations. When investments in women—as mothers, as individuals, as family members, and as citizens— lag, the economic cost of maternal death and illness is enor- mous. Ostrowski (2010) stated that when women have better education and health, then mothers have greater household decision-making power and their children are better educated, becoming productive adults able to help build long-term
82 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
health services, as well as cultural belief systems that increase the lifetime risk of maternal death.
Every year, more than half a million women die in pregnancy and childbirth around the world. This figure has altered little in the last 30 years. In sub-Saharan Africa, a number of countries have halved their levels of maternal mortality since 1990 but not in the more impoverished nations such as the Congo, Uganda, Ghana, and others. However, between 1990 and 2010, the global maternal mortality ratio declined by only 3.1% per year. This is far from the annual decline of 5.5% required to achieve MDG 5 (WHO, Maternal Mortality Fact Sheet, 2012e).
Equally distressing is the fact that worldwide, the ratio of maternal deaths to live births (the maternal mortality ratio) has remained essentially static during this period. Africa continues to have the highest maternal-child morbidity and mortality rate, with 51% of all maternal deaths occurring in sub-Saharan Africa. The maternal mortality ratio in developing countries is 240 per 100,000 births versus 16 per 100,000 in developed coun- tries. The risk of maternal mortality is highest for adolescent girls under 15 years old. HIV currently accounts for 6.2% of maternal deaths in Africa and has reversed the progress made in maternal health in some countries.
In sub-Saharan Africa, infectious diseases, childhood ill- nesses, and maternal causes of death account for as much as 70% of the burden of disease. By comparison, these conditions account for only one third of the burden in South Asia and Oceania, and less than 20% in all other regions. In addition, whereas the average age of death throughout Latin America, Asia, and North Africa increased by more than 25 years between 1970 and 2010, it rose by less than 10 years in most of sub- Saharan Africa (WHO, Global Burden of Disease Report, 2012b). The WHO found that some of the sociocultural factors that prevent women and girls from benefiting from quality health services and attaining the best possible level of health include the following (WHO, Women’s Health Fact Sheet, 2013h): • Unequal power relationships between men and women • Social norms that decrease education and paid employment
opportunities • An exclusive focus on women’s reproductive roles • Potential or actual experience of physical, sexual and emo-
tional violence Within Africa, the greatest disease burden remains from
maternal health, child health, HIV, TB, and malaria; outside Africa the greatest disease burden is the rising incidence of noncommunicable diseases and rising life expectancy (Summers, 2013). Throughout the world, women between 15 and 44 years of age account for approximately one third of the world’s disease burden, and women between 45 and 59 for one fifth of the burden. This burden comprises diseases and conditions that are either exclusively or predominantly found in women, including maternal mortality and morbidity, cervical cancer, anemia, STIs, osteoarthritis, and breast cancer, with HIV/AIDS leading the statistics (Mathers, 2009).
Although most of these conditions can be dealt with by cost-effective prevention and screening programs, many less
economic growth. The World Bank found that during economic crises, poor families who sent women to work were better able to make ends meet.
Progress and investment in maternal health have lagged far behind estimates of what is needed to achieve MDG 5, Improve Maternal Health. Progress in the last 20 years on key maternal health indicators varies by outcome and region, but it has been uneven, inequitable, and inadequate overall. The two regions of the world with the worst maternal health status—South Asia and sub-Saharan Africa—show minimal signs of improvement largely because of poverty, disempower- ment of women, and overall poor health status of women in developing countries. Women’s reproductive health, especially their ability to control their fertility and avoid HIV infection, is also closely associated with their health as mothers. Although maternal death and disability represent a high burden of disease in the developing world, interventions to improve maternal health are available and cost-effective (Kaiser Family Foundation, 2013c; Kott, 2011; WHO, Family Planning Fact Sheet, 2013g).
In Uganda, Reproductive Health Uganda (RHU), formerly the Family Planning Association of Uganda (FPAU), provides services in 29 of the country’s districts, targeting young people and marginalized groups to improve reproductive health. They offer family planning; HIV/AIDS testing and counseling; diag- nosis and treatment of sexually transmitted infections (STIs); advocacy against female genital mutilation (FGM); and post- abortion care to high-risk constituencies such as internally dis- placed persons (IDPs), people at high risk of HIV/AIDS, young women in conflict-affected areas, sex workers, hawkers, saloon- ists, bicycle taxi drivers, maids—any group subject to violence and disempowerment (www.rhu.or.ug). Despite FPAU’s intent to improve the reproductive health of Ugandan women, there are barriers to the success of this initiative: continued cultural practices related to submissiveness of women and dependency on men for well-being of self and the children; bride wealth practices that give ownership to the man and permit beatings and other abuses of his wife; kinship patterns in which widowed women belong to the oldest brother; the fact that child care and all work related to the home and the children are performed by the women and girls; the fact that a woman’s worth is still dependent on her ability to reproduce, even knowing that the more pregnancies a woman incurs, the less healthy the newborn and mother; and the practice of polygamy, allowing for trans- mission of STIs and HIV/AIDS.
The WHO and UNICEF have continued their worldwide initiatives to reform the health care received by women and children in less developed countries (WHO, Maternal Health Fact Sheet, 2013h). However, studies on women’s health indi- cate that more than one third (35%) of all maternal deaths around the world are due to severe bleeding, primarily postpar- tum hemorrhage; sepsis (8%); unsafe abortion (9%); hyperten- sion (18%); and conditions that complicate pregnancy such as malaria, anemia, and HIV (20%). In developing nations there is a significant incidence of lack of prenatal care during preg- nancy and high fertility rates, often due to a lack of access to contraception and other family planning and reproductive
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address the unmet need for family planning by 2015 (WHO, 2012c). In some countries it is difficult to counsel women on family planning and spacing their children so as to promote maternal and fetal health when a woman’s value depends on her ability to reproduce and more than 50% of children die before they reach adolescence.
The result of poor maternal health accounts for the increase in premature births and the increased risk for high morbidity rates in children less than 5 years because of their own compro- mised nutritional and immune state. Low birth weight is a major risk factor for premature births, which account for more than one quarter (29%) of newborn deaths, followed by asphyxia (22%), sepsis (15%), pneumonia (10%), congenital abnormalities (7%), diarrhea (2%), and tetanus (2%). Under- nutrition and lack of access to clean water and sanitation sig- nificantly increase children’s vulnerability to death. Newborn deaths account for most child deaths (41%), followed by diar- rhea (14%), pneumonia (14%), malaria (8%), injuries (3%), HIV/AIDS (2%), and other infectious or noncommunicable diseases (18%, including measles [1%]) (Kaiser Family Founda- tion, Global Health Policy, 2013b). In 2012 approximately 6.6 million children died before the age of 5 which is nearly one half the number that died in 1990 but still much too high a number of deaths (World Bank, 2013b).
Even though programs in many countries have been initi- ated, safe motherhood initiatives are still needed throughout the world. These programs and initiatives need to include providing accessible family planning services and prenatal and postnatal health care services, ensuring access to safe abortion procedures, and improving the nutritional status of all women.
developed countries have ignored women’s health issues other than those directly related to pregnancy and childbirth for two major reasons: (1) women are not seen as valued members of society, and (2) most of the afflicted women are poor, malnour- ished, and cannot pay for health care services.
Sub-Saharan Africa accounts for the majority of the world’s births. Although all countries profess to offer prenatal services and safe birthing services, most are unavailable, inaccessible, and unaffordable by women (WHO, Maternal Health Fact Sheet, 2013h). An African woman’s risk of dying from pregnancy-related causes is 1 in 20, followed by Bangladesh, Pakistan, and India. These three countries account for nearly half of the world’s maternal deaths, but only 29% of the world’s births; they have more maternal deaths each week than Europe has in a year. Still, an accurate reporting of maternal deaths is difficult to obtain because many of the women who die are poor and live in remote areas, and their deaths are considered by many to be unimportant (Mathers, 2009) (See table above).
Risk factors for maternal mortality include poor nutritional status, disease conditions, high parity, and age less than 20 years and greater than 35 years. To date, little attention has been paid to the problem of maternal mortality, even though the reported incidences are high throughout the world. The WHO and the UN are addressing this problem by calling for government ini- tiatives and actions to address maternal morbidity and mortal- ity from obstetrical deaths as well as those that arise from indirect causes. MDG 5 aims to reduce the maternal mortality ratio by three quarters, improve the proportion of births attended by skilled health personnel, promote universal access to reproductive health, improve contraceptive rates, decrease adolescent birth rates, provide antenatal care coverage, and
Lifetime Risk of Maternal Deaths in Sub-Saharan Africa versus Industrialized Nations. (From ChildInfo: Monitoring the situation of children and women. Available at http://www.childinfo.org/ maternal_mortality.html. Accessed March 20, 2014)
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84 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
digestive diseases, and blood loss during menstruation may also worsen anemia. A deficiency of iron in the diet can reduce appetite, physical productivity, the ability to learn, and growth.
The American Society of Hematology (2013) reported that while the global prevalence of anemia decreased between 1990 and 2010 (from 40.2% to 32.9%), the disease has demonstrated an increase in global YLDs from 65.5 million to 68.4 million. The DALY burdens associated with major depression (63.2 million YLDs), chronic respiratory diseases (49.3 million YLDs), and general injuries (47.2 million YLDs) are less than the DALY burden of anemia. This is due to the increased incidence of anemia in children <5 years. This age group accounted for more cases of anemia than any other age group and had the highest severity of disease in low- and middle-income regions. Unfor- tunately the data also demonstrated a widening gender gap in anemia burden over time with female prevalence rates remain- ing higher in most regions and age groups.
Other common dietary deficiencies include zinc, iodine, vitamin A, folic acid, and calcium. Zinc is important because it is an essential part of many enzymes and plays an important role in protein synthesis and cell division. The health conse- quences of zinc deficiency include poor immune system func- tion, growth retardation, and delayed sexual maturity in children. Zinc deficiency is caused by low intake and/or low absorption of bioavailable zinc. Diets low in meat and fish increase the risk of zinc deficiency, because zinc is poorly bio- available in cereals. Vitamin A is another essential nutrient in the human diet, contributing to the functioning of the retina, the growth of bone, and the immune response. Apart from preventable, irreversible blindness, vitamin A deficiency also causes reduced immune function, leading to an increased risk of severe infectious disease and anemia. It also increases the risk of death during pregnancy for both the mother and fetus and after birth for the newborn. An estimated 250 million preschool children in developing countries are affected by vitamin A defi- ciency, although severe deficiency that causes blindness is declining (Kaiser Family Foundation, 2013c; WHO, Global Prevalence of Vitamin A Deficiency, 2013i).
The impact of malnutrition and dietary deficiencies is sig- nificant. Any malnourished condition in a population can increase susceptibility to illness. For example, the principal causes of death among malnourished persons are measles, diar- rheal and respiratory disease, TB, pertussis, and malaria. The loss of life from these diseases can be measured as 231 DALYs worldwide, with one fourth of the 231 being directly attribut- able to malnourishment and dietary deficiencies. Individual governments and organizations such as the International Red Cross, WHO, and many international religious and private foundations have been active in promoting better nutrition. Worldwide initiatives directed at overcoming nutritional defi- cits include the following (Global Nutrition Alliance, 2010): control of infectious diseases, nutritional education, control of intestinal parasites, micronutrient fortification of food, food supplementation, and food price subsidies.
Médecins sans Frontières (Doctors without Borders) was the first to use the life-saving supplement, invented in 2003 by a French scientist, called Plumpy’nut. Plumpy’nut requires no
Nutrition and World Health Many children around the world are underweight and have multiple micronutrient deficiencies such as for iron, zinc, and vitamin A. Poor nutrition by itself or that associated with infec- tious disease accounts for a large portion of the world’s disease burden (Mathers, 2009; WHO, 2013d). Improved nutrition is related to stronger immune systems, decreased illness, better maternal and child health, longer life spans, and improved learning outcomes for children. Healthy protein balances are able to support major physiological stress with improved healing and ability to utilize protein-binding drugs; better nutrition is a prime entry point to ending poverty and a mile- stone to achieving better quality of life. Environmental and economic conditions related to poverty contribute to under- consumption of nutrients, especially those nutrients needed for protein building such as iodine, vitamin A, and iron. World- wide, women and children suffer disproportionately from nutrition deficits, especially the micronutrients just mentioned (Mathers, 2009).
Children in Haiti die daily from hunger; more than 60% of the population is undernourished and children under the age of 5 suffer an even higher percentage. more than 800 million people (or one out of every five people in developing nations) are undernourished; and every few seconds, about every time one takes a breath, a child in the developing world dies of hunger and related diseases (Global Nutrition Alliance, 2010). Poor nutrition also leads to stunting, or low height and weight for a given age. Stunting often results from eating foods that do not provide adequate energy or protein. Because protein foods are usually more expensive than nonprotein food sources, many households reduce, or unconsciously eliminate, protein-rich foods to save money (Hunter, unpublished research, 2012). I have cared for and watched many children with marasmus (total caloric deprivation) and Kwashiorkor (protein deficiency starvation) die who could have been saved if affordable protein and nutritious food were available. Usually this condition begins because an infant has been weaned away from breast- feeding after a year to make room for the next baby, and the food used in its place is mainly sugar and water or a starchy gruel. Kwashiorkor symptoms are apathy, muscular wasting, edema, and pigmentation loss in the skin and hair. Marasmus is a wasting away of the body tissues and symptoms are like kwashiorkor with fretfulness and an appearance of “skin and bones.”
Iron deficiencies are also common in less developed coun- tries and severely affect women and children. When iron is low, fewer red blood cells are produced, and this reduces the capacity of the blood to transport oxygen. As a result, symptoms ranging from fatigue and inability to concentrate to impaired physical and cognitive development of children can occur. Iron defi- ciency anemia may also cause problems during pregnancy, particularly in developing countries where it can increase the risk of premature delivery, as well as the risk of maternal and fetal complications and death. Inadequate iron from food is the most common reason for iron deficiency anemia, especially among infants and children. Parasites, infections, stomach and
85CHAPTER 4 Perspectives in Global Health Care
were killed and 18,000 people were reported missing after a 7.9-magnitude earthquake struck Sichuan, China; October 8, 2005—at least 80,000 people were killed and 3 million left homeless after a quake struck the mountainous Kashmir district in Pakistan.
• Volcanic eruptions: Examples are July 15, 1991 when Mount Pinatubo on Luzon Island in the Philippines erupted, blan- keting 750 square kilometers with volcanic ash and more than 800 died; November 13-14, 1985 when at least 25,000 were killed near Armero, Colombia, when the Nevado del Ruiz volcano erupted, triggering mudslides.
• Hurricanes, cyclones, and floods: Examples are July-August 2010, when monsoon rains hit northwest Pakistan and more than one fifth of the country was under water, more than 1700 people were killed, and 17.2 million people were victims; May 3, 2008, when Cyclone Nargis, with winds that exceeded 190 km/hour and waves six meters high, struck Myanmar, leaving as many as 100,000 dead, according to U.S. estimates; October 26-November 4, 1998, when Hurricane Mitch killed 11,000 in Honduras and Nicaragua and left 2.5 million homeless.
• Pandemics and famines: 1900-present, malaria has been the leading cause of death in the developing world, causing severe illness in 500 million people each year and killing more than 1 million annually; 1984-1985, the Ethiopian famine that killed at least 1 million in Ethiopia; and 1980-present, the toll from AIDS worldwide is estimated at 25 million, with 40 million others infected with HIV (http://www.cbc.ca/news/world/the-world-s-worst-natural -disasters-1.743208). When poor countries face natural disasters, such as hurri-
canes, floods, earthquakes, and fires, the cost of rebuilding becomes even more of an issue when they are already burdened with debt. Often, poor countries suffer with many lost lives and/ or livelihoods. Aid and disaster relief often do come in from international relief organizations, rich countries, and interna- tional institutions, but poor countries often pay millions of dollars a week back in the form of debt repayment.
The aftermath of a natural disaster may be as devastating as the disaster itself. Inadequate shelter, unclean water, and lack of security are some of the most commonly reported problems, even a year after the event. The physical force of a disaster not only causes immediate injury and death, but each type of disas- ter can result in its own combination of physical injuries. In earthquakes, buildings and the objects inside them can fall, injuring those who live or work there. Floods can result in drowning, and wildfires can cause burns and illness from smoke inhalation.
In addition to the direct injury and death caused by the disaster’s force, there can be other serious adverse effects on the well-being of those living in the area. The large numbers of people who are suddenly ill or injured can exceed the capacity of the local health care system to care for them. In addition to the burden of increased numbers of clients, the system itself can become a victim of the disaster. Hospitals may be damaged, roads blocked, and personnel unable to perform their duties. The loss of these resources occurs at a time when they are most
water preparation or refrigeration and has a 2-year shelf life, making it easy to deploy in difficult conditions to treat severe acute malnutrition. It is distributed under medical supervision, to humanitarian organizations for food aid distribution. The ingredients include peanut paste; vegetable oil; powered milk; powdered sugar; vitamins A, B-complex, C, D, E, and K; and minerals including calcium, phosphorus, potassium, magne- sium, zinc, copper, iron, iodine, sodium, and selenium. These are combined in a foil pouch and each 92-g pack provides 500 kilocalories (kcal) or 2.1 megajoules (MJ).
Natural and Man-Made Disasters As discussed in Chapter 23, earthquakes, floods, drought, and other natural hazards continue to cause tens of thousands of deaths, hundreds of thousands of injuries, and billions of dollars in economic losses each year around the world. Disasters represent a major source of risk for the poor and wipe out development gains and accumulated wealth in developing countries. In 2012, only 357 natural triggered disasters were registered; a decrease from 394 observed in the years past. However, natural disasters still killed a significant number, even though there was a decline in deaths. Contrary to other indica- tors, economic damages from natural disasters did show an increase to above average levels (143 billion 2012 US$), with estimates placing the figure at US$ 157 billion. Over the last decade, China, the United States, the Philippines, India, and Indonesia together constitute the top five countries that are most frequently hit by natural disasters. In 2012, China had its fourth highest number of natural disasters over the last decade with 13 floods and landslides, 8 storms, 7 earthquakes, and 1 period of extreme temperature. The single deadliest disaster in 2012 was Typhoon Bopha, which killed 1901 people in the Philippines (Center for Research on the Epidemiology of Disaster, 2013).
Natural disasters such as earthquakes, tsunamis, and floods can often come at the least expected time. Others, such as hur- ricanes and cyclones, are increasing in severity and destruction. Droughts are increasing as the threat of global warming rises. Typically, the poor are the worst hit, for they have the least resources to cope and rebuild. Hurricane Katrina resulted in a 90,000 square mile disaster zone, equivalent to the area of Great Britain, and more than 1800 died. The Indonesian tsunami of 2005 killed at least 230,000 people, and the livelihoods of mil- lions were destroyed in more than 10 countries affected by the tsunami. The earthquake in Haiti in 2010 destroyed a country and crushed the hopes of thousands of Haitians. Human activ- ity is contributing to massive extinctions, from various animal species, to forests, and the ecosystems that support marine life. The costs associated with deteriorating or vanishing ecosystems are high. The World Resources Institute reports that there is a link between biodiversity and climate change, and rapid global warming can affect an ecosystem’s chance to adapt naturally (World Resources Institute, 2012). The four worst types of natural disasters are as follows: • Earthquakes and tsunamis: Examples are January 12, 2010—
more than 230,000 people were killed when a 7.0-magnitude earthquake struck Haiti; May 12, 2008—about 70,000 people
86 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
These agents are typically found in nature, but it is possible that they could be changed to increase their ability to cause disease, to make them resistant to current medicines, or to increase their ability to be spread into the environment in order to threaten a government or intimidate or coerce a civilian population (CDC, Bioterrorism, 2013b; Infectious disease: Global Challenges. Bioterrorism, 2013). Bioterrorism is a sig- nificant public health threat that could produce widespread, devastating, and tragic consequences, and it would impose par- ticularly heavy demands on international public health and health care systems. Nurses and other health personnel need to be aware and vigilant to the health consequences of terrorism and the potential use of biological agents to instill fear and to spread disease.
A nation’s capacity to respond to the threat of bioterrorism depends in part on the ability of health care professionals and public health officials to rapidly and effectively detect, diagnose, respond, and communicate during a bioterrorism event. The national health care community—including public health agencies, emergency medical services, hospitals, and health care providers—would bear the brunt of the consequences of a bio- logical attack. Attacks with biological agents are likely to be covert, rather than overt (CDC, 2013b). Terrorists may prefer to use biological agents because they are difficult to detect; they do not cause illness for several hours to several days.
A chemical emergency occurs when a hazardous chemical has been released and the release has the potential to harm people’s health. Chemical releases can be unintentional, as in the case of an industrial accident, or intentional, as in the case of a terrorist attack. Sarin and ricin are the two most recent notorious chemicals used; however, mustard gas, cyanide, and tear gas have existed for decades. Agent Orange was used by the American troops in Vietnam, and mustard gas was commonly used during World War I and even during the Gulf War (http:// www.policymic.com/articles/62023/10-chemical-weapons -attacks-washington-doesn-t-want-you-to-talk-about; http:// science.howstuffworks.com/mustard-gas4.htm).
Radiation poisoning occurs when an excess amount of radi- ation is released to harm people’s health. These may be unin- tentional and intentional events. Intentional terrorist events are those designed to contaminate food and water with radioactive material; spread radioactive material into the environment by using conventional explosives (e.g., dynamite), called a dirty bomb, or by using wind currents or natural traffic patterns; bomb or destroy a nuclear reactor; cause a truck or train car- rying nuclear material to spill its load; or explode a nuclear weapon.
The word genocide was developed by a jurist named Raphael Lemkin in 1944. By combining the Greek word genos (race) with the Latin word cide (killing), genocide was defined by the United Nations in 1948 to mean any of the following acts committed with intent to destroy, in whole or in part, a national, ethnic, racial, or religious group, including (1) killing members of the group, (2) causing serious bodily or mental harm to members of the group, (3) deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part, (4) imposing measures intended to prevent births
critically needed. The disaster can also hamper the ability to provide routine, nonemergency health services. Many people may be unable to obtain care and medications for their ongoing health problems. The disruption of these routine services can result in an increase in illness and death in segments of the population that might not have been directly affected by the disaster. The most serious consequences of natural disasters are related to mass population displacements, unsanitary condi- tions, lack of clean water, lack of nutritious foods, lack of safe housing, and the increased risk of diseases prevalent in crowded and unsanitary living conditions: typhoid fever, cholera, dysen- tery, TB, and infectious respiratory conditions (Petrucci, 2012).
Man-made disasters may include bioterrorism, chemical agents, pandemics and epidemics, radiation, and terrorism. The five worst man-made disasters in recent history are as follows: • Bhopal Gas Tragedy, India in 1984 where more than 500,000
people were exposed to methyl isocyanine gas and other chemicals. Thousands of people died within the first hours of the leak, but over time estimates of 5000 to 16,000 deaths from the leak have been made.
• Deepwater Horizon Oil Spill, Gulf of Mexico in 2010 that killed 11; leaked anywhere from 40,000 to 162,000 barrels of oil a day; took 47,829 people 89 days to finally cap the well; and 3500 workers and volunteers on the clean-up site are suffering liver and kidney damage from their exposure to the 1.8 million gallons of toxic oil.
• Chernobyl Meltdown, Ukraine in 1986. Thirty-one volunteers died trying to shut the reactor down and nearly 4000 deaths so far have been thought to be attributable to the radiation poisoning people living near Chernobyl underwent. To this day, no one is sure what the final death toll from the Cher- nobyl meltdown will be.
• Fukushima Meltdown, Japan in 2011 with more than 100,000 people evacuated and displaced from the surrounding areas; 600 people dying during the evacuation; 300 cleanup workers receiving excessive exposure to radioactive waste; and the resulting unknown long-term health effects that could include people as far away from the meltdown as North America.
• Global Warming that impacts rising sea levels, desertification, animal extinction, and damage from intense superstorms such as Hurricane Katrina, Hurricane Sandy, and Typhoon Haiyan in the Philippines has already created some of the first groups of climate-change refugees, and some estimate that number will rise to 150 million by 2050 (http:// www.policymic.com/articles/23620/5-worst-man-made -disasters-in-history). Other man-made disasters are the bioterrorism attack and
the deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death of people, animals, or plants, which may lead to pandemics and epidemics (anthrax, cholera, Ebola virus, Lassa fever, plague, and smallpox, to name a few). A pandemic is an epidemic of infectious diseases that spread through human populations across a large region such as a continent or the globe (e.g., HIV/AIDS, smallpox, TB, H1N1, SARS); whereas an epidemic is when new cases of a certain disease in a given human population exceed what is expected (cancer, heart disease, seasonal flu).
87CHAPTER 4 Perspectives in Global Health Care
encouraging international organizations to make mental and behavioral health a priority in conflict assistance throughout the various stages of genocide; and encouraging its member organizations to emphasize the importance of social work in regard to genocide in their respective countries (Vollhardt and Bilewicz, 2013).
Surveillance Systems Surveillance systems, discussed in Chapter 24, are used to track potential risks for intentional harm to the people of the world. There are systems in place to assess the risks for man-made and natural disasters to prevent the atrocities to mankind discussed previously. These systems may be on-the-ground specialists who acquire information about the political stability of nations, or they may be satellite systems that track weather, volcanic, and earthquake activities.
How would a government find out that a deliberate outbreak had taken place? For the international system, the WHO moni- tors disease outbreaks through the Global Outbreak Alert and Response Network (Center for Research on the Epidemiology of Disaster, 2012; WHO, 2014g). This network, formally launched in April 2000, electronically links the expertise and skills of 72 existing networks from around the world, several of which were uniquely designed to diagnose unusual agents and handle dangerous pathogens. Its purpose is to keep the inter- national community constantly alert to the threat of outbreaks and ready to respond. It has four primary tasks: 1. Systematic disease intelligence and detection: The first respon-
sibility of the WHO network is to systematically gather global disease intelligence, drawing from a wide range of resources, both formal and informal. Ministries of Health, WHO country offices, government and military centers, and academic institutions all file regular formal reports with the Global Outbreak Alert and Response Network. An infor- mal network scours world communications for rumors of unusual health events.
2. Outbreak verification: Preliminary intelligence reports from all sources, both formal and informal, are reviewed and con- verted into meaningful intelligence by the WHO Outbreak Alert and Response Team, which makes the final determina- tion on whether a reported event warrants cause for inter- national concern.
3. Immediate alert: A large network of electronically connected WHO member nations, disease experts, health institutions, agencies, and laboratories is kept continually informed of rumored and confirmed outbreaks. The network also main- tains and regularly updates an Outbreak Verification List, which provides a detailed status report on all currently veri- fied outbreaks.
4. Rapid response: When the Outbreak Alert and Response Team determines that an international response is needed to contain an outbreak, it enlists the help of its partners in the global network. Specific assistance available includes tar- geted investigations, confirmation of diagnoses, handling of dangerous biohazards (biosafety level IV pathogens), client care management, containment, and logistical support in terms of staff and supplies.
within the group, and (5) forcibly transferring children of the group to another group (Genocide Watch, International Alli- ance to End Genocide, 2013; http://www.genocidewatch.org/). The most notable genocides were the Al-Anfal genocide of the Kurds in Iraq, with more than 280,000 killed and many thou- sands unaccounted for; the Rwandan genocide, where the Hutus slaughtered hundreds of thousands (possibly 1 million) of their Tutsi relatives; the Irish potato famine, where more than a million Irish died because of lack of intervention by the British to feed the starving populace; the Native American genocide, with the loss of more than 1 million indigenous people to intentional infections with smallpox, war, and starvation; the Bosnian genocide and the annihilation of the Bosnian Muslims and Serbs to ethnically cleanse the country; and the most notable, the Holocaust, in which more than 6 million Jews and other ethnically disenfranchised populations were lost (http:// listverse.com/2013/05/03/10-atrocious-genocides-in-human -history/). Genocide continues today in Syria, Darfur, and the Central African Republic.
Following genocide, there are biopsychological changes such as physical stress reactions (cardiovascular, neurological) and mental stress responses, especially post-traumatic stress disor- ders and depression. Many people flee and become refugees or internationally displaced people. These refugees flee to neigh- boring countries, placing social, political, and economic burdens on these countries. I have been to the refugee camps in Uganda for refugees from Rwanda, the Congo, Kenya, and even north- ern Uganda, whose people have been victims of the Liberation Rebel Army (LRA) as political turmoil continues to plague the civilians in East Africa. The victims of genocide often face dis- crimination in refugee camps or in their new country of per- manent residence if they do not return home. Individuals who return to their home countries are often plagued with uncer- tainty regarding lost property and other belongings.
The biological and psychosocial effects of genocide are not exclusive to the child and adult victims, but affect the perpetra- tors as well. Marginalization and dehumanization place a mental toll on the victims that often results in negative cogni- tive, behavioral, affective, relational, and spiritual effects. Many perpetrators are forced into committing these acts, and achieving desensitization is necessary for a nonviolent person to kill or to commit violent acts. This is evident in the boy soldiers of the LRA (some as young as 6 years old) who are forced to kill or be killed and become desensitized through the use of alcohol, drugs, and repeated exposure to death (Vollhardt and Bilewicz, 2013).
After genocidal conflicts have ceased, restoration of a coun- try’s infrastructure, as well as reconciliation, must begin. The ramifications of genocide are widespread, and community leaders must find the most effective ways of initiating the healing process. The United Nations has tried to develop strate- gies to prevent genocide from occurring and is encouraging initiatives that include appropriate comprehensive cultural competence in the delivery of services; supporting and organiz- ing treatment and care that is fair and just to all members of specific societies, regardless of age, gender, race, cultural beliefs, religion, sexual orientation, affiliation, and civil status;
88 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
From ICN. Nursing Matters: Terrorism and bioterrorism: nursing preparedness. Available at http//www.icn.ch/publications/disaster-planning–and relief. Accessed December 27, 2010; International Council of Nurses (ICN): Code of Ethics for Nurses, Geneva, 2000, ICN.
The International Council of Nursing (ICN, 2009) policy paper on disaster pre- paredness outlines actions, including risk assessment and multidisciplinary management strategies, as critical to the delivery of effective responses to the short-, medium-, and long-term health needs of a disaster-stricken population. These actions include the following:
Help People to Cope with Aftermath of Terrorism • Assist people to deal with feelings of fear, vulnerability, and grief. • Use groups that have survived terrorist attacks as useful resources for victims.
Allay Public Concerns and Fear of Bioterrorism • Disseminate accurate information on the risks involved, preventive measures,
use of antibiotics and/or vaccines, and reporting suspicious letters or pack- ages to the police or other authorities.
• Address hoax messages, false alarms, and threats; any perceived threat to the public health must be investigated.
Identify the Feelings That You and Others May be Experiencing • In the aftermath of terror, even health care professionals can feel bias, hatred,
vengeance, and violence toward ethnic or religious groups that are associated with terrorism. These feelings can compromise their ability to provide care for these groups. Yet as the ICN Code of Ethics for Nurses affirms, nurses are ethically bound to provide care to all people. Explain that feelings of fear, helplessness, and loss are normal reactions to a disruptive situation.
• Help people remember methods they may have used in the past to overcome fear and helplessness.
• Encourage people to talk to others about their fears. • Encourage others to ask for help and provide resources and referrals. • Remember that those in the helping professions (e.g., nurses, physicians,
social workers) may find it difficult to seek help. • Convene small groups in workplaces with counselors/mental health experts.
Assist Victims to Think Positively and to Move Toward the Future • Remind others that things will get better. • Be realistic about the time it takes to feel better. • Help people to recognize that the aim of terrorist attacks is to create fear and
uncertainty. • Encourage people to continue with the things they enjoy in their lives and to
live their normal lives.
Prepare Nursing Personnel to be Effective in a Crisis/ Emergency Situation • Incorporate disaster preparedness awareness in educational programs at all
levels of the nursing curriculum. • Provide continuing education to ensure a sound knowledge base, skill devel-
opment, and ethical framework for practice. • Network with other professional disciplines and governmental and nongov-
ernmental agencies at local, regional, national, and international levels.
BOX 4-5 What Can Nursing Do in the Event of a Disaster?
In summary, if health care professionals and emergency responders are to be prepared to manage natural or manmade disasters, it is critical that there be cooperative efforts at the international, national, state, and local levels (Box 4-5). Such disaster response is not the domain of any one specialty; nurses, doctors, mental health experts, first responders, EMTs,
volunteers, engineers, and many more need to be part of the team that helps people overcome the physical, emotional, social, and economic devastation. Nurses need to have political, his- torical, social, medical, nursing, and public health knowledge in order to be more effective in finding the resources their clients need to recover successfully.
LINKING CONTENT TO PRACTICE
The role and involvement of nurses in global health relies heavily on nursing standards of practice and core competencies of both nurses and other public health professionals. The role also varies from country to country. It is not sur- prising to learn that nursing plays a more active role in health care delivery in the more technologically advanced countries. The more developed countries have a defined role for nurses, whereas the role is less well defined, if it is defined at all, in less developed countries. However, nurses need to remember that addressing the health of the people of the world is not restricted to meeting the physical health needs but, in order to be successful, must incorporate the concept of global health diplomacy. Physical, environmental, mental, political, fiscal, economic, safety, and educational “health” are intertwined in achieving the goals we all have for helping the people of the world obtain optimal well- being. Assessment of each of these areas is cited in standards of practice for nursing and public health professionals and is essential in the global nursing role. See the Quad Council on Nursing’s competencies (Swider et al, 2014), which incorporate those of the Council on Linkages core competencies for public health professionals. Each set of competencies recommends analytic/ assessment skills that are crucial to working in a global health arena. They also talk about the importance of cultural competence skills and communication skills that are relevant to the people with whom you are working.
During the last decade, some less developed countries have implemented primary health care programs directed at prevention and management of impor- tant public health problems. With the increasing migration between and within countries because of war and famine, a greater need for nursing expertise to alleviate suffering of refugees and displaced persons has emerged. Starvation, disease, death, war, and migration underscore the need for support from the wealthier nations of the world.
More than 30 million refugees and internally displaced persons in less devel- oped countries currently depend on international relief assistance for survival. Death rates in these populations during the acute phase of displacement have been up to 60 times the expected rates. Displaced populations in Ethiopia and southern Sudan have suffered the highest death rates. In Afghanistan and in war-torn Iraq, infectious diseases accounted for one half of all admissions to the hospital—mostly malaria and typhoid fever. The greatest death rate has been in children 1 to 14 years old. The major causes of death have been measles, diarrheal diseases, acute respiratory tract infections, and malaria. In addition, poor sanitation in many hospitals and clinics and shortages of drugs and quali- fied health care workers produce huge gaps for needed health care services. Continued violence accounts for a population afraid to leave home to seek medical help.
Council on Linkages Between Academic and Public Health Practice: Core Competencies for Public Health Professionals. Washington, DC, 2010. Public Health Foundation/Health Resources and Services Administration. Quad Council of Public Health Nursing Organizations. Competencies for Public Health Nursing Practice, Washington, DC, 2003, ASTDN, revised 2009.
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LINKING CONTENT TO PRACTICE—cont’d
Nurses from more developed countries are recruited to combat the major mortality in refugee camps: malnutrition, measles, diarrhea, pneumonia, and malaria. Nurses, collaborating with other experts, are following the principles of primary health care and are promoting adequate food intake, safe drinking water, shelter, environmental sanitation, and immunizations. These life-saving practices have been implemented in the following countries: Thailand (Myanmar refugees), Rwanda, Zaire, Angola, Afghanistan, the Sudan, Uganda, and the former Yugoslavia. Nurses are making a difference; however, nurses involved in
this work must be culturally astute and responsive, be well educated about the world and well versed in the tasks required to achieve positive outcomes, able to critically reason, able to make decisions, able to identify who are appropriate team members, and be able to collaborate with the team. They ought not be afraid of taking risks, they should be action-oriented, and they need to be flexible and altruistic. Global health work is a labor of love, it is a giving of self to make a difference in the lives of others less fortunate, and it is the most rewarding work in which many nurses have ever been engaged.
P R A C T I C E A P P L I C A T I O N You are sent to a country ravaged by war, in which many people are refugees. You are asked to work side by side with other nurses, both foreign and native to the country. A. What would you do first to develop this group of nurses into
a functioning team?
B. Which health and environmental problems would you attempt to handle early in your work?
C. Identify second-stage interventions and prevention once the initial crisis stage is relieved. Answers can be found on the Evolve site.
K E Y P O I N T S • Global health is a collective goal of nations and is promoted
by the world’s major health organizations. • Global health cannot be achieved without using the con-
structs of global health diplomacy: addressing and finding solutions to physical, environmental, fiscal, economic, politi- cal, safety, educational, and trade issues.
• As the political and economic barriers between countries fall, the movement of people back and forth across international boundaries increases. This movement increases the spread of various diseases throughout the world.
• Nurses play an active role in the identification of potential health risks at U.S. borders, with immigrant populations throughout the United States, and as participants in global health care delivery.
• Understanding a population approach is essential for under- standing the health of specific populations.
• Universal access to health care for the world’s populations relies on strong primary care.
• The major organizations involved in world health are (1) multilateral, (2) bilateral and nongovernmental or private voluntary, and (3) philanthropic.
• The health status of a country is related to its economic and technical growth. More technologically and economically advanced countries are referred to as developed, whereas those that are striving for greater economic and technologi- cal growth are termed less developed. Many less developed countries shift financial resources from health and education to other internal needs, such as defense or economic devel- opment, and this shift does not help the poor.
• The global burden of disease (GBD) is a way to describe the world’s health. The GBD combines losses from premature death and losses that result from disability. The GBD repre- sents units of disability-adjusted life-years (DALYs).
• Critical global health problems still exist and include com- municable diseases such as tuberculosis, measles, mumps, rubella, and polio; maternal and child health; diarrheal dis- eases; nutritional deficits; malaria; and AIDS.
• Natural and man-made disasters have become global health concerns.
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. In your class, divide into small groups and discuss how you
might find out if there are immigrant communities in your area (you may need to contact your local health department, area social workers, or community social organizations and churches).
2. Discuss how you can gain access to one of these immigrant groups.
3. On gaining access, how would you go about determining what specific kinds of services the people need? What are their beliefs about health and health care? What customs regarding health were followed in their country of origin?
How does the American health care system differ from the health care system in their country?
4. As a nurse, what kinds of interventions can you implement with immigrant populations? What special skills or knowledge do you need to provide care to immigrant populations?
5. Write to one of the major international health organizations or visit their Internet web page and obtain their mission and goal statements. What is the focus of their health-related activ- ities? Does the organization that you identified have a specific role defined for nurses? How can a nurse who is interested become involved in their programs and activities?
90 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
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C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S — cont’d 6. Pick a country or area of the world outside the United States
that interests you. Go to the library or use the Internet to obtain information about the following: a. Status of health care in that country b. Major health concerns c. Global burden of disease (GBD) d. Whether this country is developed or lesser developed e. Which, if any, global health care organizations are involved
with the delivery of health care in that country
7. Choose one or more of the following countries, and find out from your local or state health department the health risks that are involved in visiting that country: Indonesia, Zaire, Paraguay, Bangladesh, Kuwait, Kenya, Mexico, China, and Haiti.
8. Establish communication with nurses in a country of inter- est (via telecommunication [e.g., web, phone, blog]) to discuss the state of nursing in that country, their problems, and plans to overcome some of the barriers that obstruct them from achieving their professional goals.
91CHAPTER 4 Perspectives in Global Health Care
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92 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
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93
Forces Affecting Health Care Delivery and
Population-Centered Nursing
As has been discussed in Part One, the U.S. health care system has been criticized for its rapidly rising health care costs, unevenness in the level and quality of services provided from one area of the country to another and for people in different age and socioeconomic groups. There has also been concern about the equality of access to health services. By 2008, when the recession began in the United States, the number of people who lived in poverty was increasing. In 2007 it was estimated that 12.5% of the people in the United States were living in poverty. Between 2007 and 2011 the poverty rate increased to 15%. Some of the reasons for the poverty increase had to do with the decreased numbers of people who had full-time year-round jobs. From 2008, with an unemployment rate of 4.9%, the rate grew to a high of 9.0% in 2010. Without job stability, many people were without adequate health insurance, and a sizable number of individuals and families lost their homes because of foreclosures. There were many other Americans who remained employed yet their salaries did not increase. These flat salaries did not allow the workers to keep pace with the increasing costs of consumer products and services. In 2011 the economy began to recover, but slowly. In 2015 the unemployment rate had dropped to 5.5%. Also by 2015 the number of persons living in poverty had dropped slowly.
Although the costs of health care have grown in recent years, local, state, and federal funding for public health care has not grown. The vast majority of the money spent on health care in the United States is for acute care. Approximately 3% of the total health care budget is spent on the aspects of public health that could make a difference in the health of the citizens: health promotion and disease prevention. The allocation of funds, especially for preventive care, has begun to shift as health care reform occurs.
As mentioned, there are early indications that prevention, coordination, and community-based care will be increasingly supported. As a result of the national debates—and some say “arguments” about health care reform—legal, economic, ethical, social, cultural, political, and health policy issues have grown in importance. Now more than ever in the history of population-centered nursing, nurses must understand how these issues affect their practice and the outcomes of care. Nurses will continue learning how their knowledge, skills, and voice can influence the decisions about health care. As health care changes, including public health care, nurses as the largest public health provider workforce must be a force in redefining the renewed public health system. Understanding the issues that affect decisions about health care priorities is imperative. Knowledge is power.
The chapters in Part Two discuss important economic, ethical, cultural, and policy issues that affect nurses in general and population-centered nurses specifically.
P A R T 2
94
5
Economics of Health Care Delivery
Marcia Stanhope, PhD, RN, FAAN Dr. Marcia Stanhope is currently an Associate of the Tufts and Associates Search Firm, Chicago, Ill. She is also a consultant for the nursing program at Berea College, Kentucky. She has practiced community and home health nursing, has served as an administrator and consultant in home health, and has been involved in the development of two nurse-managed centers. At one time in her career, she held a public policy fellowship and worked in the office of a U.S. Senator. She has taught community health, public health, epidemiology, policy, primary care nursing, and administration courses. Dr. Stanhope formerly directed the Division of Community Health Nursing and Administration and served as Associate Dean of the College of Nursing at the University of Kentucky. She has been responsible for both undergraduate and graduate courses in population-centered nursing. She has also taught at the University of Virginia and the University of Alabama, Birmingham. During her career at the University of Kentucky she appointed to the Good Samaritan Foundation Chair and Professorship in Community Health Nursing, and was honored with the University Provost’s Public Scholar award. Her presentations and publications have been in the areas of home health, community health and community-focused nursing practice, as well as primary care nursing.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Relate public health and economic principles to nursing
and health care. 2. Describe the economic theories of microeconomics and
macroeconomics. 3. Identify major factors influencing national health care
spending.
4. Analyze the role of government and other third-party payers in health care financing.
5. Identify mechanisms for public health financing of services.
6. Discuss the implications of health care rationing from an economic perspective.
7. Evaluate levels of prevention as they relate to public health economics.
K E Y T E R M S budget limits, p. 97 business cycle, p. 99 capitation, p. 117 cost-benefit analysis, p. 99 cost-effectiveness analysis, p. 99 cost-utility analysis, p. 99 demand, p. 97 diagnosis-related groups, p. 111 donut hole, p. 108 economic growth, p. 99
economics, p. 96 effectiveness, p. 98 efficiency, p. 98 fee-for-service, p. 102 gross domestic product, p. 99 gross national product, p. 99 health care rationing, p. 100 health economics, p. 96 human capital, p. 99 inflation, p. 96
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz • Case Studies • Glossary • Answers to Practice Application • Resource Tools
• Resource Tool 2.A: Select Major Historical Events Depicting Financial Involvement of Federal Government in Health Care Diversity
• Appendix • Appendix G.4: The Health Insurance Portability and
Accountability Act (HIPAA): What Does It Mean for Public Health Nurses?
95CHAPTER 5 Economics of Health Care Delivery
largely due to the struggling economy and weak job market (Kaiser Family Foundation, 2012a). As the Affordable Care Act is implemented, new and affordable options will become available, hopefully reducing the number of uninsured indi- viduals and families (Kaiser Family Foundation, 2012a).
• The rate of uninsured was higher among people with lower incomes and lower among those with higher incomes. For households with less than $25,000 annual income, 24.9% did not have health insurance coverage in 2012 (DeNavas-Walt et al, 2013).
• Adults are more likely to be uninsured than children (Kaiser Family Foundation, 2013).
• Young adults (ages 19-25 years) account for a disproportion- ately large share of the uninsured, largely due to their low incomes (Kaiser Family Foundation, 2013; USDHHS, 2012).
• The uninsured rate for all children was 8.9% in 2012. For children living in poverty the uninsured rate was 12.9%, which was higher than the rate of children not in poverty (7.7%) (DeNavas-Walt et al, 2013).
• Minorities are more likely to be uninsured than whites. About 32% of Hispanics and 21% of black Americans were uninsured in 2011, compared with 13% of non-Hispanic whites (Kaiser Family Foundation, 2012a; USDHHS, 2012).
There is strong evidence to suggest that poverty can be directly related to poorer health outcomes. Poorer health outcomes lead to reduced educational outcomes for children, poor nutrition, low productivity in the adult workforce, and unstable economic growth in a population, community, or nation. However, improving health status and economic health is dependent on the “degree of equality” in policies that improve living standards for all members of a population including the poor. To move toward improving a population’s health, there must be an “investment in public health” by all levels of government (Robert Wood Johnson Foundation, 2013).
Estimates indicate that public spending on health care makes a difference, but a sustained and sufficient level of investment in prevention at the federal, state, and local levels is needed to improve the overall health status of populations (Trust for America’s Health, 2013a,b and 2014). Several facts are known from the literature (Kaiser Family Foundation, 2013; Robert Wood Johnson Foundation, 2013; DeNavas-Walt et al, 2013; U.S. Department of Health and Human Services [USDHHS], 2012): • In 2012, approximately 48 million (15.4%) of the estimated
311.1 million people in the United States were without health insurance (DeNavas-Walt et al, 2013). Over the past decade, the number of uninsured individuals has increased,
K E Y T E R M S — cont’d intensity, p. 103 investment in public health, p. 95 macroeconomic theory, p. 98 managed care, p. 115 managed competition, p. 115 market, p. 97 means testing, p. 108 Medicaid, p. 110 medical technology, p. 103 Medicare, p. 110
microeconomic theory, p. 97 prospective payment system, p. 111 public health economics, p. 96 public health finance, p. 96 quality of adjusted life-years, p. 100 retrospective reimbursement, p. 116 safety net providers, p. 101 supply, p. 97 third-party payer, p. 114 —See Glossary for definitions
C H A P T E R O U T L I N E Public Health and Economics Principles of Economics
Supply and Demand Efficiency and Effectiveness Macroeconomics Measures of Economic Growth Economic Analysis Tools
Factors Affecting Resource Allocation in Health Care The Uninsured Access to Health Services Rationing Health Care Healthy People 2020
Primary Prevention The Context of the U.S. Health Care System
First Phase Second Phase
Third Phase Fourth Phase Challenges for the Twenty-First Century
Trends in Health Care Spending Factors Influencing Health Care Costs
Demographics Affecting Health Care Technology and Intensity Chronic Illness
Financing of Health Care Public Support Public Health Other Public Support Private Support
Health Care Payment Systems Paying Health Care Organizations Paying Health Care Practitioners
96 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
Care Act (PL 111-148) was passed by Congress and signed into law on March 23, 2010. There is now a greater emphasis in the Affordable Care Act (ACA) on improving participation and the outcomes of prevention, and population health.
PUBLIC HEALTH AND ECONOMICS Economics is the science concerned with the use of resources, including the production, distribution, and consumption of goods and services. Health economics is concerned with how scarce resources affect the health care industry (McPake et al, 2013; Phelps, 2012). Public health economics, then, focuses on the production, distribution, and consumption of goods and ser- vices as related to public health and where limited public resources might best be spent to save lives or best increase the quality of life (Centers for Disease Control and Prevention [CDC], 2015).
Economics provides the means to evaluate society’s attain- ment of its wants and needs in relation to limited resources. In addition to the day-to-day decision making about the use of resources, there is a focus on evaluating economics in health care (McPake et al, 2013; Phelps, 2012). While in the past there has been limited focus on evaluating public health economics, it is becoming more obvious what evaluating public health and preventive care can do in terms of cost savings and, more importantly, quality of life (Trust for America’s Health, 2013b). This type of evaluation will help to present challenges to public policymakers (legislators).
Public health financing often causes conflict because of the views and priorities of individuals and groups in society, which may differ from those of the public health care industry. If money is spent on public health care, then money for other public needs, such as education, transportation, recreation, and defense, may be limited. When trying to argue that more money should be spent for population-level health care or prevention, data are becoming available that show the investment is a good one. Public health finance is a growing field of science and practice that involves the acquiring, managing, and using of monies to improve the health of populations through disease prevention and health promotion strategies. This field of study also focuses on evaluating the use of the money and the impact on the public health system (Honoré, 2012).
Although the public health system had been considered for many years as involving only government public health agencies such as health departments, today the public health system is known to be much broader and includes schools, industry, media, environmental protection agencies, voluntary organiza- tions, civic groups, local police and fire departments, religious organizations, industry/business, and private sector health care systems, including the insurance industry. All can play a key role in improving population health (Institute of Medicine, 2003; Trust for America’s Health, 2013a).
The goal of public health finance is “to support population focused preventive health services” (Honoré, 2012). Four prin- ciples are suggested that explain how public health financing may occur (Sturchio and Goel, 2012): • The source and use of monies are controlled solely by the
government.
• More than 8 in 10 (80%) of the uninsured are in working families (Kaiser Family Foundation, 2012a). • About 62% are from families with one or more full-time
workers. • About 16% are from families with part-time workers.
• Individuals without health insurance are less likely to receive preventive care, such as blood pressure, cholesterol, and cancer screenings, than those with insurance coverage (Kaiser Family Foundation, 2012a).
• Those without health insurance are more likely to be hospi- talized for preventable problems, and when hospitalized receive fewer diagnostic and therapeutic services; they also have higher mortality rates than those with insurance (Kaiser Family Foundation, 2012a).
• Adults without insurance are nearly twice as likely to report being in fair or poor health than those with private insurance (Kaiser Family Foundation, 2012a).
• Studies indicate that gaining health insurance restores access to health care considerably and reduces the adverse effects of having been uninsured (Kaiser Family Foundation, 2012a).
• The poor are more likely to receive health care through pub- licly funded agencies.
• An emphasis on individual health care will not guarantee improvement of a population or a community’s health (see Chapter 3 for more discussion).
Approximately 97% of all health care dollars are spent for individual care whereas only 3% are spent on population-level health care. The 3% includes monies spent by the government on public health as well as the preventive health care dollars spent by private sources. These numbers indicate that there has not been a large investment in the public’s health or population health in the United States (National Center for Health Statistics [NCHS], 2012).
The United States spends more on health care than any other nation. The cost of health care has been rising more than the rate of inflation since the mid-1960s, yet the U.S. population does not enjoy better health as compared with nations that spend far less than the United States. The current health care system has been reaching the point where it is not affordable (Turnock, 2011; Trust for America’s Health, 2013b). An esti- mated $10 per person invested in community-based prevention programs can lead to improved health status of the population and reduced health care costs (Robert Wood Johnson Founda- tion, 2012). This return on investment represents medical cost savings only and does not include the significant gains that could be achieved in worker productivity, reduced absenteeism at work and school, and enhanced quality of life.
Nurses are challenged to implement changes in practice and participate in research, evidence-based practice, and policy activi- ties designed to provide the best return on investment of health care dollars (i.e., to design models of care, at a reasonable price, that improve access or quality of care). Meeting this challenge requires a basic understanding of the economics of the U.S. health care system. Nurses should be aware of the effects of nursing practice on the delivery of cost-effective care. In 2010, a new health reform law, the Patient Protection and Affordable
97CHAPTER 5 Economics of Health Care Delivery
government related. The partnerships between government and the private sector are necessary to improve the overall health status of populations. This partnership is emphasized in the ACA.
PRINCIPLES OF ECONOMICS Knowledge about health economics is particularly important to nurses because they are the ones who are often in a position to allocate resources to solve a problem or to design, plan, coordi- nate, and evaluate community-based health services and pro- grams. Two branches of economics are important to understand for their application in health care: microeconomics and mac- roeconomics. Microeconomic theory deals with the behaviors of individuals and organizations and the effects of those behav- iors on prices, costs, and the allocating and distributing of resources. Economic behaviors are based on (1) individual or organization choices and the consumer’s level of satisfaction with a particular good (product) or service, or use of a service, and (2) the amount of money available to an individual or organization to spend on a particular good or service (its budget limits). Microeconomics applied to health care looks at the behaviors of individuals and organizations that result from tradeoffs in the use of a service and budget limits. A good example of reducing services because of cost by an organization is the reduction in school health nursing services by health departments.
The microeconomic example of the industry providing pre- ventive services to its employees represents a behavior by the industry that provides for the use of a service and helps the industry’s budget by reducing health care insurance premium costs. The terms of the Patient Protection and Affordable Health Care Act (2010) allow employers to provide incentive rewards to employees for participation in wellness programs. Providing the service may also increase worker productivity and promote a healthier workforce, thus enhancing economic growth (Hall, 2010).
Because of the unique characteristics of health care, some economists believe that health care is special. There are debates about whether health care markets can ensure that health care is delivered efficiently to consumers. Cost-benefit and cost- effectiveness analyses are techniques used to judge the effect of interventions and policies on a particular outcome, such as health status (Feldstein, 2012).
Supply and Demand Two basic principles of microeconomic theory are supply and demand, both of which are affected by price. A simple illustra- tion of the relationship between supply and demand is provided in Figure 5-1. The upward-sloping supply curve represents the seller’s side of the market, and the downward-sloping demand curve reflects the buyer’s desire for a given product.
As shown in Figure 5-1, suppliers are willing to offer increas- ing amounts of a good or service in the market for an increasing price (Colander, 2012). The demand curve represents the amount of a good or service the consumer is willing to purchase at a certain price. This curve illustrates that when few quantities of a
• The government controls the money, but the private sector controls how the money is used.
• The private sector controls the money, but the government controls how the money is used.
• The private sector controls the money and how it is used. When the government provides the funding and controls the
use, the monies come from taxes, user fees (e.g., license fees and purchase of alcohol/cigarettes), and charges to consumers of the services. Services offered at the federal government level include the following: • Policymaking • Public health protection • Collecting and sharing information about U.S. health care
and delivery systems • Building capacity for population health • Direct care services
Select examples of services offered at the state and local levels include the following: • Environmental health monitoring • Population health planning • Disaster management • Preventing communicable and infectious diseases • Direct care services (see Chapter 46 for more examples)
When the government provides the money but the private sector decides how it is used, the money comes from business and individual tax savings related to private spending for illness prevention care. When a business provides disease prevention and health promotion services to its employees and sometimes families, such as immunizations, health screenings, and coun- seling, the business taxes owed to the government are reduced. This is considered a means by which the government provides money through tax savings to businesses to use for population health care.
When the private sector provides the money but the govern- ment decides how it is used, either voluntarily or involuntarily, the money is used for preventive care services for specific popu- lations. A voluntary example is the private contributions made to reaching Healthy People 2020 goals. An involuntary example is the Occupational Safety and Health Administration requiring industry to provide the financing to adhere to certain safety standards for use of machinery, air quality, ventilation, and eyewear protection to reduce disease and injury. This, for example, has the effect of reducing occupation-related injuries in the population as a whole.
When the private sector is responsible for both the money and its use of resources, the benefits incurred are many. For example, an industry may offer influenza vaccine clinics for workers and families that may lead to “herd immunity” in the community (see Chapter 12 on epidemiology). A business or community may institute a “no-smoking” policy that reduces the risk of smoking-related illnesses to workers, family, and the consumers of the businesses’ services. A voluntary philanthropic organization may give a local community money to provide services for assisting low-income communities to improve their environment (Fortunato and Sessions, 2011).
These are but a few examples of how public health services and the ensuring of a healthy population are not only
98 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
industry that offers its own services. The ACA proposes to offer preventive services free to the consumer, requiring insurance companies to cover these services (USDHHS, ACA, 2014a).
Efficiency and Effectiveness Two other terms are related to microeconomics: efficiency and effectiveness. Efficiency refers to producing maximal output, such as a good or service, using a given set of resources (or inputs), such as labor, time, and available money. Efficiency suggests that the inputs are combined and used in such a way that there is no better way to produce the service, or output, and that no other improvements can be made. The word effi- ciency often focuses on time, or speed in performing tasks, and the minimizing of waste, or unused input, during production. Although these notions are true, efficiency depends on tasks as well as processes of producing a good or service and the improvements made (Feldstein, 2012).
Effectiveness, on the other hand, refers to the extent to which a health care service meets a stated goal or objective, or how well a program or service achieves what is intended. For example, the effectiveness of a mass immunization program is related to the level of “herd immunity” developed to reduce the problem that the program was addressing (see Chapter 12). Box 5-2 illustrates the differences between efficiency and effective- ness (Feldstein, 2012).
Macroeconomics Microeconomics focuses on the individual or an organization, whereas macroeconomic theory focuses on the “big picture”— the total, or aggregate, of all individuals and organizations (e.g., behaviors such as growth, expansion, or decline of an aggre- gate). In macroeconomics, the aggregate is usually a country or nation. Factors such as levels of income, employment, general price levels, and rate of economic growth are important. This aggregate approach reflects, for example, the contribution of all organizations and groups within health care, or all industry within the United States, including health care, on the nation’s economic outlook.
good or service are available in the marketplace, the price tends to be higher than when larger quantities are available. The point on the curve where the supply and demand curves cross is the equilibrium, or the point where producer and consumer desires meet (See Box 5-1). Supply and demand curves can shift up or down as a result of the following factors (McPake et al, 2013): • Competition for a good or service • An increase in the costs of materials used to make a product • Technological advances • A change in consumer preferences • Shortages of goods or services
Provides a review of the laws of supply and demand. Using the example of industry-offered health care, it was not
likely that a small industry of fewer than 50 employees would be able to offer incentive-based on-site illness prevention services. The demand might be great to keep employees healthy and on the job. The supply has been limited by the cost and numbers of services available in the community. Therefore, the cost was likely to be higher for the small business than for the large
FIG 5-1 Supply-and-demand curve.
0
$11
$ 0 10
Demand
Supply
Equilibrium
Quantity of good or service
Price
To illustrate the differences between efficiency and effectiveness, consider the case of a nurse who is designing a community outreach program to educate high-risk, first-time mothers about the importance of childhood immu- nizations. The most efficient method to disseminate the information to a large number of mothers might be to have the child health team from the public health department hold an evening educational session, open to the public, at the health department. The most effective means of offering the program might be to link public health nurses with new mothers for one-on-one, in-home counseling, demonstration, and follow-up. The goals of the program could be stated as follows: • To change the behavior of the mothers regarding providing immunizations
for their children • To increase community mothers’ knowledge and awareness of infectious
diseases • To reduce the incidence of preventable infections in the community • To decrease the number of hospital admissions
BOX 5-2 Efficiency versus Effectiveness
The Law of Supply • At higher prices, producers are willing to offer more products for sale than
at lower prices. • The supply increases as prices increase and decreases as prices decrease. • Those already in business will try to increase production as a way of
increasing profits.
The Law of Demand • People will buy more of a product at a lower price than at a higher price,
if nothing changes. • At a lower price, more people can afford to buy more goods and more of
an item more frequently than they can at a higher price. • At lower prices, people tend to buy some goods as a substitute for more
expensive goods.
BOX 5-1 Principles of the Laws of Supply and Demand
Data from Curriculum Link, 2010.
99CHAPTER 5 Economics of Health Care Delivery
community and reducing the poverty level of the population. In short, knowledge about health economics can enhance a nurse’s ability to understand and argue a position for meeting population health needs.
Economic Analysis Tools The primary methods used to assess the economics of an inter- vention are cost-benefit analysis (CBA), cost-effectiveness analysis (CEA), and cost-utility analysis (CUA). CBA is con- sidered the best of these methods. In simple form, CBA involves the listing of all costs and benefits that are expected to occur from an intervention during a prescribed time. Costs and ben- efits are adjusted for time and inflation. If the total benefits are greater than the total costs, the intervention has a net positive value (NPV). Future or continued funding is given to the inter- vention with the highest NPV. This technique provides a way to estimate overall program and social benefits in terms of net costs. A good example of using CBA would be the cost of an influenza vaccine mass immunization program in a commu- nity. If most people in the community are vaccinated and the rate of influenza is low or decreased from past years or in rela- tion to the national average, the benefits are many. Citizens can work, play, go to school, participate in other community activi- ties, and, again, be productive. The community is healthy. These are but a few of the benefits of this program.
CBA requires that all costs and benefits be known and quan- tifiable in dollars; herein lies the major problem with its use. Although it is fairly easy to estimate the direct dollar costs of a health care program, it is often very difficult to quantify the nondollar benefits and indirect costs. For example, benefits and costs could come in the form of increased income and expenses, which are fairly easy to measure. More difficult to measure are benefits such as improved community welfare resulting from a particular program, and the costs to the community that would result if the program did not exist. The value of potential lives lost because of lack of access to health care services is one example. The potential for a great number of lives lost from H1N1 resulted in the development of programs and monies invested with pharmaceutical companies in an attempt to reduce the risk of lives lost should the United States experience an epidemic from this disease risk. Although benefits could only be assumed from the cost investment, it was determined that the investment was essential (CDC, 2009).
CEA expresses the net direct and indirect costs and cost savings in terms of a defined health outcome. The total net costs are calculated and divided by the number of health outcomes. Although the data required for CEA are the same as for CBA, CEA does not require that a dollar value be put on the outcome (e.g., on an outcome such as quality of life). CEA is best used when comparing two or more strategies or interventions that have the same health outcome in the population. Both CEA and CBA are useful to nurses as they conduct community needs analyses and develop, propose, implement, and evaluate pro- grams to meet community health needs. In both cases, the cost of a particular program or intervention is examined relative to the money spent and outcomes achieved. Using the same example of the mass immunization program, a comparison of
When the media refer to “the economy,” the phrase is typi- cally used as a macroeconomic term to describe the wealth and financial performance of the nation as an aggregate. Health care contributes to the economy through goods and services pro- duced and employment opportunities.
The primary focuses of macroeconomics are the business cycle and economic growth. Business expands and contracts in cycles. These cycles are influenced by a number of factors, such as political changes (a new president is elected), policy changes (new legislation is implemented, such as the Patient Protection and Affordable Health Care Act of 2010), knowledge and tech- nology advances (a new vaccine to treat H1N1/H5N1 is placed on the market), or simply the belief by a recognized business leader that the cycle is or should be shifting (e.g., when the head of the Federal Reserve Board changes interest rates).
The human capital approach is a measure of macroeco- nomic theory (Goodwin et al, 2014). In this approach improv- ing human qualities, such as health, are a focus for developing and spending money on goods and services because health is valued; it increases productivity, enhances the income-earning ability of people, and improves the economy. Therefore, there is a positive rate of return on the “investment in human capital.”
The individual, population, community, and nation all benefit. If the population is healthy, premature morbidity and mortality are reduced, chronic disease and disability are reduced, and eco- nomic losses to the nation are reduced. As an example, more people can work and be productive because they are healthy. The employing company makes more money because people are more productive. More taxes are paid into the local, state, and national economy, and more money is spent by individuals because they are productive, earning money, and taking advan- tage of the goods and services offered in their community.
Measures of Economic Growth Economic growth reflects an increase in the output of a nation. Two common measures of economic growth are the gross national product (GNP) and the gross domestic product (GDP). GNP is the total market value of all goods and services produced in an economy during a period of time (e.g., quarterly or annually). GDP is the total market value of the output of labor and property located in the United States (Strawser, 2014). GDP reflects only the national U.S. output, whereas GNP reflects national output plus income earned by U.S. businesses or citizens, whether within the United States or internationally. This discussion focuses on GDP, because U.S. health care spend- ing reports are based on GDP (NCHS, 2010).
Nurses face microeconomic and macroeconomic issues every day. For example, they are influenced by microeconomics when referring clients for services, informing clients and others of the cost of services, assessing community need for a particu- lar service, evaluating client access to services, and determining health provider and agency response to client needs. Nurses who work with aggregates of individuals and communities are faced with macroeconomic issues, such as health policies that make the development of new programs possible; local, state, and federal budgets that support certain programs; and the total effect that services will have on improving the health of the
100 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
program can be shown. Trust for America’s Health (2013a,b), along with a number of other agencies, is publishing reports that are beginning to show positive results and cost savings from prevention programs.
FACTORS AFFECTING RESOURCE ALLOCATION IN HEALTH CARE The distribution of health care is affected largely by the way in which health care is financed in the United States. Third-party coverage, whether public or private, greatly affects the distribu- tion of health care. Also, socioeconomic status affects health care consumption, because it has determined the ability to pur- chase insurance or to pay directly out-of-pocket. A description of the effects of barriers to health care access and the effects of health care rationing on the distribution of health care follow. Although the barriers are still issues, it remains to be deter- mined how the health care reform of 2010 will change the barriers to access and distribution. One solution proposed is the Health Insurance Marketplace (Patient Protection and Affordable Care Act, 2010).
The Uninsured In 1996, 68% of the total U.S. population had private health insurance. An additional 15% received insurance through public programs, and 17%, or 37 million, were uninsured. In 2008 the number of uninsured persons had increased to 47 million. By 2012 the number had grown to 48 million citizens (DeNavas-Walt et al, 2013). The typical uninsured person is a member of the workforce or a dependent of this worker. Unin- sured workers are likely to be in low-paying jobs, part-time or temporary jobs, or jobs at small businesses (Kaiser Family Foundation, 2012a). These uninsured workers have not been able to afford to purchase health insurance, or their employers may not have offered health insurance as a benefit. Others who are typically uninsured are young adults (especially young men), minorities, persons less than 65 years of age in good or fair health, and the poor or near poor. These individuals may have been unable to afford insurance, may lack access to job- based coverage, or, because of their age or good health status, may not perceive the need for insurance. Because of the eligibil- ity requirements for Medicaid, the near poor are actually more likely to be uninsured than the poor.
Socioeconomic status is inversely related to mortality and morbidity for almost every disease. Poor Americans with an income below the poverty level have a mortality rate nearly several times greater than that of middle-income Americans, even after accounting for age, sex, race, education, and risky health behaviors (e.g., smoking, drinking, overeating, and lack of exercise) (Robert Wood Johnson Foundation, 2009 and 2013). Historically, the link between poor health and socio- economic status resulted from poor housing, malnutrition, inadequate sanitation, and hazardous occupations. Today, explanations include the cumulative effects of a number of characteristics that explain the concept of poverty. These char- acteristics include low educational levels, unemployment or low occupational status (blue-collar or unskilled laborer), low
the overall outcomes of the client visit to the clinic for vaccina- tion in one community versus the mass immunization program at the community center in another community could be done. Outcomes could be the percentage of the population vaccinated by each method and the rate of influenza in each community. In this process, if the higher cost program results in lower rates of illness then that program would be considered the most effective.
An objective commonly used when CEA is performed in health care is improvement in quality of adjusted life-years (QALYs) for clients. QALYs are the sum of years of life multi- plied by the quality of life in each of those years. The QALY assigns a value, ranging between 0 (death) and 1 (perfect health), to reflect quality of life during a given period of years (Lindemark et al, 2014). In conducting a CEA, the cost of a program or an intervention is compared with real or expected improvements in clients’ quality of life. The How To Box lists the steps involved in conducting a CEA. The QALY is often used in malpractice suits to award money to clients who have been injured by health care.
HOW TO Do a Cost-Effectiveness Analysis (CEA) In a cost-effectiveness analysis (CEA), the outcome of the service option is measured in a natural, nonmonetary unit such as years of life gained, therapeutic successes such as reducing the numbers of influenza cases in a community, or lives saved. Results are expressed as the net cost required to produce one or each of the outcomes. The cost to outcome is expressed as a ratio of cost per unit of outcome, where the numerator is a monetary value corre- sponding to the net expenditure of resources and the denominator is the net improvement in health expressed in nonmonetary terms. The steps for performing a simplified CEA are as follows: 1. Establish a program or service goals and objectives. 2. Consider all possible alternatives to achieve the goal or objec-
tives, which could mean comparing two different programs that are attempting to achieve the same outcome.
3. Measure net effects to reflect a change in health status or health outcome.
4. Analyze costs for each alternative or program for reducing the cases of influenza in a community, such as a mass immunization clinic for a total community population or having individuals choose to go to their private provider for the vaccine.
5. Combine CEA results with other types of information such as past results of a similar program in a different year and the change in influenza cases in the community for the year of the comparison of programs, not included in the CEA, to make the most appropriate therapeutic or policy decision.
Depending on the program or intervention goals, the most effective means of providing a service is not necessarily the least costly, particularly in the short run. This is particularly true in public health, where the cost-effectiveness of a preventive service may not be known until sometime in the future. For example, the total cost savings of a community no-smoking program might be difficult to project 10 years into the future. After 10 years, the number of lung cancer cases or deaths that have occurred can be compared with those in the 10 years before the program, and the cost-effectiveness of the no-smoking
101CHAPTER 5 Economics of Health Care Delivery
expanding Medicaid coverage whereas others continue with prior coverage plans (USDHHS, ACA, 2014a). However, all persons must have some form of insurance coverage or they will be charged a fee.
Poverty level income is adjusted annually for each state by the federal government to indicate how much money an indi- vidual or families may earn to qualify for subsidies such as food stamps, Medicaid, and CHIP. In 2014 the federal poverty level for an individual was $11,670; for a family of four the poverty level was $23,850. If, for example, an individual’s income was 133% of the poverty level, then that individual earned no more than $15,521.10 (USDHHS, 2014b).
Rationing Health Care Rationing health care in any form implies reduced access to care and potential decreases in acceptable quality of services offered. For example, a health provider’s refusal to accept Medicare or Medicaid clients is a form of rationing. As with access to care, rationing health care is a public health issue. Where care is not provided, the public health system and nurses must ensure that essential clinical services are available. Managed care was thought to offer the possibility of more appropriate health care access and better-organized care to meet basic health care needs of the total population. A shift in the general approach to health care from a reactionary, acute-care orientation toward a proac- tive, primary prevention orientation has been necessary for some time to achieve not only a more cost-effective but also a more equitable health care system in the United States.
The ACA, while providing coverage to more people, will not do away with rationing because the new law provides for a five- tiered plan (bronze, silver, gold, platinum, and catastrophic) and by creating state-based American Health Benefit Exchanges. Persons at differing levels of poverty will have reductions in out-of-pocket expenses based on income up to 400% of the poverty level and may receive tax credits and subsidies to assist with out-of-pocket expenses (USDHHS, ACA, 2014a).
Healthy People 2020 Healthy People 2020 goals are examples of strategies to provide better health care access for all people. The Levels of Prevention Box shows the levels of economic prevention strategies.
wages, being a child or an older person over the age of 65 years, or being a member of a minority group (NCHS, 2012).
Access to Health Services Access to health services is a public health issue (USDHHS, 2010). Medicaid is intended to improve access to health care for the poor. Although persons with Medicaid have improved access compared with the uninsured, Medicaid recipients have been only about half as likely to obtain needed health services (e.g., medical-surgical care, dental care, prescription drugs, and eyeglasses) as the privately insured. Specifically, the poorest Americans have Medicaid insurance, yet they also have the worst health (Kaiser Family Foundation, 2013).
The primary reasons for delay, difficulty, or failure to access care included inability to afford health care and a variety of insurance-related reasons, including the insurer not approving, covering, or paying for care; the client having preexisting condi- tions; and physicians refusing to accept the insurance plan. Other barriers include lack of transportation, physical barriers, communication problems, child care needs, lack of time or information, or refusal of services by providers. In addition, lack of after-hours care, long office waits, and long travel dis- tance are cited as access barriers. Community characteristics also contribute to individuals’ ability to access care. For example, the limited prevalence of managed care and the limited number of safety net providers, as well as the wealth and size of the community, affect accessibility.
Because reimbursement for services provided to Medicaid recipients has been low, physicians are discouraged from serving this population. Thus, people on Medicaid frequently have not had a primary care provider and may have relied on the emer- gency department for primary care services. Although physi- cians can respond to monetary incentives in client selection, emergency departments are required by law to evaluate every client regardless of ability to pay. Emergency department copay- ments are modest and are frequently waived if the client is unable to pay. Thus, low out-of-pocket costs have provided incentives for Medicaid clients and the uninsured to use emer- gency departments for primary care services.
With the ACA, some of the issues and barriers that have previously existed may disappear. This depends on whether Congress continues attempts to repeal all or part of PL 111-148 or change some of the mandates in the law. By 2014 Medicaid recipients may benefit from the law in its current structure as follows: (1) Medicaid will expand to include all non–Medicare- eligible persons under age 65 with incomes up to 133% of federal poverty level, (2) all Medicaid-eligible persons will be guaranteed a benchmark benefit package, and (3) states will be given the option to develop a basic health plan for uninsured individuals who do not qualify for the Medicaid program, at 133% to 200% of the poverty level. At present, all states provide Medicaid and CHIP (Children’s Health Insurance Program) health care coverage for some individuals, families and children, pregnant women, the elderly with certain incomes, and people with disabilities. Some states cover all adults below certain income levels. Because coverage differs by state, one must seek information about the specific state of interest. Some states are
LEVELS OF PREVENTION
Primary Prevention Work with legislators and insurance companies to support Affordable Care Act coverage for health promotion to reduce the risk of disease.
Secondary Prevention Encourage clients who are pregnant to participate in prenatal care and WIC (Women, Infants, and Children) to increase the number of healthy babies and reduce the costs related to preterm baby care.
Tertiary Prevention Participate in home visits to mothers who are at risk for neglecting babies to reduce the costs related to abuse.
Economic Prevention Strategies
102 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
profitable. However, with the increasing costs of health care and consumer demand and the changes in financing mechanisms, there is a new trend toward financing more preventive care services as is reflected in the ACA coverage for these services.
Today, third-party payers will be covering preventive ser- vices, recognizing that the growth of the health care system can no longer be supported. Under capitated health plans, health care providers stand to make money by keeping clients healthy and reducing health care use. Through combining client inter- ests with financial interests of the health care industry, primary prevention and public health can be raised to the status and priority of acute care and chronic care. Despite difficulties, methods for determining prevention effectiveness, such as CEAs and CBAs, are becoming standard and used more widely. Two agendas for preventive services have been published that promote the preventive agenda: • The U.S. Preventive Services Task Force, Guide to Clinical
Preventive Services (Agency for Healthcare Research and Quality [AHRQ], 2014) for clinicians in primary care that outlines the regular screening and risk factors to look for at various ages
• The Community Preventive Services Task Force (2014), which emphasizes population-level interventions to promote primary prevention Regardless of the method, prevention-effectiveness analyses
(PEAs) are outcome oriented. This area of research seeks to link interventions with health outcomes and economic outcomes, and to reveal the tradeoffs between the two. In theory, support for increasing national investment in primary prevention is sound and long-standing. Since the public health movement of the mid-nineteenth century, public health officials, epidemiolo- gists, and nurses have been working to advance the agenda of primary prevention to the forefront of the health care industry. Today, these efforts continue across a number of disciplines and in both the public and the private sectors, and through the efforts for health care reform (Healthy People 2020 Box).
PRIMARY PREVENTION Society’s investment in the health care system has been based on the premise that more health services will result in better health, but non–health care factors also have an effect. Of the major factors that affect health—personal biology and behavior (or lifestyle), environmental factors and policies (including physical, social, health, cultural, and economic environments), social networks, living and working conditions, and the health care system—medical services are said to have the least effect. Behavior and lifestyle have been shown to have the greatest effect, with the environment and biology accounting for the greatest effect on the development of all illnesses (NCHS, 2012).
Despite the significant impact of behavior and environment on health, estimates indicate that 97% of health care dollars are spent on secondary and tertiary care. Such a reactionary, secondary/tertiary care system results in high-cost, high- technology, and disease-specific care and is consistent with the U.S. system’s traditional emphasis on “sickness care.” A more pro- active investment in disease prevention and health promotion targeted at improving health behaviors, lifestyle, and the environ- ment has the potential to improve the health status of populations, thereby improving quality of life while reducing health care costs.
The USDHHS has argued that a higher value should be placed on primary prevention. The goal of this approach is to preserve and maximize human capital by providing health pro- motion and social practices that result in less disease. An emphasis on primary prevention may reduce dollars spent and increase quality of life. As data are made available about the effects of the emphasis of the ACA on primary prevention and primary care, then dollars spent and increased quality of life may be evaluated.
The return on investment in primary prevention through gains in human capital has not been acknowledged in the past, unfortunately. As a consequence, large investments in primary prevention and public health care have not been made. Reasons given for this lack of emphasis on prevention in clinical practice and lack of financial investment in prevention include the following: • Provider uncertainty about which clients should receive ser-
vices and at what intervals • Lack of information about preventive services • Negative attitudes about the importance of preventive care • Lack of time for delivery of preventive services • Delayed or absent feedback regarding success of preventive
measures • Less reimbursement for these services than curative
services • Lack of organization to deliver preventive services • Lack of use of services by the poor and elderly • More out-of-pocket expenses for the poor and those who
lack health insurance A focus on prevention could mean reducing the need for
and use of medical, dental, hospital, and health provider ser- vices. Under fee-for-service payment arrangements, this would mean that the health care system, the largest employer in the United States, would be reduced in size and would become less
HEALTHY PEOPLE 2020
• AHS-1: Increase the proportion of persons with health insurance. • AHS-2: (Developmental) Increase the proportion of insured persons with
coverage for clinical preventive services. • AHS-6: Reduce the proportion of individuals that experience difficulties or
delays in obtaining necessary medical care, dental care, or prescription medicines.
AHS, Access to Health Services.
Objectives Related to Access to Care
THE CONTEXT OF THE U.S. HEALTH CARE SYSTEM The U.S. health care system is a diverse collection of industries that are involved directly or indirectly in providing health care services. The major players in the industry are the health professionals who provide health care services, pharmacy and
103CHAPTER 5 Economics of Health Care Delivery
smallpox, influenza, malaria, and yellow fever. Health concerns of the time related to social and public health issues, including contaminated food and water supplies, inadequate sewage dis- posal, and poor housing conditions (Shi and Singh, 2011). Family and friends provided most health care in the home. Hospitals were few in number and suffered from overcrowding, disease, and unsanitary conditions. Sick persons who were cared for in hospitals often died as a result of these conditions. Most people avoided being cared for in a hospital unless there was no alternative. In this first developmental phase, health care was
equipment suppliers, insurers (public/government and private), managed care plans (health maintenance organizations, pre- ferred provider organizations), and other groups, such as edu- cational institutions, consulting and research firms, professional associations, and trade unions (see Chapter 3). Today, the health care industry is large, and its characteristics and operations differ between rural and urban geographic areas.
In the twenty-first century, health policy and national poli- tics reflect the importance of health care delivery in the general economy. Conflicts arise between competing special-interest groups that have different goals and objectives when it comes to the producing and consuming of health services. To some degree this is caused by federal and state policy changes about how health services are financed (public and private).
Figure 5-2 illustrates the four basic components that make up the framework of health services delivery: service needs and intensity, facilities, technology, and labor. Intensity is the extent of use of technologies, supplies, and health care services by or for the client. Intensity includes and is a partial measure of the use of technology (NCHS, 2012). Medical technology refers to the set of techniques, drugs, equipment, and procedures used by health care professionals in delivering medical care to indi- viduals. It also includes information technology and the system within which such care is delivered (NCHS, 2012).
Health care systems have developed in four phases from the 1800s through 2000. These developmental stages correspond to different economic conditions. Developmentally, the four components of the health services delivery framework have changed over time, reflecting macrolevel, or societal, changes in morbidity and mortality, national health policy, and economics (Figure 5-3).
First Phase The first developmental stage (1800 to 1900) was characterized by epidemics of infectious diseases, such as cholera, typhoid, FIG 5-2 Components of health services development.
Service intensity Facilities
L a b o r
T e c h n o l o g y
FIG 5-3 Developmental framework for health service needs and intensity, facilities, technology, and labor.
Stage 1
1800-1900
• Infectious epidemics • Inadequate and unsafe hospital care • Minimal technology • Experience-based training
• Acute infections, trauma • Specialty hospitals emerge • Therapeutic advances • Shift to science-based training
• Chronic diseases • Increasing numbers and types of facilities • “Durable” technologies— therapeutics and diagnostics • Development of medical specialties, new “types” of employees
• Emergence of new and old infectious diseases • Mergers, “integration” • “Super” drug therapies, computerization, “service” technologies • Primary care, “turf” issues, interprofessisonal care teams • Managed care • Health care/insurance reform
Stage 2
1900-1945
Stage 3
1945-1984
Stage 4
1984-present
104 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
nursing, with an emphasis on following and executing physi- cians’ orders. Nurses in training were unmarried and under the age of 30. They provided the bulk of care in hospitals (Kovner et al, 2011). Public health nurses, who tracked infectious dis- eases and implemented quarantine procedures, worked more collegially with physicians (Kovner et al, 2011). In this period the university-based nursing programs were established to accommodate the expanding practice base of nursing. Client education became a nursing function early in the development of the health care delivery system.
Third Phase The third developmental stage (1945 to 1984) included a shift away from acute infectious health problems of previous stages toward chronic health problems such as heart disease, cancer, and stroke. These illnesses resulted from increasing wealth and lifestyle changes in the United States. To meet society’s needs, the number and types of facilities expanded to include, for example, hospital clinics and long-term care facilities. The Joint Commission on Accreditation of Hospitals, established in 1951 and later renamed The Joint Commission on Accreditation of Healthcare Organizations (and now called The Joint Commis- sion [TJC]), focused on the safety and protection of the public and the delivery of quality care.
Changes in the overall health of American society also shifted the focus of technology, research, and development. Major tech- nological advances included developments in the realms of che- motherapeutic agents; immunizations; anesthesia; electrolyte and cardiopulmonary physiology; diagnostic laboratories with complex modalities such as computerized tomography; organ and tissue transplants; radiation therapy; laser surgery; and spe- cialty units for critical care, coronary care, and intensive care. The first “test tube baby” was born via in vitro fertilization, and other fertility advances soon emerged. Negative staining tech- niques for screening viruses via electronic microscope became available in the 1960s (Shi and Singh, 2011).
Health care providers constituted more than 5% of the total U.S. workforce during this period. The three largest health care employers were hospitals, convalescent institutions, and physi- cians’ offices. Between 1970 and 1984 alone, the number of persons employed in the health care industry grew by 90%. The number of personnel employed in the community also increased. The expansion of care delivery into other sites, such as community-based clinics, increased not only the number but also the types of health care employees.
Technological advances brought about increased special training for physicians and nurses, and care was organized around these specialties. The ongoing shortage of nurses throughout the century was being seen in the 1970s and early 1980s. Nursing education expanded from hospital-based diploma and university-based baccalaureate education to include associate degree programs at the entry level. As the diploma schools of nursing began closing in the early- to mid- 1980s, the number of baccalaureate and associate degree pro- grams began to increase. Graduate nursing education expanded to include the nurse practitioner (NP) and clinical nurse spe- cialist (CNS) to meet increasing demands for the education of
paid for by individuals who could afford it, through bartering with physicians or through charity from individuals or organi- zations. The first county health departments were established in 1908.
Technology to aid in disease control was very basic and prac- tical but in keeping with the knowledge of the time. The physi- cian’s “black bag” contained the few medicines and tools available for treatment. The economics of health care was influ- enced by the types of health care providers and the number of practitioners, and the labor force then was composed mostly of physicians and nurses who attained their skills through appren- ticeships, or on-the-job training. Nurses in the United States were predominantly female, and education was linked to reli- gious orders that expected service, dedication, and charity (Kovner et al, 2011). The focus of nursing was primarily to support physicians and assist clients with activities of daily living.
Second Phase The second developmental stage (1900 to 1945) of U.S. health care delivery was focused on the control of acute infectious diseases. Environmental conditions influencing health began to improve, with major advances in water purity, sanitary sewage disposal, milk and water quality, and urban housing quality. The health problems of this era were no longer mass epidemics but individual acute infections or traumatic episodes (Shi and Singh, 2011).
Hospitals and health departments experienced rapid growth during the late 1800s and early 1900s as technological advances in science were made (Kovner et al, 2011). In addition to private and charitable financing of health care, city, county, and state governments were beginning to contribute by providing ser- vices for poor persons, state mental institutions, and other spe- cialty hospitals, such as tuberculosis hospitals. Public health departments were emphasizing case finding and quarantine. Although health care was paid for primarily by individuals, the Social Security Act of 1935 signaled the federal government’s increasing interest in addressing social welfare problems.
Clinical medicine entered its golden age during this period. Major technological advances in surgery and childbirth and the identification of disease processes, such as the cause of perni- cious anemia, increased the ability to diagnose and treat dis- eases. The first serological tests used as a tool for diagnosis and control of infectious diseases were developed in 1910 to detect syphilis and gonorrhea (Shi and Singh, 2011). The first virus isolation techniques were also developed to filter yellow fever virus, for example. The discovery and development of pharma- cological agents, such as insulin in 1922 for control of diabetes, sulfa drugs in 1932 for treatment of infectious diseases, and antibiotics such as penicillin in the 1940s, eradicated certain infectious diseases, increased treatment options, and decreased morbidity and mortality (Shi and Singh, 2011).
Advances in technology and knowledge shifted physician education away from apprenticeships to scientifically based college education, which occurred as a result of the Flexner Report in 1910. It was the beginning of medical education as it is today. Nurses were trained primarily in hospital schools of
105CHAPTER 5 Economics of Health Care Delivery
acute care hospital, the nature of the care delivered in hospitals changed remarkably, as evidenced by the following: • Patients admitted to hospitals were more acutely ill. • Length of stay for patients admitted to hospitals became
shorter. • Care delivery became more intense as a result of the first
two items. The widespread use of computers and the Internet enabled
society to become increasingly sophisticated about health. The public’s increasing knowledge about health care and awareness of health care advances influenced the demand for health care, such as diagnostic and therapeutic services for treatment. Fur- thermore, pharmaceutical companies and other technological suppliers actively marketed their products through television, printed advertisements, the Internet, and other sources, so clients rapidly became aware of the new technologies.
Health professionals were increasingly dependent on tech- nology to care for clients. Distance, as a barrier to the diagnosis and treatment of disease, was overcome through the use of telehealth. The insurance industry became the principal buyer of technology for the client. They often made decisions about when and if a certain technology would be used for a client problem. Nurses became dependent on technologies to monitor client progress, make decisions about care, and deliver care in innovative ways.
The shift away from traditional hospital-based care to the community, together with the need to consider new models of care, brought about an increased emphasis on providing primary care, on developing care delivery teams, and on col- laborating in practice and education. The substitution of one type of health personnel for another occurred to control care delivery costs. As examples, NPs were replacing physicians as primary care providers, and unlicensed personnel were replac- ing staff nurses in hospitals and long-term care facilities. These replacements caused much debate, with territorial, or “turf,” battles, for example, between physicians and nurses.
The increase in specialization by health professionals led to changes in certification, qualifications, education, and stan- dards of care in health professions. These factors, in turn, caused an increase in the number and kinds of providers to meet the demands of the health care system. The Bureau of Labor Statis- tics predicted that health care employment would be among the top eight professional and related industries with significant employment growth through 2020 (Lockard and Wolf, 2012).
In the last part of the twentieth century, molecular tools were developed that provided a means of detecting and character- izing infectious disease pathogens and a new capacity to track the transmission of new threats, such as bioterrorism, and determine new ways to treat them.
Challenges for the Twenty-First Century In the twenty-first century the emergence of new and the reemergence of old communicable and infectious diseases are occurring as well as larger foodborne disease outbreaks and acts of terrorism. Seven out of ten of all deaths in the United States are related to chronic disease (USDHHS, 2011). One in every two Americans has one or more chronic diseases. There
nurses in a specialty such as public health. The first doctoral programs in nursing were instituted to build the scientific base for nursing and to increase the number of nurse faculty members.
The role of the commercial health insurance industry increased, and a strong link between employment and the providing of health care benefits emerged. Furthermore, the federal government’s role expanded through landmark policy- making that would affect health care delivery well into the twenty-first century. Specifically, the passage of Titles XVIII and XIX of the Social Security Act in 1965 created the Medicare and Medicaid programs, respectively. The health care system appeared to have access to unlimited resources for growing and expanding.
Throughout the twentieth century, many public health advances were achieved. The life expectancy of U.S. citizens increased and has been related to public health activities. The most important achievements were in vaccinations, improved motor vehicle safety, safer workplaces, safer and healthier foods, healthier mothers and babies, family planning, fluoride in drinking water, and recognition of tobacco as a health hazard (Shi and Singh, 2011).
Fourth Phase The fourth developmental stage (1984 to 2015) has been a period of limited resources, with an emphasis on containing costs, restricting growth in the health care industry, and reor- ganizing care delivery. For example, amendments were made to the Social Security Act in 1983 that created diagnostic-related groups and a prospective system of paying for health care pro- vided to Medicare recipients. The 1997 Balanced Budget Act legislated additional federal changes in Medicare and Medicaid. Private-sector employer concerns about the rising costs of health care for employees and fear of profit losses spurred a major change in the delivery and financing of health care. Managed care systems were developed.
This period included drastic change in the settings and orga- nization of health care delivery. Transforming health care orga- nizations became commonplace, and buzz words of the period were reorganization, reengineering, restructuring, and down- sizing. Organization mergers occurred at an increased rate to consolidate care, to save money, and to coordinate care across the continuum (i.e., from “cradle to grave”). Merger discussions focused on horizontal integration, which indicated the union of similar agencies (e.g., a merger of hospitals), and vertical inte- gration between different types of organizations (e.g., an acute care hospital, long-term care institution, and a home health facility).
Initially these pressures brought about hospital closings and a shifting of care to other settings, such as ambulatory and community-based clinics and specialty diagnostic centers that offer technologies such as magnetic resonance imaging (MRI) and sonography. Rehabilitative, restorative, and palliative care, once delivered in the hospitals, was shifted to other settings, such as subacute care hospitals, specialty rehabilitation hospi- tals, long-term care institutions, and even individual homes. Although the basis of care delivery was no longer the traditional
106 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
hospital intensivists is growing, with hospitals employing physi- cians to be in-house and available to patients and to their com- munity physicians to cover nonurgent, urgent, and emergent care while the patient is hospitalized. More nurse practitioners and physician assistants can be found working side by side with the physician in the community and in the hospital as a member of the office, clinic team, or hospital staff. (See QSEN box below about teamwork and collaboration)
is some concern that certain chronic diseases may be caused or intensified by infectious disease processes. Often there are com- plications that occur as a result of infectious disease, such as HIV/AIDS and tuberculosis, which can result in chronic lung disease and certain types of cancer, because of the compromised immune system. Health behaviors and economics related to poverty are also continuing to build the path to acute and chronic health problems (e.g., the global obesity epidemic) (World Health Organization [WHO], 2010). While some people choose to ignore behavioral factors related to obesity, such as physical activity and eating, those with insufficient income choose foods high in fat and sugar because those are the cheaper foods to obtain. The chronic disease burden is concentrated among the poor. Poor people are more vulnerable for several reasons, including increased exposure to risks and decreased access to health services. Chronic diseases can cause poverty in individuals and families and draw them into a downward spiral of worsening disease and poverty.
Investment in chronic disease prevention programs is going to be essential for many low- and middle-income countries struggling to reduce poverty. For the United States, this issue is addressed in the ACA (2010). Health promotion and protec- tion, disease surveillance, emergency preparedness, new labora- tory and epidemiologic methods, continued antimicrobial and vaccine development, and environmental health research are continuing challenges for this century. The role of technology has also intensified during this century.
Technology is now defined as the application of science to develop solutions to health problems or issues such as the pre- vention or delay of onset of diseases or the promotion and monitoring of good health. Examples of technology include medical and surgical procedures (angioplasty, joint replace- ments, organ transplants), diagnostic tests (laboratory tests, biopsies, imaging), drugs (biological agents, pharmaceuticals, vaccines), medical devices (implantable defibrillators, stents), prosthetics (artificial body parts), and new support systems (electronic health records, e-prescribing, and telemedicine).
The labor force is changing to include radiology oncologists, geneticists, and surgical subspecialists, as well as allied and support professions such as medical sonographers, radiation technologists, and laboratory technicians. These have all been created to support the use of specific types of technology (HealthIT.gov).
The infrastructure necessary to support more complex tech- nologies is also considered to be a part of health care technol- ogy. Electronic health records and electronic prescribing are methods for coordinating the increasingly complex array of services provided, as well as allowing for electronic checks of quality to reduce medical errors (e.g., for drug interactions). Because technologies have become a part of standard medical practice, there are concerns about whether they are consistently being used properly and about the quality of the information provided by tests, imaging, and other technological outputs (NCHS, 2010).
In addition to the labor force changes just described, physi- cians are increasingly moving away from solo practice to group practices, selling primary care practices to hospitals, or working as hospital or corporation employees. The emerging role of
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Refers to the ability to function effectively with nursing and interprofessional teams and to foster communication, mutual respect, and shared decision making to provide quality client care. • Knowledge: Identify system barriers and facilitators of effective team
functioning • Skill: Participate in designing systems that support effective teamwork • Attitudes: Values the influences of systems solutions in achieving effec-
tive functioning
Teamwork and Collaboration Question As a strategy set forth by the Affordable Care Act, a fund was established to support prevention and wellness activities within states to reduce risks. Among the options for spending the funds was the establishment of programs and processes to reduce the rate of chronic disease.
Monies have been distributed to states to promote prevention and wellness. Find out through your state government how the money is to be used.
The Quad Council PHN competency: community dimensions of practice, indicates that beginning PHN’s will collaborate with community partners to promote the health of their clients.
Have PHNs at the state level or locally in your state been involved in col- laborations to determine how chronic disease rates might be reduced in your area. If yes, how? If not, can you suggest how they might be? Also the PHN competency that addresses financial management and planning, suggests that PHNs may provide input into the fiscal planning and the narrative component of proposals submitted for external funding.
Determine what the process will be for obtaining local funds for chronic disease and whether PHNs have had or will have input onto the proposals.
Teamwork and Collaboration
Discussions are increasing regarding the integration of public health and primary care and developing the primary health care system (see Chapter 3).
Public health nurses are more involved with population- centered care, assessment of community needs, and the devel- opment or implementation of programs that meet the needs of certain populations. There is a move to provide more care to clients in the home, such as the programs to provide care to new mothers and babies who are defined as at-risk. Public health nurses play key roles in developing and implementing plans for bioterrorism and natural disasters in the community (see Chapter 9).
Nursing education is seeing a dramatic change in this century. There is a recommendation to move all advanced prac- tice nursing to the level of the new doctoral program, begun in 2000, titled the Doctorate of Nursing Practice. This has the potential for closing specialist master’s programs in nursing.
107CHAPTER 5 Economics of Health Care Delivery
FIG 5-4 Distribution of U.S. health care expenditures, 2011. (From National Center for Health Statistics: Health, United States, 2012, with Special Feature on Emergency Care. Hyatts- ville, MD, 2013, U.S. Government Printing Office. Updated tables retrieved December 2014 from http://www.cdc.gov/ nchs/hus/contents2012.htm#113)
Hospital care
Physician and clinical services
Dental services
Other professional services
Other personal health care
Nursing home care
Home health care
Retail outlet sales of medical products
Government administration
Net cost health insurance
Public health
Research and construction
32%
20%
4%3%
5% 6%
3%
13%
12%
6%
3%
6%
This means the new BSN graduate, for example, can go into a doctoral program at graduation and become an advanced public health nurse or a nurse practitioner working in the com- munity. The health care industry is one of the largest employers in the United States, and despite the economic downturn in 2008, has continued to grow. In addition, the largest number of employees in the industry are RNs (American Association of Colleges of Nursing, 2010; Lockard and Wolf, 2012).
Along with other changes in health care delivery and health insurance plans, the ACA (2010) has proposed an emphasis on prevention and wellness by establishing the National Preven- tion, Health Promotion, and Public Health Council to coordi- nate health promotion and public health activities as well as the creation of a prevention and public health fund to expand and sustain these activities. These activities will assist in the develop- ment of a national strategy to improve health, reduce chronic disease rates, and address health disparities.
TRENDS IN HEALTH CARE SPENDING Much has been written in the popular and scientific literature about the costs of U.S. health care and how society makes deci- sions about using available and scarce resources. Given that economics in general and health care economics in particular are concerned with resource use and decision making, any dis- cussion of the economics of health care must consider past and current health care spending. The trends shown here reflect public and private decisions about health care and health care delivery in the past. Past spending reflects past decision making; likewise, past decisions reflect the values and beliefs held by society and policymakers that undergird policymaking at any given point in time.
According to the Centers for Medicare and Medicaid Ser- vices (CMS) (formerly the Health Care Financing Administra- tion), national health expenditures reached $2.5 trillion in 2011. This is compared with the $600 billion in health care dollars that were spent in 1990 (Centers for Medicare and Medicaid Services [CMS], 2012a). The CMS predicts total U.S. health spending in 2019 will be $4.5 trillion. Health spending has outpaced increases in the gross domestic product, accounting for 17.3% of the GDP by 2009 rising to 17.8% in 2012 and projected to increase to 19.3% of the GDP in 2019. The percent GDP can be translated into dollars per 100 spent out of pocket. In 2009 $17.30 of every $100 was spent for health care. It also means that in 2009 approximately $8100 was spent on health care for every person in the U.S. population. In 2019 it is pro- jected that out-of-pocket costs will be approximately $20 for every $100 spent. The effect of this economic growth represents a large increase in contrast to the approximately 13% GDP spent between 1992 and 2001. The GDP was at 17.8% in 2012 (CMS, 2012a). It is projected that with the implementation of the ACA costs will actually decline.
Figure 5-4 shows a breakdown of the distribution in health care expenses for 2011, and Table 5-1 shows the growth in U.S. health care expenditures between 1960 and 2019 (NCHS, 2012). During fiscal year 2012-2013, the amount spent for public health activities ranged from $7.63 per person in
From Centers for Medicare and Medicaid Services, Office of the Actuary: National Health Care Expenditures and Projections: 1960– 2021. U.S. Department of Health and Human Services, 2012a. Retrieved December 2014 from http://www.cms.gov/ NationalHealthExpendData/
Calendar Year
Total Health Expenditures (in billions of dollars)
Total Health Expenditures per Capita per Person (in billions of dollars)
Percentage of Gross Domestic Product
1960 26.7 143 5.1 1970 73.1 348 7.0 1980 245.8 1,067 8.8 1990 696.0 2,738 12.0 2000 1,309.9 4,560 13.3 2009 2,472.2 8,047 17.3 2010 2,563.6 8,402.3 17.9 2011* 2,695.0 8,660.5 17.9 2021* 4,482.7 14,102.6 19.6
TABLE 5-1 Health Care Expenditures: 1960-2019*
*Projected expenditures.
108 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
• One in 7 citizens in 2013 was 65 and older compared to 1 in 5 in 1990. By 2050 they are estimated to comprise up to 20% of the
population. In addition, the number of individuals 85 and older is expected to double between 1990 and 2050 because the population is living longer, healthier lives (U.S. Census Bureau, 2014).
Although many older adults are independent and active, they are likely to experience multiple chronic and degenerative con- ditions that may become disabling. They are admitted to hos- pitals more often than the general population, and their average length of stay is more than 3 days longer than the overall average. They visit physicians more often and make up a larger percentage of nursing home residents than the general popula- tion (NCHS, 2012).
Life expectancy, at an average of 78.7 years, and health status have been increasing in the United States. However, older adults continue to consume a large portion of financial resources. Health care providers are concerned about the growth in the older adult population because public funding sources, such as Medicare, have not been increasing their reimbursement rates sufficiently to cover inflation, and thus providers have been col- lecting a smaller amount for visits by older adult clients each year.
The aging of the population also spurs concerns about funding their health care because of changes in the proportion of employed individuals to fully retired individuals. Persons in the workforce pay the majority of income taxes and all Social Security payroll taxes. The funding base for Medicare decreases as the population ages, as retirement rates increase, and as the numbers in the workforce decrease. As a result, some policy- makers believe that Medicare and system reforms could ensure adequate financing and delivery of health care services to an aging population (PL 111-148, 2010).
Health policy reform options being considered include increased age limits to become eligible for Medicare, means testing (i.e., determining a lack of financial resources) for Medi- care eligibility, increased coverage for long-term care insurance, increased incentives for prevention, and less expensive and more efficient delivery arrangements and care settings (e.g., managed care arrangements). One example of a policy change to reduce the Medicare program burden was the prescription plan (Medi- care D) that was passed by Congress in 2005 and became effective in January 2006. This plan, although complicated, required most Medicare recipients to provide a copayment for prescription medications. Although controversial, the plan is thought to provide a positive impact for the elderly who could not afford to pay for their prescriptions, while reducing the cost burden for those who had to pay full price for prescriptions.
The ACA promises to close the “donut hole” by 2020 while providing a 50% discount when the Medicare recipients pur- chase medications covered on the brand name list, until 2020 (ACA and Medicare, 2014). The donut hole is the point at which a prescription D recipient has met the limit that the health insurance policy will pay for prescriptions in a given year and the requirement that the recipient will then be responsible for paying full price for all medicines until the end of the year covered by the health insurance.
Arizona to $144.99 per person in Hawaii (Trust from America’s Health, 2014).
The largest portions of health care expenses were for hospital care and physician services, respectively, in 2011 (NCHS, 2012). Only a small fraction of total health care dollars was spent on home health, public health, and research and construction in 2011. The trends over time indicate that this has been an ongoing pattern of spending.
FACTORS INFLUENCING HEALTH CARE COSTS Health economists, providers, payers, and politicians have explored a variety of explanations for the rapid rate of increase in health expenses as compared with population growth. That individuals have, over time, consumed more health care is not an adequate explanation. The following factors are frequently cited as having caused the increases in total and per capita health care spending since 1960: inflation, changes in popula- tion demographics, and technology and intensity of services (NCHS, 2012).
Demographics Affecting Health Care A major demographic change underway in the United States is the aging of the population. Population changes are also affected by illnesses such as acquired immunodeficiency syndrome, and by chemical dependency epidemics. These changes have impli- cations for providers’ health services, and they affect the overall costs of health care. Because the majority of older adults and other special populations receive services through publicly funded programs, the growing health needs among these popu- lations have great impact on costs, payments, and providers associated with Medicaid and Medicare programs. As the popu- lation ages and the baby boom generation ages and retires, federal expenses for Social Security have increased (Congres- sional Budget Office [CBO], 2010). At 78 million strong, the oldest of the baby boomers—born between 1946 and 1964—are already making unsustainable demands on federal entitlement programs such as Medicare and Medicaid (see Chapter 3 for further discussion).
In its Long-Term Outlook for Medicare, Medicaid and Total Health Care Spending, the Congressional Budget Office (CBO) reports that spending for those programs was projected to account for 3% each of GDP in 2011 (CMS, 2012a).
By 2035, in the absence of change, spending for Medicare alone (which is more likely to be impacted by aging baby boomers) will have more than doubled to 8%, and by 2080 it will have grown to 15% unless changes as recommended by the ACA (2010) are effective.
The aging population is expected to affect health services more than any other demographic factor: • In 1950 more than 50% of the U.S. population was under 30
years of age. • In 1994, 50% of the population was 34 years of age
or older. • In 1990 individuals 65 and older comprised 12% of the
population. • In 2013 they comprised 14% of the population.
109CHAPTER 5 Economics of Health Care Delivery
Technology and Intensity The introduction of new technology enhances the delivery of care, but it also has the potential to increase the costs of care. As new and more complex technology is introduced into the system, the cost is typically high. However, clients often demand access to the technology, and providers want to use it. In an effort to keep health care costs down, however, payers have attempted to restrict the use of certain technologies. For example, the drug Viagra, developed for the treatment of impo- tence by Pfizer Pharmaceuticals, is a controversial technological advance that, as soon as it was available to the public, was in high demand and prescribed by providers. Initially, use was restricted by payers because of cost. The adoption of new
technology demands investment in personnel, equipment, and facilities. Furthermore, new technology adds to administrative costs, especially if the federal government provides financial coverage for the service or is involved in regulating the technol- ogy. Table 5-2 outlines federal policy that has impacted technol- ogy and the cost of health care over time.
Chronic Illness Chronic illness is a factor that is showing its impact on health care spending. Chronic disease accounted for 70% of deaths in the United States (USDHHS, 2011) and accounted for 75% of all health care spending in 2013 (USDHHS 2014c). Using Medical Expenditure Panel Survey (MEPS) data, chronic medical conditions are identified by those costing the most, the
Year Federal Regulation
1906 Prescription drug regulation: Food, Drug, and Cosmetic Act, now the U.S. Food and Drug Administration (FDA) 1935 Social Security Act (PL 74-271): Provides grants-in-aid to states for maternal and child care, aid to crippled children, and aid to the blind and aged 1938 Food, Drug, and Cosmetic Act (PL 75-540): Establishes federal FDA protection for drug safety and protection for misbranded goods, drugs, cosmetics 1946 Hill-Burton Act (PL 79-725): Enacts Hospital Survey and Construction Act providing national direct support for community hospitals; establishes
rudimentary standards for construction and planning; establishes community service obligation 1954 Hill-Burton Act amended (PL 83-482): Expands scope of program for nursing homes, rehabilitation facilities, chronic disease hospitals, and diagnostic or
treatment centers 1963 Community Mental Health and Mental Retardation Center Construction Act (PL 88-164) 1965 Medicare Title 18; Medicaid Title 19 (PL 89-97): Amendments to Social Security Act provide Medicare and Medicaid to support health care services for
certain groups 1966 Comprehensive Health Planning Act (PL 89-749): For health services, personnel, and facilities in federal/state/local partnerships 1971 President Nixon introduces concept of HMOs as the cornerstone of his administration’s national health insurance proposal 1972 Social Security Act Amendments (PL 92-603): Extend coverage to include new treatment technologies for end-stage renal disease; provide for
professional standards review organizations to review appropriateness of hospital care for Medicare/Medicaid recipients 1973 HMO Act (PL 93-222): Provides assistance and expansion for HMOs 1975 National Health Planning and Resources Development Act (PL 93-641): Designates local health system areas and establishes a national certificate-of-
need (CON) program to limit major health care expansion at local and state levels 1978 Medicare End-Stage Renal Disease Amendment PL 95-292: Provides payment for home dialysis and kidney transplantation
Health Services Research, Health Statistics, and Health Care Technology Act PL 95-623 establishes national council on health care technology to develop standards for use
1981 Omnibus Budget Reconciliation Act of 1981 (PL 97-351): Consolidates 26 health programs into 4 block grants (preventives, health services, primary care, and maternal and child health)
1982 Tax Equity and Fiscal Responsibilities Act (PL 97-248): Seeks to control costs by limiting hospital costs per discharge adjusted to hospital case mix 1983 Amended Social Security Act (PL 98-21): Establishes new Medicare hospital prospective payment system based on diagnosis-related groups (DRGs) 1986 1974 Health Planning and Resource Development Act (PL 93-641): was amended and moves certificate of need program to states 1989 Omnibus Reconciliation Act of 1989 (PL 101-239): Creates physician resource–based fee schedule to be implemented by 1992, with emphasis on
high-tech specialties of surgery; creates Agency for Healthcare Policy and Research to research effectiveness of medical and nursing services, interventions, and technologies
1990 Ryan White CARE Act (PL 101-381): Authorizes formula-based and competitive supplemental grants to cities and states for HIV-related outpatient medical services
Safe Medical Devices Act (PL 101-629): Gives FDA authority to regulate medical devices and diagnostic products 1993 Omnibus Budget Reconciliation Act (OBRA 93) (PL 103-66): Cuts Medicare funding and ends ROE payments to skilled nursing facilities; provides support
for immunizations for Medicaid children 1996 Health Insurance Portability and Accountability Act: Protects health insurance coverage for laid-off or displaced workers 1997 Balanced Budget Act of 1997: Creates a new program for states to offer health insurance to children in low-income and uninsured families 1998 Balanced Budget Act of 1997 (PL 105-33): Authorizes third-party reimbursement for Medicare Part B services for NPs and CNSs 2003 Medicaid Nursing Incentive Act (HR 2295): Expands direct reimbursement to all NPs and CNSs and recognizes specialized services offered by advanced
practice registered nurses such as primary care case management, pain management, and mental health services 2006 Medicare Part D: Provides a plan for prescription payments 2010 Patient Protection and Affordable Care Act passed and signed into law on March 23, 2010 2012 The Affordable Care Act provides for $18 million to expand health information technology to 37 health center networks
TABLE 5-2 Federal Regulations Contributing to Health Care Technology/Cost Controls
110 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
number of bed days, work-loss days, and activity impairments. The most chronic medical condition was stroke.
FINANCING OF HEALTH CARE Against the backdrop of today’s chronic conditions, it must be appreciated that health care financing has evolved through the twentieth and into the twenty-first century from a system sup- ported primarily by consumers to a system financed by third- party payers (public and private). From 1980 to 2011, the percentage of third-party public insurance payments increased slightly while the percentage of out-of-pocket payments had declined. Combined state and federal governments paid the most in 2011 (CDC, 2014c).
Public Support The U.S. federal government became involved in health care financing for population groups early in its history. In 1798 the federal government created the Marine Hospital Service to provide medical care for sick and disabled sailors, and to protect the nation’s borders against the importing of disease through seaports. The Marine Hospital Service is considered the first national health insurance plan in the United States (see Health Care Reform, Chapter 3). The National Health Board was estab- lished in 1879 and was later renamed the U.S. Public Health Service (PHS). Within the PHS, the federal government devel- oped a public health liaison with state and local health depart- ments for the purpose of controlling communicable diseases and improving sanitation. Additional health programs were also developed to meet obligations to federal workers and their families within the PHS, the Department of Defense, and the Veterans Administration (VA) (see Chapter 8).
Medicare and Medicaid, two federal programs administered by the CMS, account for the majority of public health care
spending. Table 5-3 compares these programs. The CMS is the federal regulatory agency within the U.S. Department of Health and Human Services (USDHHS) that is responsible for oversee- ing and monitoring Medicare and Medicaid spending. This agency routinely collects and reports actual health care use and spending and projects future spending trends. Through these programs, the federal government purchases health care ser- vices for population groups through independent health care systems, such as managed care organizations, private practice physicians, and hospitals.
Medicare The Medicare program, established in Title XVIII of the Social Security Act of 1965, provides hospital insurance and medical insurance to persons aged 65 and older, to permanently disabled persons, and to persons with end-stage renal disease—altogether approximately 46 million people in 2013 (CMS, 2014). Medi- care has two parts: Part A (hospital insurance) covers hospital care, home care, hospice care, and skilled nursing care (limited); Part B (noninstitutional care insurance) covers “medically nec- essary” services such as health care provider services, outpatient care, home health, and other medical services such as diagnostic services, and physiotherapy. In 1999 a program called Medicare Advantage was added to the program (Part C). This is an option that can be chosen for additional coverage. This option includes both Part A and B services. The Part C plans are coordinated care plans that include health maintenance organizations (HMOs), private fee-for-service plans, and medical savings accounts (MSAs). Part C provides for all health care coverage costs after a high deductible (CMS, 2014).
Medicare Part A is primarily financed by a federal payroll tax that is paid by employers and employees. The proceeds from this tax go to the Hospital Insurance Trust Fund, which is managed by the CMS. If a person did not have federal payroll
From U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services: Medicare and You, and Medicaid Benefits, Baltimore, MD, 2015, USDHHS.
Feature Medicare Medicaid
Where to obtain information
Local Social Security Administration office State welfare office
Recipients Client is 65 years or older, is disabled, or has permanent kidney failure
Specified low-income and needy, children, aged, blind, and/or disabled; those eligible to receive federally assisted income
Type of program Insurance Insurance Government affiliation Federal Joint federal/state Availability All states All states Financing of hospital
insurance Medicare Trust Fund, mandatory payroll deduction,
recipient deductibles, trust fund interest Federal and state governments
Financing of medical insurance
Recipient premium payments; general revenue, U.S. Treasury
Federal and state governments
Types of coverage Part A. Inpatient and outpatient hospital services, skilled nursing facilities (SNFs), limited nursing home care, home health services and hospice
Part B. Prevention and screening services Part D. Prescription drugs from a formulary
Inpatient and outpatient hospital services; nursing facility services: home health, physician services, rural health clinic services, community health center services; laboratory and x-rays; family planning; advanced practice nurse services, free-standing birth center services; medical care transportation; tobacco cessation counseling for pregnant women, vaccines for children; many optional services are available by state’s choice
TABLE 5-3 Comparison of Medicare and Medicaid Program Features
111CHAPTER 5 Economics of Health Care Delivery
deductions, Part A can be obtained by paying a monthly premium. Part A coverage is available to all persons who are eligible to receive Medicare, with older adults comprising the majority of these individuals. There is concern about the future of the Medicare Trust Fund, because projected expenses may be more than the trust fund resources. Payments to hospitals for covered services have been and continue to be higher than fund growth. Thus Medicare reimbursement policy has been chang- ing in an attempt to control increasing hospital costs. Part A requires a deductible from recipients for the first 60 days of services with a reduced deductible for 61 to 90 days of service. The deductible has increased as daily hospital costs have increased. For skilled nursing facility (SNF) care, persons pay nothing for the first 20 days and a cost per day for days 21 through 100. After 100 days, persons must pay the total cost for care (CMS, 2013a). The person pays zero for hospice care and home health.
The medical insurance package, Part B, is a supplemental (voluntary) program that is available to all Medicare-eligible persons for a monthly premium ($99.90 minimum in 2012) (CMS, 2012a). The vast majority of Medicare-covered persons elect this coverage. Part B provides coverage for services other than hospital (physician care, outpatient hospital care, outpa- tient physical therapy, mental health, and home health care) that are not covered by Part A, such as laboratory services, ambulance transportation, prostheses, equipment, and some supplies. After a deductible, up to 80% of reasonable charges are paid for medical and other services. For mental health ser- vices, 55% of the costs are paid. Part B resembles the major medical insurance coverage of private insurance carriers. Figure 5-5 shows the total expenses of the Medicare program from 1966 to 2012.
Since the passing of the Medicare amendments to the Social Security Act in 1965, the cost of Medicare has increased dra- matically. Hospital care continues to be the major factor
FIG 5-5 Medicare expenditures for selected years from 1966 to 2012. (From Centers for Medicare & Medicaid Services: National Health Expenditure Accounts: National Health Expen- diture Data: Historical. 2012. Retrieved December 2014 from http://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/ NationalHealthAccountsHistorical.html)
700,000
600,000
500,000
400,000
300,000
200,000
100,000
0 1960
M ill
io n s
($ )
1970 1980 1990
Year
2000 2010 2020
contributing to Medicare costs. However, because of the shorter hospital stays, home health and nursing home costs have increased dramatically. As a result of rising health costs, Con- gress passed a law in 1983 that radically changed Medicare’s method of payment for hospital services. In 1983 federal legisla- tion (PL 98-21) mandated an end to cost-plus reimbursement by Medicare and instituted a 3-year transition to a prospective payment system (PPS) for inpatient hospital services (HCFA, 1998). The purpose of the new hospital payment scheme was to shift the cost incentives away from the providing of more care and toward more efficient services. The basis for prospective reimbursement is the 468 diagnosis-related groups (DRGs) (See Evidence-Based Practice Box). Also, the Balanced Budget Act of 1997 determined that payments to Medicare SNFs would be made on the basis of the PPS, effective July 1, 1998 (HCFA 1998). The PPS payment rates cover SNF services, including routine, ancillary, and capital-related costs (CMS, 2013b). In 2001 CMS developed a PPS for DRGs for home health with Health Insurance Prospective Payment System (HIPPS) codes.
In 2009 the average amount spent for services for Medicare beneficiaries was approximately $8000 (Kaiser Family Founda- tion, 2012b). The average out-of-pocket spending is skewed to those beneficiaries who are older or have declining health. Approximately one in four Medicare beneficiaries spends 30% or more of their income on out-of-pocket health expenses (Kaiser Family Foundation, 2012b). This is because of the limits in Medicare coverage, including certain preventive care, and the limited number of physicians and agencies who accept
This retrospective study examined the incidence, costs, and factors associated with potentially avoidable hospitalizations (PAH) in dually eligible Medicare and Medicaid beneficiaries. This population was selected due to their complex clinical needs and high costs of care. Potentially avoidable hospitalizations were defined by an expert panel that identified conditions and associated Diagnostic Related Groups (DRGs) which can often be prevented or safely and effectively managed in a skilled nursing facility or home- and community- based services. Seventy-eight percent of the PAH were responsible from five conditions: pneumonia, congestive heart failure, urinary tract infections, dehy- dration, and chronic obstructive pulmonary disease. The total costs of these hospitalizations were $3 billion for Medicare beneficiaries and $463 million for Medicaid beneficiaries. A sensitivity analysis found that between 77,000 and 260,000 hospitalizations and between $625 million and $1.9 billion in expenditures could be avoided each year in this population.
Nurse Use Community health nursing initiatives, such as health education and case management, could significantly reduce the amount of hospital admissions in this population. Such interventions could greatly reduce the negative health effects and quality of life for this population, as well as reduce the high health care costs for this group.
EVIDENCE-BASED PRACTICE
From Walsh EG, Wiener JM, Haber S, et al: Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and home- and community-based services waiver program. J Am Geriatr Soc 60:821–829, 2012.
112 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
states to provide care for children less than 6 years of age and to pregnant women under 133% of the poverty level. For example, if the poverty level were $12,000, a pregnant woman could have a household income as high as $16,000 and still be eligible to receive care under Medicaid. These changes also provided for pediatric and family nurse practitioner reimbursement.
In the 1990s states were allowed to petition the federal gov- ernment for a waiver. If the waiver was approved, the states could use their Medicaid monies for programs other than the six basic services. The first waiver to be approved was given to Oregon for their health care reform plan. Other states have received waivers to develop Medicaid managed care programs for special populations. The 2010 health care reform plan provides for new approaches to offering Medicaid services and incentives for states to offer Medicaid services rather than through the waiver option as described previously (PL 111-148, 2010).
The major expense categories for the Medicaid program have historically been skilled and intermediate nursing home care and inpatient hospital care. When combined, these two categories account today for 3% of all costs to the program (NCHS, 2012).
Public Health Most public government agencies operate on an annual budget, and they plan for costs by estimating salaries, expenses, and costs of services for a year. Public health agencies, such as health departments and WIC (Women, Infants, and Children) pro- grams, receive primary funding from taxes, with additional money for select goods and services through private third-party payers. Selected public health programs receive reimbursement for services as follows: through grants given by the federal
Medicare and Medicaid payment. Older adults who do not have supplemental insurance must cover the difference between the Medicare payment and the additional costs for services.
Medicaid The Medicaid program, Title XIX of the Social Security Act of 1965, provides financial assistance to states and counties to pay for medical services for poor older adults, the blind, the dis- abled, and families with dependent children. The Medicaid program is jointly sponsored and financed with matching funds from the federal and state governments. In 2013, 55 million people were enrolled in Medicaid (Kaiser Family Foundation, 2014). Medicaid expenditures from 1966 to 2012 are shown in Figure 5-6. Since the beginning of Medicaid, full payment has been provided for five types of services (NCHS, 2012): • Inpatient and outpatient hospital care • Laboratory and radiology services • Physician services • Skilled nursing care at home or in a nursing home for people
more than 21 years of age • Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
programs for those less than 21 years of age The 1972 Social Security amendments added family plan-
ning to the list of full-pay services. States can choose to add prescriptions, dental services, eyeglasses, intermediate care facilities, and coverage for the medically indigent as program options. By law, the medically indigent are required to pay a monthly premium.
Any state participating in the Medicaid program is required to provide the six basic services to persons who are below state poverty income levels. Optional programs are provided at the discretion of each state. In 1989 changes in Medicaid required
FIG 5-6 Medicaid expenditures for selected years from 1987 to 2012. (From Centers for Medi- care & Medicaid Services: National Health Expenditure Accounts: National Health Expenditure Data: Historical. 2012. Retrieved December 2014 from http://www.cms.gov/Research-Statistics- Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealth AccountsHistorical.html)
450,000
400,000
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
M ill
io n s
($ )
Year
Total
1966 1970 1975 1980 1985 1990 1995 2000 2005 2010 2012
Federal State and local
113CHAPTER 5 Economics of Health Care Delivery
Evolution of Health Insurance Insurance for health care was first offered for the private sector in 1847 by a commercial insurance company. The purpose of the insurance was to provide security and protection when health care services were needed by individuals. The idea behind insurance was that it provided security, guaranteeing (within certain limits) monies to pay for health care services to offset potential financial losses from unexpected illness or injury related to accidents, catastrophic communicable diseases (such as smallpox and scarlet fever), and recurring (but unexpected) chronic illnesses.
A comprehensive study in the 1920s by the Committee on the Costs of Medical Care showed that a small portion of the population was paying most of the costs of medical care for the majority of the people. The Depression of the 1930s, rising medical costs, and the need to spread financial risk across com- munities spurred the development of the third-party payment system. The system began as a major industry in the 1930s with the Blue Cross system, which initially provided prepayment for hospital care. In 1939 Blue Shield created plans to provide physician payment. The Blue Cross plans began as tax-free, nonprofit organizations established under special enabling leg- islation in various states.
In the 1940s and 1950s, hospital and medical-surgical cover- age increased. Employee group coverage appeared, and profit- making commercial insurance underwriters began offering health insurance packages with competitive premiums. The commercial insurance companies could offer lower premium rates because of the methods used to set rates. Insurance and premium setting, in general, are based on the notion of risk pooling (i.e., insurance companies were willing to risk the unlikely event that all or even a large portion of individuals covered under a plan would need payment for health services at any given time). Blue Cross used a community rate, establish- ing a similar premium rate for all subscribers regardless of illness potential. In contrast, the commercial companies used
government to states for prenatal and child health; through Medicare and Medicaid for home health, nursing homes, and WIC and EPSDT programs; and through collecting of fees on a sliding scale for select client services, such as immunizations. (Trust for America’s Health, 2014).
In 2011 only 3% of all health care–related federal funds was expended for federal health programs such as WIC, versus 97% for other types of health and illness care (such as hospital and physician services). In addition to this 3% allotment, public health funds also come through states and territorial health agencies. State and local governments contributed 16% to public and general assistance, maternal and child health, public health activities, and other related services in 2010 (NCHS, 2013).
Other Public Support The federal government finances health services for retired military persons and dependents through TRICARE, the VA, and the Indian Health Service (IHS). These programs are very important in providing needed health care services to these populations (see Chapter 8).
The Affordable Care Act: Public Health Support The ACA provides for prevention and public health funds with emphasis on chronic disease. Funds are provided to states to implement these provisions. See Table 5-4 for more detail. Also check the state of interest to see what that state is doing to implement this provision in ACA.
Private Support Private health care payer sources include insurance, employers, managed care, and individuals. Although insurance and con- sumers have been prominent health care payment sources for some time, the role of employers, managed care, and consumers became increasingly prominent and powerful during the first decade of the twenty-first century, particularly as concerns grew about the use and changing nature of health insurance.
• Prevention and Public Health Fund • The fund is an unprecedented investment in promoting
wellness, preventing disease, and protecting against public health emergencies
• Much of this work is done in partnership with states and communities: • To help control the obesity epidemic • Fight health disparities • Detect and quickly respond to health threats • Reduce tobacco use • Train the nation’s public health workforce • Modernize vaccine systems • Prevent the spread of HIV/AIDS • Increase public health programs’ effectiveness and efficiency • Improve access to behavioral health services
• Preventing Chronic Disease: A Smart Investment • Chronic diseases: The Prevention Fund helps states • Tackle the leading causes of death and root causes of costly, preventable chronic disease:
• Detect and respond rapidly to health security threats • Prevent accidents and injuries
TABLE 5-4 The Affordable Care Act’s Prevention and Public Health Fund in Your State
Since the Affordable Care Act was passed in 2010, the U.S. Department of Health and Human Services has awarded $1.25 billion in Prevention Fund grants. Check your state to see what is being done to promote the public’s health.
114 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
Family Foundation, 2009). This substantial contribution to health care by the private business sector gave the employer considerable health care buying power in making policy about what services insurance would cover. Most older Americans were covered by Medicare; low-income children can now be covered by the Children’s Health Insurance Program (CHIP) if enrolled by parents or guardians; and as previously described, some low-income adults were covered by Medicaid.
Before the growth of insurance (i.e., before 1930 and the beginning of Blue Cross), the health care consumer had more influence over health care costs because payment was out of pocket. Consumers made decisions about how they would spend their money, making certain tradeoffs—for example, about the type of health care they were willing to buy and how much they would pay. Entering the system was restricted in large part to those who could afford to pay for care, or to those few who could find care financed through charitable and phil- anthropic organizations. With the beginning of the insurance (or third-party payer) system, health care costs were set by payers, and they determined the type of care or service that would be offered and its price. This began to change somewhat in the 1980s with the increased use of managed care.
As the cost of health insurance has increased, some employ- ers, in an effort to bypass the costs established by insurers, have found it less costly to self-insure. The employer does this by contracting directly with providers to obtain health care ser- vices for employees rather than going through health insurance companies. Some large businesses directly employ on-site pro- viders for care delivery or offer on-site wellness programs. These programs within the private sector offer opportunities for nurses to provide wellness programs and health assessments to screen and monitor employees and their families. This move to self-insure resulted in savings to companies and reduced overall sick-care costs (Kovner et al, 2011).
In a truly competitive market, the consumer buys goods and services at will, knowing the costs and expected value of services bought and choosing the provider of those services. In the health system where a third party pays for the services, this transaction has less meaning. The third party makes decisions about the level and type of care that will be purchased for clients and determines how payment will be made. The service pro- vider and client have no influence on how services will be reim- bursed. However, the consumer may select the payer/plan and indeed may influence the system through political channels.
The average monthly cost for private health insurance has increased greatly through the years. Premiums reflect a shift of the health care cost burden from employers to employees as the percentage of employer contributions to health care declines. The decrease in employer contribution to health insurance pre- miums parallels the economic downturn of 2008, the move away from traditional insurance plans, and the move toward managed care plans or self-insurance plans by both small and large employers or toward dropping health insurance as a benefit. In 2008, 2 million people lost employer health insur- ance coverage (Kaiser Family Foundation, 2012a).
From an economic point of view, the shift in responsibility for the cost of health insurance is not bad. In theory, this shift
an experience rate, in which the premium was based on an esti- mate of the illness risk or the number of claims to be made by the subscriber (Hicks, 2012).
Premium competition, the offering of health insurance as a fringe benefit, and the use of health insurance as a negotiable collective bargaining item led to an increase in covered benefits, first-dollar coverage for medical care expenses, and increased employer-paid premiums. In turn, these factors pushed up insurance premium costs and health care costs and enabled insurance plans to cover high-cost segments of the population (the aged, poor, or disabled) because of the number of low-risk enrollees.
The health needs of high-risk populations led to the passage of Medicare and Medicaid legislation. These and other national health programs targeted health care coverage for specific pop- ulation groups. Because these programs directed additional money into the health care system to subsidize care, there were financial incentives to encourage the providing of services (i.e., the more services that were ordered, the greater the amount of money that would be received). Other incentives were related to the use of services by clients (i.e., the more available the payment was for services that might otherwise have gone unused, the more services that were requested).
Greater increases in health insurance premiums have occurred as a result of pressure from employers, consumers, and policymakers. Driving forces behind this pressure are quality of care, client dissatisfaction, clients’ rights, and the concern that these areas are being compromised in the managed care system. Furthermore, the initial cost savings from managed care may have occurred already, and costs will have to be increased to simply maintain coverage, not to mention providing new ser- vices and technologies. Although managed care changed the structure of financing and delivery of care, it was soon recog- nized that managed care was not the solution to the health care system’s problems (Shi and Singh, 2011).
Employers Since the beginning of Blue Cross and Blue Shield, health insur- ance has been tied to employment and the business sector. This tie was strengthened during World War II to compensate, attract, and retain employees. Since that time, employers have played the major role in determining health insurance benefits. However, with the economic downturn in 2008, employers began to reduce their health insurance benefits or return the cost of insurance. It is of interest that if a client has health insur- ance, the payment to the provider is less than the payment made by the client who does not have health insurance.
In 2005 approximately 70% of the population under 65 years of age had private health insurance, most of which was obtained through the workplace (NCHS, 2005). In 2009 the percentage had decreased to about 60% (Kaiser Family Foundation, 2009). In 2005, 87% of employers paid 50% to 100% of the insurance premium (Kaiser Family Foundation, 2005). In 2009 employees paid a minimum of 26% to 36% of the health insurance premium with the employee’s share of a family premium dou- bling in cost since 2000. For employees of small firms, the percentage of payment increased for all premiums (Kaiser
115CHAPTER 5 Economics of Health Care Delivery
health maintenance. Therefore, managed care uses disease pre- vention, health promotion, wellness, and consumer education (Kovner et al, 2011). In addition to risk-based plans, wherein the managed care organization accepts a set fee to cover all costs of care for the enrollee, there are cost-based plans. An example of such a managed care organization is the primary care case management (PCCM) organization often used by Medicaid programs. These PCCMs are composed of a variety of health care providers contracted with states to locate, coordinate, and monitor covered primary care and other services on a per client case management fee payment. Whereas HMOs assume risks for the costs of care, the PCCMs do not (NCHS, 2010).
Although they seem relatively new to many clients of care, HMOs have actually been around since the 1940s. The Health Maintenance Organization Act was enacted in 1972, and since that time, the number of individuals receiving care through HMOs and other types of managed care organizations has increased considerably. Managed care is based, in part, on the principles of managed competition. Managed competition was introduced in health care in the late 1980s and early 1990s to address the increasing costs of health care and to introduce quality into the forefront of discussions. Managed competition simply means that clients make decisions and choose the health care services they want on the basis of the quality or reputation of the service. To make decisions, they use knowledge and infor- mation about health care problems, care, and providers, and they look at the costs of care. However, health care is a complex market and not one in which information about health care, health problems, and the costs of care are easy to get. With the passing of the ACA(2010), Accountable Care Organizations are being introduced as a new approach to managing care.
Medical Savings Accounts Another insurance reform discussion at the political level con- cerns medical savings accounts (MSAs). These are also referred to as health savings accounts. MSAs are touted as a way of turning health care decision-making control over to the indi- viduals receiving care. MSAs are tax-exempt accounts available to individuals who work for small companies, usually estab- lished through a bank or insurance company, that enable the individuals to save money for future medical needs and expenses (Internal Revenue Service [IRS], 2012). Money is contributed to an MSA by the employer, and the initial money put into an MSA does not come out of taxable income. Also, interest earned in MSAs is tax free, and unused MSA money can be held in the account from year to year until the money is used. MSAs, in theory, would allow individuals to make cost/quality tradeoffs and would require that individuals become knowledgeable about health care, become involved in health care decision making, and take responsibility for the decisions made. Providers, in turn, must be willing to provide and disclose information to individuals and give up control of health care decision making. The HIPAA and MSAs are examples of health insurance reform efforts, and these efforts will very likely remain in the forefront of political dis- cussions for some time to come, especially with the health care reform discussions.
makes consumers more knowledgeable about (sensitive to) the price of health services. This means that they have more infor- mation for health care decision making and may consider price in making the decision to access types of health care services. Satisfaction with the quality of service rests with the person buying the insurance and receiving health care. As with employ- ers, employees may choose health insurance voluntarily. There- fore three factors—the shifting of responsibility for health insurance premiums to employees, the changing demographics of the workforce in general, and the loss of employment due to the economic downturn—have resulted in a decline in employee enrollment in health insurance plans. Employees are choosing to use their resources to meet basic needs and are assuming the risks of having an illness for which they may have to pay. A minor health problem can lead to major medical debt for someone without health insurance (Kaiser Family Foundation, 2013). PL 111-148 includes a mandate for all citizens and legal residents to have qualifying health coverage. Employers will be required to offer coverage also, except for employers with fewer than 50 employees. These two requirements were to be in effect by 2014 unless repealed by Congress.
Given that access to health insurance is tied to employment, there was growing concern in the late 1980s and early 1990s about the employment layoffs and downsizing occurring in private business. Those who lost their jobs lost their ability to pay for health insurance and to qualify to purchase insurance privately. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted to protect health insurance coverage for workers and families after a job change or loss (Health Care Financing Administration [HCFA], 1999; Nichols and Blumberg, 1998). Although this has increased the number of people who have access to health insurance and health care, there are claims that individual premiums are high, that insur- ance companies have lost their ability to pool risks, and that HIPAA is just one more federal control mechanism undermin- ing competitive market influences.
Individuals In 2011, individuals paid only approximately 14% of total health expenditures out of pocket (NCHS, 2014). However, these figures do not reflect the amount of money the consumer pays in taxes to finance government-supported programs such as Medicare and Medicaid, insurance premiums, and money paid for supplemental insurance to cover the gaps in a primary health insurance policy or Medicare.
Managed Care Arrangements Managed care is the term used for a variety of health care arrangements that integrate the financing and the delivery of health care. Managed care offers an array of services to purchas- ers, such as employers, Medicaid, or Medicare, for a set fee. These are called risk-based plans. This fee, in turn, is used to pay providers through preset arrangements for services delivered to individuals who are covered (NCHS, 2012). The concept of managed care is based on the notion that the use of costly care could be reduced if consumers had access to care and services that would prevent illness through consumer education and
116 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
payment to skilled nursing facilities is also adjusted for case mix and geographic variations (CMS, 2012c).
Positive and negative incentives are built into these reim- bursement schemes. The retrospective method of payment encourages organizations to inflate prices in one area to offset agency losses in another. These losses can result from providing service to nonpaying clients or from providing care to clients covered under plans that do not cover the total costs of deliver- ing a service (Kovner et al, 2011). The major disadvantage of this system is that little regard is given to the costs involved. This practice of charging a payer at a higher rate to cover losses in providing care is referred to as cost-shifting.
Prospective cost reimbursement encourages agencies to stay within budget limits and adds an incentive for providing less service to contain or reduce costs. If an organization provides care to a particular patient or group of patients and keeps the costs of delivering the service lower than the amount of reim- bursement, the provider keeps the difference; however, if the provider’s costs exceed the reimbursement, the provider must assume the risk and pay the difference. The major disadvantage of this method is that organizations tend to overemphasize controlling costs and sometimes compromise quality of care.
A growth in contracting, or competitive bidding, for health care services, intended to create incentives for providers to compete on price, has occurred as managed care has increased in health care markets. For example, contracting has been used by states to provide Medicaid services to eligible persons. Hos- pitals and other health care providers that do not have a con- tract with the state to provide services are not eligible to receive Medicaid payments for client care. Managed care organizations also use this approach to negotiate with health care organiza- tions, such as hospitals, for coverage of services to be provided to covered enrollees, often called covered lives.
Paying Health Care Practitioners The traditional method of paying health care practitioners is known as fee for service (Kovner et al, 2011) and is like the retrospective method just described. The practitioner deter- mines the costs of providing a service, delivers the service to a client, and submits a bill for the delivered service to a third- party payer; the payer then pays the bill. This method is based on usual, customary, and reasonable (UCR) charges for specific services in a given geographic region, determined by periodic regional evaluations of physician charges across specialties (Kovner et al, 2011). Historically, Medicare, Medicaid, and private insurance companies have used this method of reim- bursing physicians.
A major effort to regulate and control the costs of physician fees was introduced in 1990 in the Omnibus Reconciliation Act. After a study by the Physician Payment Review Commission established by Congress, the resource-based relative value scale (RBRVS) was established. The RBRVS method reimburses phy- sicians for specific services provided and the amount of resources required to deliver the service. Resources are defined broadly and include not only the costs of providing the service, but also the training that is required to provide a particular service and
HEALTH CARE PAYMENT SYSTEMS Several methods have been used by public and private sources to pay health care providers for health care services. These include retrospective and prospective reimbursement for paying health care organizations, and fee-for-service and capitation for paying health care practitioners (Kovner et al, 2011).
Paying Health Care Organizations Retrospective reimbursement is the traditional reimburse- ment method, whereby fees for the delivery of health care ser- vices in an organization are set after services are delivered (Kovner et al, 2011). In this scenario, reimbursement is based on either organization costs or charges. The cost method reimburses organizations on the basis of cost per unit of service (e.g., home health visit, patient-day) for treatment and care. Costs include all or a percentage of added, allowable costs. Allowable costs are negotiated between the payer and provider and include items such as depreciation of building, equipment, and administrative costs (e.g., adminis- trative salaries, utilities, and office supplies) (Kovner et al, 2011). For example, the unit of service in home health is the visit, and the agreed-on price is a set amount of money that the home health agency will be paid for a home visit in the region of the United States in which the home care agency is located.
The charge method reimburses organizations on the basis of the price set by the organization for delivering a service (Kovner et al, 2011). In this case, the organization determines a charge for providing a particular service, provides the service to a client, and submits a bill to the payer; the payer in turn provides payment for the bill. With this method, the charge may be greater than the actual cost to the agency to deliver the service. When the charge method is used, the client often has to pay the difference between what is paid and what is charged.
Prospective reimbursement, or payment, is a more recent method of paying an organization, whereby the third-party payer establishes the amount of money that will be paid for the delivery of a particular service before offering the services to the client (Kovner et al, 2011). Since the establishment of prospec- tive payment in Medicare in 1983, private insurance has fol- lowed by requiring preapprovals before clients can receive certain services, such as hospital admission or mammograms more than once a year (Kovner et al, 2011). Under this payment scheme, the third-party payer reimburses an organization on the basis of the payer’s prediction of the cost to deliver a par- ticular service; these predictions vary by case mix (i.e., different types of clients, with different types, levels, and intensities of health problems), the client’s diagnosis, and geographic loca- tion. This process is used in the DRG system of the hospital (Kovner et al, 2011).
Similarly, ambulatory care services received by Medicare recipients are classified into ambulatory payment classes (APCs), which reflect the type of ambulatory clinical services received and resources required (CMS, 2012b). Prospective
117CHAPTER 5 Economics of Health Care Delivery
who function in certain capacities, such as NPs, CNSs, and midwives, also provide primary care to clients and receive reim- bursement for their services. Being recognized as primary care providers and eligible to receive reimbursement has not been an easy achievement. There are currently more than 250 nurse- managed clinics in the United States providing population- based preventive services, primary care, or specific wellness programs. Most are receiving financial support through Medi- care, Medicaid, contracts, gifts, grants, and private donations.
Hospital nursing care costs have traditionally been included as part of the overall patient room charge and reimbursed as such. Other agencies, such as home health care agencies, include nursing care costs with administrative costs, supplies, and equipment costs. Nursing organizations, such as the American Nurses Association (ANA), have long advocated that nursing care should become a separate budget item in all organizations so that cost studies can show the efficiency and effectiveness of the nursing profession.
Spurred by efforts to control the costs of medical care, effec- tive January 1, 1998, NPs and CNSs were granted third-party reimbursement for Medicare Part B services only, under Public Law 105-33 (ANA, 1999). This new law set reimbursement for NPs and CNSs at 85% of physician rates for the same service, an extension of previous legislation that allowed the same reim- bursement rate to NPs and CNSs practicing in rural areas (Buppert, 1999). This law was passed after years of work in this area, including research documenting NP and CNS contribu- tions to health care delivery and client outcomes and after active lobbying efforts by professional nursing organizations. Reim- bursement for these nurses has not changed to any extent since the 1990s.
In addition, data about the cost-to-benefit ratio, efficiency, and effectiveness of nursing care in general have been collected. Today, more than 250 nurse-managed clinics provide health care services to individuals in the United States who might not otherwise have access to health care, such as older adults, the homeless, and schoolchildren. All of these events have moved the discipline toward more autonomy in nursing practice and are serving as a means for evaluating and documenting nurses’ contributions to health care delivery (Esperat et al, 2012).
the time required to perform certain procedures, including client diagnosis and treatment. The RBRVS method of reim- bursement, adopted by Medicare in 1991, acknowledges the breadth and depth of knowledge required by primary care phy- sicians in the community to provide services aimed at preven- tion, health promotion, teaching, and counseling.
Capitation is similar to prospective reimbursement for health care organizations. Specifically, third-party payers deter- mine the amount that practitioners will be paid for a unit of care, such as a client visit, before the delivery of the service, thereby placing a limit on the amount of reimbursement received per patient (Kovner et al, 2011). In contrast to a fee- for-service arrangement, where the practitioner determines both the services that will be provided to clients and the charges for those services, practitioners being paid through capitation are given the rate they will be paid for a client’s care, regardless of specific services provided. Therefore, for example, physicians and nurse practitioners are aware in advance of the payment they will receive to perform a routine, uncomplicated physical examination or a more complex, detailed physical examination, diagnosis, and treatment (Kovner et al, 2011).
In capitated arrangements, physicians and other practitio- ners are paid a set amount to provide care to a given client or group of clients for a set period of time and amount of money. This arrangement, typically used by managed care organiza- tions, is one whereby the practitioner contracts with the managed care organization to provide health care services to plan members for a preset and negotiated fee. The agreed-on fee is negotiated between the practitioner and the managed care organization before the delivery of services and is set at a dis- counted rate, and the practitioner and managed care organiza- tion come to a legal agreement, or contract, for the delivery and payment of services. The managed care organization pays the predetermined fee to the practitioner, often before the delivery of services, to provide care to plan members for a set period (Kovner et al, 2011).
Reimbursement for Nursing Services Historically, practitioners eligible to receive reimbursement for health care services included physicians only. However, nurses
LINKING CONTENT TO PRACTICE
The balance of interest within society and health care will continue to shift toward a focus on quality, safety, and elimination of health disparities through public and private sector partnerships. Health care system concerns of the twenty-first century are expected to focus on examining the quality of health care relative to the costs of care delivered, reduction in disparities, access to care, and health care reform. These changes will result from continued efforts of both the public and private sectors to reform the U.S. health care system. The current era of health care delivery will be noted as a time of vast changes in all sectors of health care delivery.
Nurses must plan for future changes in health care financing by becoming aware of the costs of nursing services, identifying aspects of care where cost
savings can be safely achieved, and developing knowledge on how nursing practice affects and is affected by the principles of economics. Nursing must continue to focus on improving the overall health of the nation, defining its con- tribution to the health of the nation, deriving the value of nursing care, and ensuring its economic viability within the health care marketplace. Nurses must effect changes in the health care system by providing leadership in developing new models of care delivery that provide effective, high-quality care and by assuming a greater role in evaluating client care and nurse performance. It is through their leadership that nurses will contribute to improved decision making about allocating scarce health care resources, and promoting primary prevention as an answer to improve many of the current population level health outcomes.
118 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
P R A C T I C E A P P L I C A T I O N Connie, a nursing student, has identified a caseload of five families in a chronic disease program offered by the local public health department. She is interested in assessing the costs of care to her clients and to the agency. Connie approaches the public health nurse administrator and asks the following questions: A. How is the agency reimbursed for chronic disease manage-
ment? Has the Affordable Care Act changed the way reim- bursement occurs?
B. Does the client have a responsibility for paying for services?
C. Are nursing care costs known? D. Are services rationed to clients? On what basis? E. What effect will the chronic disease management program
have on the community population? Answers can be found on the Evolve site.
K E Y P O I N T S • From 1800 to 2000, the U.S. health care delivery system
experienced four developmental stages, with different emphases on health care economics. With the twenty-first century, the health care delivery system has changed the focus of the fourth developmental stage.
• Four basic components provide the framework for the devel- opment of delivery of health care services: service needs and intensity, facilities, technology, and labor (workforce).
• Three major factors have been associated with the growth of the health care delivery system: price inflation, changes in population demographics, and technology and service intensity.
• Chronic disease is becoming a major health factor affecting health care spending, with one in two Americans experienc- ing at least one chronic disease.
• Health care financing has evolved through the twentieth century from a system financed primarily by the consumer to a system financed primarily by third-party payers. In the twenty-first century, the consumer is being asked to pay more.
• To solve the problems of rising health care costs, the Afford- able Care Act has been passed; this act also includes some form of rationing.
• Excessive and inefficient use of goods and services in health care delivery has been viewed as the major cause of rising health care costs.
• Economics is concerned with use of resources, including money, to fulfill society’s needs and wants.
• Health economics is concerned with the problems of pro- ducing services and programs and distributing them to clients.
• The goal of public health economics is maximal benefits from services of public health providers, leading to health and wellness of the population.
• The goal of public health is to provide the most good for the most people.
• Nurses need to understand basic economic principles to avoid contributing to rising health care costs.
• The GNP reflects the market value of goods and services produced by the United States.
• The GDP reflects the market value of the output of labor and property located in the United States.
• Microeconomic theory shows how supply and demand can be used in health care.
• Macroeconomic theory helps one look at national and com- munity issues that affect health care.
• Social issues, economic issues, and communicable disease epidemics mark the problems of the twenty-first century.
• Medicare and Medicaid are two government-funded pro- grams that help meet the needs of high-risk populations in the United States.
• A majority of the U.S. population has had health insurance. It is now mandated by law and has a penalty if citizens are not covered.
• The uninsured segment represents millions of people, mostly the working poor, older adults, and children, and those who lost jobs in the economic downturn of 2008.
• Poverty has a detrimental effect on health. • Health care rationing has always been a part of the U.S. health
care system and will continue to be with health care reform. • Nurses are cost-effective providers and must be an integral
part of health care delivery. • Healthy People 2020 is a document that has established U.S.
health objectives. • Human life is valued in health economics, as is money. An
emphasis on changing lifestyles and preventive care will reduce the unnecessary years of life lost to early and prevent- able death.
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Define the following terms in your own words: economics,
health economics, public health economics, public health finance, gross national product, gross domestic product, consumer price index, and human capital. How do these terms relate to your work as a nurse?
2. Compare the advantages and disadvantages of applying eco- nomics to public health care issues. Be specific.
3. Compare and contrast efficiency and effectiveness of a public health program. What factors make these difficult to control?
119CHAPTER 5 Economics of Health Care Delivery
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from population health. Be precise in your answer. 5. Review Chapter 6. Debate in class the ethical implications of
the goal of rationing. Focus your debate on the implications for nursing practice. What are some of the complexities of this question?
6. Invite a public health nurse administrator to meet with your class or clinical conference group. Ask how inflation, changes in population, and technology have changed the public health care delivery system and nursing practice. How could we check for ourselves to find the answers?
120 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
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U.S. Department of Health and Human Services (USDHHS): Health, United States, 2013. Publication No. 2014-1232. Rockville, MD, 2014c, Centers for Disease Control and Prevention, National Center for Health Statistics.
World Health Organization (WHO): World Health Statistics, 2010. Geneva, 2010, WHO.
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6
Application of Ethics in the Community
Jeanette Lancaster, PhD, RN, FAAN* Dr. Lancaster is Professor and Dean Emerita of Nursing at the University of Virginia. She has edited this book with Dr. Marcia Stanhope through its
previous eight editions.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Describe a brief history of the ethics of nursing practice. 2. Analyze ethical decision-making processes. 3. Compare and contrast ethical theories and principles,
virtue ethics, caring and the ethic of care, and feminist ethics.
4. Comprehend the ethics inherent in the core functions of public health nursing.
5. Analyze codes of ethics for nursing and for public health. 6. Apply the ethics of advocacy to nursing practice.
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks—Of special note, see the link for these sites:
• International Council of Nurses Code of Ethics for Nurses
• Nursing Ethics Column in Online Journal of Issues in Nursing
• American Nurses Association Center for Ethics and Human Rights
• Kennedy Institute of Ethics: https://kennedyinstitute .georgetown.edu
• Bioethics Research Library at Georgetown University: https://bioethics.edu
• Bioethics Research at the Hastings Center • Quiz • Case Studies • Glossary • Answers to Practice Application
K E Y T E R M S advocacy, p. 132 assessment, p. 129 assurance, p. 130 beneficence, p. 126 bioethics, p. 122 code of ethics, p. 123 communitarianism, p. 127 consequentialism, p. 125
deontology, p. 126 distributive justice, p. 126 ethical decision making, p. 123 ethical dilemmas, p. 124 ethical issues, p. 124 ethics, p. 125 feminine ethic, p. 129 feminist ethics, p. 129
*Special thank you to Dr. Mary Silva who offered valuable guidance for the revision of this chapter. A special thanks to James Fletcher, Mary Silva, and Jeanne Sorrell for the many contributions to this chapter in previous editions of the text.
122 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
The role of nurses who practice in the community is to focus on protecting, promoting, preserving, and maintaining health while preventing disease. These goals reflect the ethical princi- ples of promoting good and preventing harm. In addition, nurses struggle with the rights of individuals and families versus the rights of local groups within a community. On the other hand, nurses struggle with the rights of a community or popu- lation versus the rights of individuals, families, and local groups within a community. These two types of struggle reflect the tensions among respect for autonomy, rights-based ethical theory, and community-based ethical theory.
Nurses also deal with consequence-based ethical theory, obligation-based ethical theory, and the ethical components of advocacy, justice, health policy, caring, women’s moral experi- ences, and the moral character of health care practitioners. They are guided by codes of ethics and ethical decision-making frameworks. The purpose of this chapter, then, is to make explicit the preceding content as it relates to the ethics inherent in nursing.
HISTORY Chapter 2 discusses the history of public health nursing. The focus in this chapter is a brief history of nursing and public health ethics and the relationship between them and nursing.
Modern nursing has a rich heritage of ethics and morality, beginning with Florence Nightingale (1820 to 1910). Her values and the moral significance she inculcated into the profession have endured. She saw nursing as a call to service and viewed the moral character of persons entering nursing as important. She also viewed nursing within a broad social context, where
poor people mattered and where soldiers harmed in the Crimean War (1854 to 1856) did not have to endure unhealthy environ- ments. Because of her commitment to poor individuals in com- munities, as well as her stances on primary prevention and on population-based evidence that healthy environments save sol- diers’ lives, she is seen as nursing’s first enduring moral leader who defined the community as her client.
In 1860, Nightingale established the first nursing program in London. It was hospital based, but the curriculum contained not only care of the sick, but also public health concepts with their inherent ethical tenets. Many of these programs were associated with religious institutions. Students, therefore, often received ethics courses with a slant toward a particular religion’s values. Soon thereafter in the United States, the notion of hospital-based nursing programs took hold, but nursing prac- tice in the community was not a part of the curricula.
In the 1960s, two seminal events occurred. First, the Ameri- can Nurses Association (ANA) recommended that all nursing education should occur in institutions of higher education. As this process slowly took place, ethics, as a course per se, was removed from many schools of nursing, although ethical values remained. Second, because of major advances in science and technology that affected health care, the field of bioethics began to emerge and was reflected in nursing curricula. Today, most nursing programs integrate bioethical content into their courses or have separate courses on this topic; some do both. Although some of these courses relate bioethics to community nursing, the emphasis has been primarily on acute care nursing.
Nurses’ codes of ethics are important in the history of public health nursing practice. According to the American Nurses Association (ANA), the Nightingale Pledge is generally
K E Y T E R M S — cont’d feminists, p. 129 moral distress, p. 124 morality, p. 128 nonmaleficence, p. 126 policy development, p. 130 principlism, p. 126
respect for autonomy, p. 126 utilitarianism, p. 125 virtue ethics, p. 127 virtues, p. 128 —See Glossary for definitions
C H A P T E R O U T L I N E History Ethical Decision Making Ethics
Definition, Theories, Principles Virtue Ethics Caring and the Ethic of Care Feminist Ethics
Ethics and the Core Functions of Population-Centered Nursing Practice
Assessment
Policy Development Assurance
Nursing Code of Ethics Public Health Code of Ethics Advocacy and Ethics
Codes and Standards of Practice Conceptual Framework for Advocacy Practical Framework for Advocacy Advocacy: Issues That Have Ethical Implications
123CHAPTER 6 Application of Ethics in the Community
Ethics is a branch of philosophy that includes both a body of knowledge about the moral life and a process of reflection for determining what persons ought to do or be regarding this life.
Bioethics is a branch of ethics that applies the knowledge and processes of ethics to the examination of ethical problems in health care.
Moral distress is an uncomfortable state of self in which one is unable to act ethically.
Morality is shared and generational societal norms about what constitutes right or wrong conduct.
Values are beliefs about the worth or importance of what is right or esteemed. Ethical dilemma is a puzzling moral problem in which a person, group, or
community can envision morally justified reasons for both taking and not taking a certain course of action.
Codes of ethics are moral standards that delineate a profession’s values, goals, and obligations.
Utilitarianism is an ethical theory based on the weighing of morally signifi- cant outcomes or consequences regarding the overall maximizing of good and minimizing of harm for the greatest number of people.
Deontology is an ethical theory that bases moral obligation on duty and claims that actions are obligatory irrespective of the good or harmful consequences that they produce. Because humans are rational, they have absolute value. Therefore, persons should always be treated as ends in themselves and never as mere means.
Principlism is an approach to problem solving in bioethics that uses the principles of respect for autonomy, beneficence, nonmaleficence, and justice as the basis for organization and analysis of ethical issues and dilemmas.
Advocacy is the act of pleading for or supporting a course of action on behalf of a person, group, or community.
BOX 6-1 Key Ethical Termsconsidered to be nursing’s first code of ethics (ANA, 2001). After the Nightingale Pledge, a “suggested” code and a “tenta- tive” code were published in the American Journal of Nursing but were not formally adopted. In 1950, the ANA House of Delegates formally adopted the Code for Professional Nurses. In 1956, 1960, 1968, 1976, 1985, and 2001 the code was amended or revised. After 5 years of work, the ANA House of Delegates adopted the Code of Ethics for Nurses with Interpretive State- ments in 2001 (ANA, 2001). This code was revised in 2015 (ANA, 2015).
Nurses also should be familiar with the first known interna- tional code of ethics, developed by the International Council of Nurses (ICN) in 1953 (ICN, 1953). Like the ANA code, the ICN code has undergone various revisions and adoptions. The most recent version of the ICN Code of Ethics for Nurses was revised in 2012. This code makes it clear that nurses must respect human rights, including the right to life, to dignity, and to be treated with respect. The ICN Code of Ethics for Nurses has four principal elements that outline the standards of conduct. They are as follows: (1) nurses and people; (2) nurses and practice; (3) nurses and the profession; and (4) nurses and co-workers (ICN, 2012, pp. 2-4).
In addition to codes of ethics, the nursing literature and nursing associations have consistently reflected a commitment to ethics, as well as an awareness of nursing’s ethical obligations to society. From the 1980s to the present, the number of centers for nursing and health care ethics has increased steadily. The majority of these centers are located in academic settings; however, in 1991 the ANA founded its Center for Ethics and Human Rights. The historical contributions of this center have affected the persistent ethicality of nursing. In 2008, the ANA published Nursing and Health Care Ethics: A Legacy and a Vision, which creatively assesses historical contributions of nursing scholars in ethics and explores a vision for the future scholar- ship of nursing ethics (Pinch and Haddad, 2008). Also in 2008, the ANA published Guide to the Code of Ethics for Nurses: Interpretation and Application (Fowler, 2008).
The bioethics movement of the late 1960s influenced not only nursing ethics, but also public health ethics. However, until recently, the relationship between public health and ethics was implicit rather than explicit (Callahan and Jennings, 2002; Petrini, 2010). The publication in 2015 of Essentials of Public Health Ethics by Bernheim and colleagues is a major contribu- tion to describing the complex relationship between public health and ethics.
Finally, in 2000, public health professionals, individually and through their associations, initiated the writing of a code of ethics that was supported by the American Public Health Association (APHA). In 2001 the Public Health Code of Ethics was widely disseminated via the APHA website for critique (www.apha.org) and was adopted in 2002 (Olick, 2005). The code presents principles, rules, and ideals to guide public health practice but is not intended to provide a specific action plan for ethical decision making. Our language often programs us to think in terms of opposites, such as right or wrong, so that we think we need to choose one or the other. Often, there are more than two sides to an ethical issue. When we try to understand
the differing values of individuals and groups in a community, we find important points to consider on different sides of an ethical issue and focus not only on what we think is right, but also on what we should respect in each perspective of an ethical issue. As Bernheim and colleagues (2015, p. 3) point out, “Public health is an ethical enterprise, resting on moral foundations, yet some public health interventions appear to threaten or compro- mise other moral norms, such as liberty, privacy, and confiden- tiality.” As is discussed later in this chapter, advances in social media pose ethical concerns about both privacy and confiden- tiality. Also, vulnerable or high-risk populations as discussed in Chapter 32 can pose ethical concerns and necessitate careful decision making by nurses. Gjengedal and colleagues (2013) point out that a key to acting ethically with vulnerable popula- tions is to try to understand the clients from their perspective rather than from the perspective of the nurse that may be prejudiced.
Before discussing ethics related to nursing practice in the community, some key ethical terms are defined in Box 6-1. Other ethical terms are defined within the context of the chapter.
ETHICAL DECISION MAKING Ethical decision making is that component of ethics that focuses on the process of how ethical decisions are made. The process is the thinking that occurs when health care profession- als must make decisions about ethical issues and ethical
124 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
dilemmas. Ethical issues are moral challenges facing a person or a profession. In nursing, one such challenge is how to prepare an adequate and competent workforce for the future. In con- trast, ethical dilemmas are human dilemmas and puzzling moral problems in which a person, group, or community can envision morally justified reasons for both taking and not taking a certain course of action. One example of an ethical dilemma is how to allocate resources to two equally needy pop- ulations when the resources are sufficient to serve only one of the populations. Ethical theories, principles, and decision- making frameworks help us think through these issues and dilemmas. In describing what ethics is, Bernheim and colleagues concentrate on normative ethics and say that in general terms, “normative ethics involves identifying and justifying moral norms regarding right and wrong, good and bad, and determin- ing the meaning, range and strength of those moral norms for purposes of guiding human action” (2015, p. 4)
Ethical decision-making frameworks use problem-solving processes. They provide guides for making sound ethical deci- sions that can be morally justified. Many such frameworks exist in the health care literature, and some are presented in this chapter. A caveat, however, is in order. Weston (2006, p. 22) notes that the first requirement of ethics is to think apprecia- tively and carefully about moral matters. We should not simply obey rules or authorities without thinking for ourselves; thinking for ourselves is both a moral responsibility and a hard-won right.
Keeping the preceding caveat in mind, the following generic ethical decision-making framework is presented: 1. Identify the ethical issues and dilemmas. 2. Place them within a meaningful context. 3. Obtain all relevant facts. 4. Reformulate ethical issues and dilemmas, if needed. 5. Consider appropriate approaches to actions or options (such
as utilitarianism, deontology, principlism, virtue ethics, caring and the ethic of care, feminist ethics).
6. Make a decision and take action. 7. Evaluate the decision and the action.
The steps of a generic ethics framework are often nonlinear, and, with the exception of step 5, they do not change substan- tially. The rationale for each of the seven steps is presented in Table 6-1. The six approaches to actions or options in the ethical decision-making framework (step 5) are outlined throughout the chapter in the How To Boxes.
Two factors affect this ethical decision-making framework: (1) the growing multiculturalism of the American society, and (2) moral distress. First, nurses often deal with ethical issues and dilemmas related to the diverse and at times conflicting values that result from ethnicity. From a moral perspective, what should the nurse do when facing ethnicity conflicts?
Callahan (2000) offers useful insights into these conflicts. He describes four situations in which ethnic diversity can be judged in relationship to cultural standards: 1. Situations that place persons at direct risk of harm, whether
psychological or physical 2. Situations in which ethnic cultural standards conflict with
professional standards
Step Rationale
1. Identify the ethical issues and dilemmas
Persons cannot make sound ethical decisions if they cannot identify ethical issues and dilemmas
2. Place them within a meaningful context
The historical, legal, sociological, cultural, psychological, economic, political, communal, environmental, and demographic contexts affect the way ethical issues and dilemmas are formulated and justified
3. Obtain all relevant facts
Facts affect the way ethical issues and dilemmas are formulated and justified
4. Reformulate ethical issues and dilemmas if needed
The initial ethical issues and dilemmas may need to be modified or changed on the basis of context and facts
5. Consider appropriate approaches to actions or options
The nature of the ethical issues and dilemmas determines the specific ethical approaches used
6. Make decisions and take action
Professional persons cannot avoid choice and action in applied ethics
7. Evaluate decisions and action
Evaluation determines whether or not the ethical decision-making framework used resulted in morally justified actions related to the ethical issues and dilemmas
TABLE 6-1 Rationale for Steps of Ethical Decision-Making Framework
3. Situations in which the greater community’s values are jeop- ardized by specific ethnic values
4. Situations in which specific ethnic community customs are annoying but not problematic for the greater community Callahan (2000, p. 43) discusses how to judge diversity in the
four situations. In situation 1, he says that “we in America imposed some standards on ourselves for important moral reasons; and there is no good reason to exempt [ethnic] sub- groups from those standards.” For situations 2 and 3, he sug- gests a thoughtful tolerance but also some degree of moral persuasion (not coercion) for ethnic groups to alter values so that they are more in keeping with what is normative in the American culture. However, Callahan says that “in the absence of grievous harm, there is no clear moral mandate to interfere with those values” (p. 43). Finally, regarding situation 4, he believes in moral tolerance of nonthreatening ethnic traditions, because there is no moral mandate to do otherwise.
Second, because decision making is central to the practice of nursing, and many decisions are difficult to make, it is useful to consider experience of ethical or moral distress. Moral or ethical distress occurs when a person is unable to act in a way that he or she thinks is right. You do not feel that you are able to act in a manner consistent with your own values, cultural expectations, and religious beliefs. When this conflict occurs, it can lead to a personal sense of failure in the kind of care you give and to subsequent performance issues and may lead to work and/or career dissatisfaction. However, there are ways to handle moral distress, as by (1) identifying the type(s) of situ- ations that lead to distress; (2) communicating that concern to
125CHAPTER 6 Application of Ethics in the Community
your manager and examining ways to work toward addressing the stressor; or (3) seeking support from colleagues. It is often useful to talk with colleagues. You may learn that they have similar concerns or that they have found ways to interrupt the stressful situation(s) (Carlock and Spader, 2007). Understand- ing both multiculturalism and moral distress aids in making ethical decisions.
Two cases are presented in later sections of the chapter. Examine each using the ethical decision-making processes out- lined in the How To Boxes and the codes of ethics provided in the chapter. These cases provide an excellent opportunity to discuss with classmates your personal beliefs about the applica- tion of ethical processes and to assess your own thoughts, feel- ings, and possible actions. The cases deal with what the nurse’s response should be when (1) the question arises about whether a parent can adequately care for a young child or the child should be removed from the mother, and (2) a client is not able or willing to take personal responsibility and does not want the nurse to report the situation. The Evidence-Based Practice box provides a summary of a research study that examined conflict- ing ethical concerns.
*Moral rules of action that produce the greatest good for the greatest number of communities or populations affected by or most affected by the rules.
HOW TO Apply the Utilitarian Ethics Decision Process 1. Determine moral rules that are important to society and that are
derived from the principle of utility.* 2. Identify the communities or populations that are affected or most
affected by the moral rules. 3. Analyze viable alternatives for each proposed action based on
the moral rules. 4. Determine the consequences or outcomes of each viable alterna-
tive on the communities or populations most affected by the decision.
5. Select the actions on the basis of the rules that produce the greatest amount of good or the least amount of harm for the communities or populations that are affected by the actions. (Remember that the utilitarian ethics decision process is one of
the approaches in step 5 of the generic ethical decision-making framework.)
are general obligations that humans have as members of society. Among these general obligations are not to harm others, to respect others, to tell the truth, and to keep promises. Some- times, however, a situation dictates that a person tell a lie or break a promise because the consequences of telling the truth or keeping the promise may bring about more harm than good. For example, as a nurse you have promised a family that you will visit them at a certain time, but your schedule has gone awry because of unexpected circumstances. One of the other families you visit is in a state of crisis—their adolescent child is suicidal—and your nursing intervention is needed. Most nurses would agree that this is not a good time to keep the original promise. You are morally justified in breaking your promise because you fear that more harm than good would be done if the promise were kept.
This example of promise breaking illustrates several things about ethical thinking. First, ethical judgments are concerned with values. The goal of an ethical judgment is to choose that action or state of affairs that is good or is right in the circum- stances. Second, ethical judgments generally do not have the certainty of scientific judgments. For example, nurses diagnose an ethical situation on the basis of the best available informa- tion and then choose the course of action that seems to provide the best ethical resolution to the situation. In some situations, the decision is based on outcomes or consequences. That approach to ethical decision making is called consequential- ism. It maintains that the right action is the one that produces the greatest amount of good or the least amount of harm in a given situation. Utilitarianism is a well-known consequentialist theory that appeals exclusively to outcomes or consequences in determining which choice to make.
In other situations, nurses touch on options open to funda- mental beliefs. In such circumstances, these nurses may con- clude that the action is right or wrong in itself, regardless of the amount of good that might come from it. This is the position
ETHICS Definition, Theories, Principles Ethics is concerned with a body of knowledge that addresses questions such as the following: How should I behave? What actions should I perform? What kind of person should I be? What are my obligations to myself and to fellow humans? There
Park (2013) developed and evaluated a case-based computer program to teach nursing students to effectively make ethical decisions. She used seven ethical cases chosen from 18 possible cases that were developed by practicing nurses and a six-step Integrated Ethical Decision-Making Model developed by the author. Interviews with the practicing nurses concerned ethical cases they had encountered as well as practical moral issues they had experienced. A total of 251 undergraduate students from three nursing schools used the program in their nursing ethics course. The program used in this study was based on Principles of Biomedical Ethics introduced by Beauchamp and Childress (2008). These principles are discussed in the chapter and they include autonomy, nonmaleficence, beneficence, justice, fidelity, veracity, and confidentiality. A goal of the program was for the students to learn to make an ethical decision justifiable in a real setting by applying ethical knowledge and critical thinking. The six steps of the Integrated Ethical Decision-Making Model were as follows: (1) the identification of an ethical program; (2) the collection of additional information to identify the problem and develop solutions; (3) the development of alternatives for analysis and comparison; (4) the section of the best alternatives and justification; (5) the development of diverse, practical ways to implement ethical decisions and actions; and (6) the evaluation of the effects and development of strate- gies to prevent a similar occurrence of the problem.
The study demonstrated that a case-based computer approach could suc- cessfully replicate real-world ethical case vignettes in a structured decision- making process. The users said the program was helpful to them in ethical decision making.
EVIDENCE-BASED PRACTICE
From Ulrich C, O’Donnell P, Taylor C, et al: Ethical climate, ethics stress, and the job satisfaction of nurse and social workers in the United States, Soc Sci Med 65(8):1708–1719, 2007.
126 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
*In public health nursing client may be a person, group, or community.
Modified from Bateman N: Advocacy Skills for Health and Social Care Professionals. Philadelphia, PA, 2000, Jessica Kingsley, p 63.
Respect for autonomy: Based on human dignity and respect for individuals, autonomy requires that individuals be permitted to choose those actions and goals that fulfill their life plans unless those choices result in harm to another.
Nonmaleficence: Nonmaleficence requires that we do no harm. It may be impossible to avoid harm entirely, but this principle requires that health care professionals act according to the standards of due care, always seeking to produce the least amount of harm possible.
Beneficence: This principle is complementary to nonmaleficence and requires that we do good. We are limited by time, place, and talents in the amount of good we can do. We have general obligations to perform those actions that maintain or enhance the dignity of other persons whenever those actions do not place an undue burden on health care providers.
Distributive justice: Distributive justice requires that there be a fair distribu- tion of the benefits and burdens in society based on the needs and contribu- tions of its members. This principle requires that, consistent with the dignity and worth of its members and within the limits imposed by its resources, a society must determine a minimal level of goods and services to be available to its members.*
BOX 6-2 Ethical Principles
known as deontology. It is based on the premise that persons should always be treated as ends in themselves and never as mere means to the ends of others. Deontological theory is often called nonconsequentialist. It is a “theory of duty holding that some features of actions other than or in addition to con- sequences make actions right or wrong” (Beauchamp and Childress, 2013, p. 361).
HOW TO Apply the Principlism Ethics Decision Process 1. Determine the ethical principles (respect for autonomy, nonma-
leficence, beneficence, justice) that are relevant to an ethical issue or dilemma.
2. Analyze the relevant principles within a meaningful context of accurate facts and other pertinent circumstances.
3. Act on the principle that provides, within the meaningful context, the strongest guide to action that can be morally justified by the tenets foundational to the principle. (Remember that the principlism ethics decision process is one
of the approaches in step 5 of the general ethical decision-making framework.)
Childress (2013). This approach to ethical decision making in health care arose in response to life-and-death decision making in acute care settings, where the question to be resolved tended to concern a single localized issue such as the withdrawing or withholding of treatment (Holstein, 2001). In these circum- stances, preserving and respecting a client’s autonomy became the dominant issue. According to Beauchamp and Childress (2013), these four clusters of moral principles are central to the field of biomedical ethics. Principles are more general guides than are rules. Principlism is a “theory about how prin- ciples link to and guide practice” (Beauchamp and Childress, 2013, p. 25).
Despite its success as a basis for analysis in bioethics, prin- ciplism has come under attack (e.g., Callahan, 2000, 2003; Walker, 2009), and there are grounds for the criticism. First, the principles are said to be too abstract and narrow to serve as guides for action. Second, the principles themselves can conflict in a given situation, and there is no independent basis for resolving the conflict. Third, some persons claim that effective ethical problem solving must be rooted in concrete, individual experiences. Fourth, ethical judgments are alleged to depend more on the judgment of sensitive persons than on the applica- tion of abstract principles. The How To Box below can serve as a guide for how to use the principlism ethics decision process.
HOW TO Apply the Deontological Ethics Decision Process 1. Determine the moral rules (e.g., tell the truth) that serve as
standards by which individuals can perform their moral obligations.
2. Examine personal motives for proposed actions to ensure that they are based on good intentions in accord with moral rules.
3. Determine whether the proposed actions can be generalized so that all persons in similar situations are treated similarly.
4. Select the action that treats persons as ends in themselves and never as mere means to the ends of others. (Remember that the deontological ethics decision process is one
of the approaches in step 5 of the generic ethical decision-making framework.)
The dominance of the principle of respect for autonomy has been challenged by critics concerned about decision making in non–acute care settings, where the ethical decision is more likely to be about, for example, long-term care or access to health care for persons of diverse cultures (Callahan and Jennings, 2002; Walker, 2009). Thus, whereas autonomy may be stressed in acute care settings, an overemphasis on autonomy may inhibit ethical decisions in public health. In public health, beneficence and distributive justice are frequently a greater issue than autonomy. For this reason, it is useful to look at other models for ethical decision making, including models that expand the focus of nursing beyond the individual nurse-client relation- ship to the social environment and systems that impact health care (Bekemeier and Butterfield, 2005).
Utilitarianism and deontology were developed from the Age of Enlightenment’s focus on universals, rationality, and isolated individuals. Each theory maintains that there is a universal first
Members of the health professions have specific obligations that exist because of the practices and goals of the profession. These health care obligations have been interpreted in terms of a set of principles in bioethics. The primary principles are respect for autonomy, nonmaleficence, beneficence, and dis- tributive justice as shown in Box 6-2. These principles are “general guidelines for the formulation of more specific rules” (Beauchamp and Childress, 2013, p. 13). This approach has been called principlism, and is clearly discussed in the seventh edition of Principles of Biomedical Ethics by Beauchamp and
127CHAPTER 6 Application of Ethics in the Community
principle—the principle of utility for utilitarianism and the categorical imperative for deontology—that serves as a rational norm for our behavior and allows us to calculate the rightness or wrongness of each individual action. Both utilitarianism and deontology also follow the lead of classic liberalism in asserting that the individual is the special center of moral concern (Stein- bock et al, 2008). Giving priority to individual rights and needs means that these should not be sacrificed for the interests of society (Steinbock et al, 2008). The focus on individual rights leads to complications in the interpretation of distributive or social justice.
Public health ethics rests on a set of general moral consider- ations. Bernheim and colleagues (2015, p. 21) identify nine moral considerations in public health: (1) producing benefits; (2) avoiding, preventing, and removing harms; (3) producing the maximal balance of benefits over harms and other costs (often called utility); (4) distributing benefits and burdens fairly (distributive justice); (5) respecting autonomous choices and actions, including liberty of actions; (6) protecting privacy and confidentiality; (7) keeping promises and commitments; (8) disclosing information as well as speaking honestly and truth- fully (often grouped under transparency); and (9) building trust. These nine moral considerations in public health nursing are easy to apply. Distributive justice, or social justice, refers to the allocation of benefits and burdens to members of society. Benefits refer to basic needs, including material and social goods, liberties, rights, and entitlements. Wealth, education, and public services are benefits. Burdens include such things as taxes, military service, and the locations of incinerators and power plants. Justice requires that the distribution of benefits and burdens in a society be fair or equal. There is wide agree- ment that the distribution should be based on what one needs and deserves, but there is considerable disagreement as to what these terms mean. Three primary theories of distributive justice that are defended today include egalitarian, libertarian, and liberal democratic theories.
Egalitarianism is the view that everyone is entitled to equal rights and equal treatment in society. Ideally, each person has an equal share of the goods of society, and it is the role of gov- ernment to ensure that this happens. The government has the authority to redistribute wealth if necessary to ensure equal treatment. Thus, egalitarians are supportive of welfare rights— that is, the right to receive certain social goods necessary to satisfy basic needs, including adequate food, housing, educa- tion, and police and fire protection. The weaknesses of egali- tarianism are both practical and theoretical. It would be practically impossible to ensure the equal distribution of goods and services in any moderately complex society. Assuming that such a distribution could be accomplished, it would require a coercive authority to maintain it (Coursin, 2009; Hellsten, 1998). Further, egalitarianism is unable to provide any incentive for each of us to do our best, because there is no promise of our merit being rewarded.
The libertarian view of justice holds that the right to private property is the most important right. Libertarians recognize only liberty rights—the right to be left alone to accomplish our goals. Hellsten (1998, p. 822) notes, “The central feature of the
libertarian view on distributive justice is that it is totally indi- vidualist. It rejects any idea that societies, states, or collectives of any form can be the bearers of rights or can owe duties.” Libertarians see a limited role for government, namely, the pro- tection of property rights of individual citizens through provid- ing police and fire protection. While they also concede the need for jointly shared, publicly owned facilities such as roads, they reject the idea of welfare rights and view taxes to support the needs of others as coercive taking of their property. Given the libertarian rejection of the priority of the state, however, it is not clear where the right to property originates (Hellsten, 1998).
The work of John Rawls (2001) represents the liberal demo- cratic theory. Rawls attempts to develop a theory that values both liberty and equality. He acknowledges that inequities are inevitable in society, but he tries to justify them by establishing a system in which everyone benefits, especially the least advan- taged. This is an attempt to address the inequalities that result from birth, natural endowments, and historic circumstances. Imagining what he calls a “veil of ignorance” to keep us unaware of our actual advantages and disadvantages, Rawls would have us choose the basic principles of justice (p. 15). Once impartial- ity is guaranteed, Rawls (2001, p. 42) maintains that all rational people will choose a system of justice containing the following two basic principles:
Each person has the same indefeasible claim to a fully ade- quate scheme of equal basic liberties, which scheme is com- patible with the same scheme of liberties for all; and social and economic inequalities are to satisfy two conditions: first, they are to be attached to offices and positions open to all under conditions of fair equality of opportunity; and second, they are to be to the greatest benefit of the least advantaged members of society (the difference principle).
As the veil of ignorance and the justice principles indicate, Rawls and other justice theorists all assume the Enlightenment concept of isolated, atomic selves in competition for scarce resources. The significance of justice, then, becomes the assur- ance of fairness to individuals. Violating the dictates of distribu- tive justice is an offense to the dignity of the collective preferences of autonomous, rational moral agents. The interests of the com- munity may be in conflict with the interests of individuals; yet, confined to the Enlightenment ideal, the needs of society are not directly addressed, nor is society given any priority.
This Enlightenment assumption has been challenged by a number of ethical theories loosely grouped together under the heading communitarianism. The dominant themes of com- munitarianism are that individual rights need to be balanced with social responsibilities; individuals do not live in isolation but are shaped by the values and culture of their communities (Wringe, 2006). Among the theories with a communitarian focus are virtue ethics, caring and the ethic of care, and feminist ethics.
Virtue Ethics Virtue ethics is one of the oldest ethical theories; it belongs to a tradition dating back to the ancient Greek philosophers Plato and Aristotle. It is not concerned with actions, as utilitarianism
128 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
and deontology are, but instead asks: What kind of person should I be? The goal of virtue ethics is to enable persons to flourish as human beings. According to Aristotle, virtues are acquired, excellent traits of character that dispose humans to act in accord with their natural good. During the seventeenth and eighteenth centuries, the Greek concept of the good as a principle of explanation went out of favor. In public health nursing the virtue of care, or caring, is central to professional ethics. “The ethics of care emphasizes traits valued in intimate personal relationships such as sympathy, compassion, fidelity and love” (Beauchamp and Childress, 2013, p. 35). Caring refers to the “emotional commitment to, and willingness to act on behalf of, persons with whom one has a significant relationship” (Beauchamp and Childress, 2013, p. 35). Beauchamp and Chil- dress (2013) examine five focal virtues for health professionals. They are (1) compassion, which focuses on the pain, suffering, disability, and misery of another person; (2) discernment, which involves the ability to use sensitive insight, astute judg- ment, and understanding to make good decisions; (3) trustwor- thiness, which is essential in health care when clients put themselves in the hands of others; (4) integrity, with a differen- tiation between moral integrity and professional integrity; and (5) conscientiousness, which is the character trait of acting to achieve what one believes to be the right thing to do given the circumstances. The appeal to virtues results in a significantly different approach to moral decision making in health care (Olson, 2008). In contrast to moral justification via theories or principles, the emphasis is on practical reasoning applied to character development.
HOW TO Apply the Care Ethics Decision Process 1. Recognize that caring is a moral imperative. 2. Identify personally lived caring experiences as a basis for relating
to self and others. 3. Assume responsibility and obligation to promote and enhance
caring in relationships. (Remember that the care ethics decision process is one of the
approaches in step 5 of the generic ethical decision-making framework.)
technological advances in health care science and to the desire of nurses to differentiate nursing practice from medical prac- tice. The discussion of the centrality of caring to nursing is reflected in Eriksson’s (2002) work on a caring science theory, which she sees as ethical in its essence. Proponents of caring support its premises; its detractors believe that nursing is not the only essentially caring profession and that caring, when placed within a broader societal context, represents the use of a disempowering concept to identify the essence of nursing. However, most nurses, including those who work in the com- munity, would agree that there is a relationship between caring and ethics or morality.
Modified from Volbrecht RM: Nursing Ethics: Communities in Dialogue. Upper Saddle River, NJ, 2002, Prentice Hall, p 138.
HOW TO Apply the Virtue Ethics Decision Process 1. Identify communities that are relevant to the ethical dilemmas
or issues. 2. Identify moral considerations that arise from a communal per-
spective and apply the consideration to specific communities. 3. Identify and apply virtues that facilitate a communal
perspective. 4. Modify moral considerations as needed to apply to the specific
ethical dilemmas or issues. 5. Seek ethical community support to enhance character
development. 6. Evaluate and modify the individual or community character traits
that impede communal living. (Remember that the virtue ethics decision process is one of the
approaches in step 5 of the generic ethical decision-making framework.)
Carol Gilligan (1982) and Nel Noddings (1984) are often associated with the ethic of care. Gilligan (1982) speaks of a personal journey wherein, by listening and talking to people, she began to notice two distinct voices about morality and two ways of describing the interpersonal relationships between self and others. Contrary to what has been written about Gilligan and the two distinct voices (i.e., male and female) related to moral judgment, here is what she actually wrote: “The different voice I describe is characterized not by gender [italics added] but theme. Its association with women is an empirical observation, and it is primarily through women’s voices that I trace its devel- opment. But this association is not absolute, and the contrasts between male and female voices are presented here to highlight a distinction between two modes of thought and to focus [on] a problem of interpretation rather than to represent a general- ization about either sex” (Gilligan, 1982, p. 2). Her 1982 book is based on three qualitative studies about conceptions of morality and self and about experiences of conflict and choice. She discovered what she calls the “voice of care” through inter- views with girls and women (Beauchamp and Childress, 2013). She identified two modes of moral thinking: an ethic of care and an ethic of rights and justice. Although she did not say that these two modes correlated with gender, she did maintain that men tended to be involved with the ethic of rights and justice whereas women were more likely to affirm an ethic of care centering on responsiveness in “an interconnected network of needs, care, and prevention of harm” (Beauchamp and Childress, 2013, p. 35). From these studies she formulated her basic premises about responsibility, care, and relationships. These premises, in Gilligan’s (1982) own voice, are as follows: • “Sensitivity to the needs of others and the assumption of
responsibility for taking care lead women to attend to voices other than their own” (p. 16).
Caring and the Ethic of Care Caring in nursing, the ethic of care, and feminist ethics are all interrelated and, historically, all converged between the mid- 1980s and early 1990s. Seminal work in caring in nursing was done by nurse-scholars (e.g., Leininger, 1984; Watson, 2007), who wrote about caring as the essence of or the moral ideal of nursing. This conceptualization occurred as a response to the
129CHAPTER 6 Application of Ethics in the Community
HOW TO Apply the Feminist Ethics Decision Process 1. Identify the social, cultural, legal, political, economic, environ-
mental, and professional contexts that contribute to the identi- fied problem (e.g., underrepresentation of women in clinical trials).
2. Evaluate how the preceding contexts contribute to the oppres- sion of women.
3. Consider how women’s lives are defined by their status in sub- ordinate social groups.
4. Analyze how social practices marginalize women. 5. Plan ways to restructure those social practices that oppress
women. 6. Implement the plan. 7. Evaluate the plan and restructure it as needed.
(Remember that the feminist ethics decision process is one of the approaches in step 5 of the generic ethical decision-making framework.)
Modified from Volbrecht RM: Nursing Ethics: Communities in Dialogue. Upper Saddle River, NJ, 2002, Prentice Hall, p 219.
• “Women not only define themselves in a context of human relationships but also judge themselves in terms of their ability to care” (p. 17).
• “The truths of relationship, however, return in the rediscov- ery of connection, in the realization that self and other are interdependent and that life, however valuable in itself, can only be sustained by care in relationships” (p. 127). Noddings’ (1984) personal journey started at a point differ-
ent from that of Gilligan’s. Noddings noticed that ethics was described in the literature primarily on the basis of principles and logic. The goal for Noddings’ book, therefore, was to express a feminine view that could be accepted or rejected by women or men.
The basic premises of Noddings (1984), in her own voice, are as follows: • “The essential elements of caring are located in the relation
between the one caring and the cared-for” (p. 9). • “Caring requires me to respond with an act of commitment:
I commit myself either to overt action on behalf of the cared- for or I commit myself to thinking about what I might do” (p. 81).
• “We are not ‘justified’—we are obligated—to do what is required to maintain and enhance caring” (p. 95).
• “Caring itself and the ethical ideal that strives to maintain and enhance it guide us in moral decisions and conduct” (p. 105). What both Gilligan and Noddings have in common has been
called a feminine ethic, because they believe in the morality of responsibility in relationships that emphasize connection and caring. To them, caring is not a mere nicety but a moral impera- tive. Nevertheless, a long-term healthy debate has surrounded their premises.
feminist ethics are relevant to public health. Rogers notes that a feminist perspective leads us to think critically about connec- tions among gender, disadvantage, and health, as well as the distribution of power in public health processes. Because these issues affect health, feminist perspectives and approaches are important for nursing practice.
What is meant by feminists and feminist ethics? Feminists are women and men who hold a worldview advocating economic, social, and political equality for women that is equiv- alent to that of men. Consequently, feminists reject the devalu- ing of women and their experiences through systematic oppression based on gender. In analyzing the common good, feminists pay careful attention to power relations that constitute a community, to the rules that regulate it, and to who pays and who benefits from membership in the community (Rogers, 2006). Feminists also can ascribe to the ethic of care.
Feminist ethics encompasses the tenets that women’s think- ing and moral experiences are important and should be taken into account in any fully developed moral theory, and that the oppression of women is morally wrong. Study of feminist ethics entails knowledge about and critique of classical ethical theories developed by men as well as ethical theories developed by women. Study of feminist ethics includes knowledge about the social, cultural, political, legal, economic, environmental, and professional contexts that insidiously and overtly oppress women as individuals, or within a family, group, community, or society. Feminists and persons who ascribe to feminist ethics are not passive; they demand social justice and political action, preferably at the societal level and through legislation.
ETHICS AND THE CORE FUNCTIONS OF POPULATION-CENTERED NURSING PRACTICE The three core functions of public health nursing (i.e., assess- ment, policy development, and assurance) are discussed in Chapter 1. This discussion, however, did not stress the basic assumption that public health nursing is an ethical endeavor, with moral leadership at its core. Now the links of these three core functions to ethics are described.
Assessment To review, “assessment refers to systematically collecting data on the population, monitoring the population’s health status, and making information available about the health of the com- munity” (see Chapter 1). Three ethical tenets underlie this core function. The first relates to competency related to knowledge development, analysis, and dissemination. An ethical question related to competency is: Are the persons assigned to develop community knowledge adequately prepared to collect data on groups and populations? This question is important because the research, measurement, and analysis techniques used to gather information about groups and populations usually differ from the techniques used to assess individuals. Wrong research techniques can lead to wrong assessments, which in turn may hurt rather than help the intended group or population. A startling example of this is the case of Henrietta Lacks, whose cancerous cervical cells were taken without her or her family’s
Feminist Ethics Although feminist ethics finally has entered nursing, for many years, nurses appeared reluctant to embrace feminism and its ethics (Silva, 2008). According to Rogers (2006), the tenets of
130 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
knowledge or permission and have now launched a medical revolution and a multimillion-dollar industry as the HeLa cells used in countless medical experiments (Skloot, 2010).
The second ethical tenet relates to virtue ethics or moral character. An ethical question related to moral character is: Do the persons selected to develop, assess, and disseminate com- munity knowledge possess integrity? Beauchamp and Childress (2013) define integrity as the holistic integration of moral char- acter. The importance of this virtue is self-evident: without integrity, the core function of assessment is endangered. Persons with compromised integrity are easy prey for potential or real scientific misconduct. An example of a failure of integrity for nurses would be bias in collecting or reporting based on racism or homophobic grounds.
The third ethical tenet relates to “do no harm.” An ethical question related to “do no harm” is: Is disseminating appropriate information about groups and populations morally necessary and sufficient? The answer to “morally necessary” is yes, but to “morally sufficient,” it is no. The fallacy with dissemination is that there is no built-in accountability that what is disseminated will be read or understood. If not read or understood, harm could come to groups and populations regarding their health status.
Policy Development To review, “policy development refers to the need to provide leadership in developing policies that support the health of the population, including the use of the scientific knowledge base in making decisions about policy” (see Chapter 1). At least three ethical tenets underlie this core function. First, an important goal of both policy and ethics is to achieve the public good (Silva, 2002). Denhardt and Denhardt (2000), Rogers (2006), and Ruger (2008) among others say that the concept of “the public good” is rooted in citizenship. For example, Denhardt and Denhardt (2000) view citizenship, or what they call “demo- cratic citizenship” (p. 552), as a stance in which citizens play a more substantial role in policy development. For this to occur, citizens must be willing to be both informed about policy, and to do what is in the best interests of the community. The approach is basically one in which the voice of the community is the foundation on which policy is developed, rather than the voice of community and public health administrators.
The second ethical tenet purports that service to others over self is a necessary condition of what is “good” or “right” policy (Silva, 2002). Denhardt and Denhardt (2000) offer three per- spectives on this matter: • Serve rather than steer. An increasingly important role of the
public servant (e.g., nurses and administrators) is to help citi- zens articulate and meet their shared interests rather than to attempt to control or steer society in new directions (p. 553).
• Serve citizens, not customers. The public interest results from a dialogue about shared values rather than the aggregation of individual self-interests. Therefore, public servants do not merely respond to the demands of “customers” but focus on building relationships of trust and collaboration with and among citizens (p. 555).
• Value citizenship and public service above entrepreneurship. The public interest is better advanced by public servants and
citizens committed to making meaningful contributions to society rather than by entrepreneurial managers acting as if public money were their own (p. 556). Service is at the core of these three perspectives, and service
has always been one of the enduring values of nursing. The third ethical tenet holds that what is ethical is also good
policy (Silva, 2002). What is ethical should be the singular foun- dational pillar on which nursing is based. Moral leadership is critical to policy development because it is the highest human standard and therefore should result in ethical health care policies.
Assurance To review, “assurance refers to the role of public health in ensuring that essential community-oriented health services are available, which may include providing essential personal health services for those who would otherwise not receive them. Assur- ance also refers to making sure that a competent public health and personal health care workforce is available” (see Chapter 1). At least two ethical tenets underlie this core function.
The first purports that all persons should receive essential personal health services or, put in terms of justice, “to each person a fair share” or, reworded, “to all groups or populations a fair share.” This is an egalitarian perspective of justice. This perspective does not mean that all persons in a society should share all of society’s benefits equally, but that they should share at least those benefits that are essential. People who see justice as fairness often think that basic health care for all is essential for social justice within a society. The case in Box 6-3 provides an example where the nurse needs to balance the client’s right to autonomy and the principle of distributive justice.
The second ethical tenet purports that providers of public health services be competent and available. Although the Public Health Code of Ethics (Public Health Leadership Society [PHLS], 2002) does not speak directly to workforce availability, it does speak directly to ensuring professional competency of public health employees. In addition to the Public Health Code of Ethics, the Healthy People 2020 objectives (U.S. Department of Health and Human Services [USDHHS], 2010) addresses competencies and workforce needs; a new objective (HP 2020-6) calls for an increased number of health care professionals certi- fied in geriatrics.
The Healthy People 2020 objectives address the need for all public health workers not only to have knowledge of public health, but also to have additional competencies as needed to fulfill their job responsibilities. Specific areas of knowledge include information technology, biostatistics, environmental health, cultural and linguistic competence, and genomics. The objectives also address needs of future public health leaders, who must be educated to meet new challenges in health care. Emphasis is also given to the availability and provision of life- long learning opportunities for public health employees.
NURSING CODE OF ETHICS As noted in the history section of this chapter, the Code of Ethics for Nurses with Interpretive Statements was adopted by
131CHAPTER 6 Application of Ethics in the Community
Created by Mary E. Gibson, Assistant Professor, School of Nursing, University of Virginia.
Amelia Lewis, a 31-year-old African American woman with multiple mental health diagnoses, has been monitored in the local mental health system for over 10 years. She is the mother of Tyesha, who is 3 years old. Multiple agencies have monitored Ms. Lewis and her little girl, who live in a sparsely furnished apartment in subsidized housing. A guardian handles all of Ms. Lewis’s financial affairs. Ms. Lewis’s relationship with the father of Tyesha has deteriorated, and he does not live with her.
Ms. Lewis has issues of trust, and she is often suspicious of the care providers who come to her home. She does rely on some of the professionals with whom she interacts on a weekly or biweekly basis. She is both cognitively delayed and suffers from schizophrenia. Her developmental level places her at a stage at which her own needs are her primary focus, and this is not expected to change; her interaction with Tyesha is perfunctory, involving little outward affection. She is unable to understand that Tyesha is not capable of self-care and that her 3-year-old child will not always obey when Ms. Lewis instructs her to do something. Tyesha’s needs, level of functioning, and cognitive development are quickly surpassing her mother’s ability to cope. Frustration and misunderstanding ensue when Ms. Lewis thinks that Tyesha does not listen to her, and encouragement and parent education have done little to improve the situation as Tyesha gets older and more assertive. This has made toilet training, provision of an appropriate diet, and other aspects of normal child care problematic.
Many services besides those for mental health are involved to help this family of two cope. There is concern about abuse or neglect of Tyesha due to Ms. Lewis’s lack of understanding of how to be a parent. Supplemental Security Income provides monetary support because of her mental disability and they have Medicaid coverage for their health care needs, as well as food stamps and modest financial assistance through Temporary Assistance for Needy Families (TANF). Ms. Lewis cannot currently work and take care of her child due to her mental disability. Before Tyesha’s birth, Ms. Lewis held a job and maintained self-care, but the care of Tyesha has precluded her managing employment at this time. Child Protective Services are also monitoring Ms. Lewis’s situation to
determine to what extent she can meet the needs of her child. Ms. Lewis attends a local program to complete her General Education Development (GED), which provides child care during the day. Though Ms. Lewis is not expected to com- plete her GED, this program provides structured time for Tyesha three times a week. The child is considered developmentally normal at this time, and an infant development program monitors her progress on developmental issues. The Child Health Partnership, an agency that addresses the needs of challenged families, provides regular visits, family support, and parenting education, and the GED teachers make regular home visits to check on Ms. Lewis and Tyesha. Ms. Lewis thinks things are going just fine.
The Child Health Partnership nurse is concerned about this family and thinks that some permanent resolution of the situation is inevitable. There is minimal coordination of services and there is no “lead agency” in the family’s care. Choose one of the ethical decision processes or one set of code of ethics dis- cussed in the chapter and discuss and debate these questions: 1. Should the nurse involved in the Child Health Partnership program initiate
any action to try to coordinate the work of the many agencies involved with this family?
2. Who has a professional responsibility to determine when the mother can no longer cope with the developing child?
3. Whose needs, Ms. Lewis’s or Tyesha’s, should take precedence? 4. Using one of the ethics decision processes, analyze the role of the nurse in
this situation. For example, considering the utilitarian ethics decision process, decide if it is morally right for you to take the child away from the mother? If you do this, what are the implications for the mother, the child, and the community? What would be the possible consequences of removing the child? Of not removing the child? What principles can best guide your decision making? What possible moral dilemmas will you experience?
5. Safety is a core concept of public health nursing. Using two of the six quality and safety competences (patient-centered care and safety) for nurses identi- fied in the Quality and Safety Education for Nurses (QSEN) work, develop a plan of action for the nurse who is caring for this family.
BOX 6-3 Case #1: Autonomy and Distributive Justice
the ANA House of Delegates in 2001. The Code was revised in 2015 and consists of nine provisions and the accompanying interpretive statements. The Code provides the following: • A succinct statement of the ethical values, obligations and
duties of every individual who enters the nursing profession • Serves as the profession’s nonnegotiable ethical standard • Expresses nursing’s own understanding of its commitment
to society (p. 5) These purposes are reflected in the nine provisional state-
ments of the code. The Code of Ethics for Nurses and its inter- pretive statements apply to population-centered nurses, although the emphasis for each type of nursing sometimes varies (for the ANA Code of Ethics for Nurses, see http://www.nursingworld.org/MainMenuCategories/Ethics Standards/CodeofEthicsforNurses.aspx).
As previously noted, the American Nurses Association has produced a Guide to the Code of Ethics for Nurses: Interpretation and Application, which serves as a companion reader to the 2001 Code of Ethics for Nurses (Fowler, 2008). This reader contains specific applications to nursing practice for each of the code’s nine interpretive statements.
Whereas provisions 1 through 3 focus on the recipients of nursing care, provisions 4 through 6 focus on the nurse. This
focus addresses nurses’ accountability, competency, and contri- butions to their employment conditions.
Provisions 7 through 9 focus on the bigger picture of both the nursing profession and national and global health concerns. Regarding the nursing profession, the emphasis is on professional standards, active involvement in nursing, and the integrity of the profession. All nurses have a responsibility to meet these obliga- tions. Regarding national and global health concerns, the empha- sis is on social justice and reform. According to the ANA code (2015, p xi), The Code specifies that the patients and clients of nurses can be “individuals, families, communities or popula- tions.” The Code also specifies that health is a universal right and this right has economic, political, social and cultural dimensions. Many of the components of the Code support and help to elabo- rate on the ethical responsibilities related to chapters and content throughout the text such as genomics, social determinants of health, cultural uniqueness and so forth, the Levels of Prevention box presents actions related to ethics.
PUBLIC HEALTH CODE OF ETHICS The Public Health Code of Ethics (PHLS, 2002) mentioned in the history section of this chapter consists of a preamble; 12
132 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
From U.S. Department of Health and Human Services: Healthy People 2020. Retrieved December 2014 from http://www.healthypeople.gov.
HEALTHY PEOPLE 2020
There are two new objectives outlined in Healthy People 2020 related to access to health services: • AHS-1: Increasing the proportion of persons who receive appropriate
evidence-based clinical preventive services • AHS-4: Increasing the proportion of practicing primary care providers,
including nurse practitioners. Both of these objectives relate to access to care and reflect important ethical
considerations for nurses.
principles related to the ethical practice of public health (Box 6-4); 11 values and beliefs that focus on health, commu- nity, and action; and a commentary on each of the 12 principles. The preamble asserts the collective and societal nature of public health to keep people healthy. The 12 principles incorporate the ethical tenets of preventing harm; doing no harm; promot- ing good; respecting both individual and community rights; respecting autonomy, diversity, and confidentiality when pos- sible; ensuring professional competency; manifesting trustwor- thiness; and promoting advocacy for disenfranchised persons within a community. Examples of values and beliefs include a right to health care resources, the interdependency of humans living in the community, and the importance of knowledge as a basis for action. The Healthy People box cites two new objec- tives that relate to ethics.
When the Code of Ethics for Nurses and the Public Health Code of Ethics are assessed, some commonalities emerge. These codes provide general ethical principles and approaches that are both enduring and dynamic. They guide nurses and public health personnel in thinking about the underlying ethics of their profession. Although the two codes do not specify
LEVELS OF PREVENTION
Primary Prevention Use the Code of Ethics for Nurses to guide your nursing practice.
Secondary Prevention If you are unable to behave in accordance with the Code of Ethics for Nurses (e.g., you speak in a way that does not communicate respect for a client), take steps to correct your behavior. You could explain to the client your error and apologize.
Tertiary Prevention If you have treated a client or staff member in a way that is inconsistent with ethics practices, seek guidance on other choices you could have made.
Ethics
(nor should they specify) details for every ethical issue, other mechanisms such as standards of practice, ethical decision- making frameworks, and ethics committees help work out the details. Nevertheless, the preceding two codes address most approaches to ethical justification, including traditional and emerging ethical theories and principles, humanist and feminist ethics, virtue ethics, professional-individual and/or community relationships, and advocacy. Many websites provide further information on codes of ethics and other ethical concerns in public health; all can be accessed through the WebLinks section of this book’s Evolve website. Some of them are noted in the Additional Resources feature at the beginning of the chapter.
ADVOCACY AND ETHICS Advocacy is an important concept in nursing that embodies an ethical focus grounded in quality of life. The American Public Health Association (APHA) represents a powerful voice for public health advocacy, focusing on finding ways to involve health care professionals in influencing policies related to pro- tection of all Americans and their communities from prevent- able, serious health threats and helping to ensure access to health care and eliminating health disparities (APHA, 2014).
*A section of the Public Health Code of Ethics is presented.
1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that respects the rights of individuals in the community.
3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from com- munity members.
4. Public health should advocate and work for the empowerment of disenfran- chised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.
5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.
6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.
7. Public health institutions should act in a timely manner on the information they have, within the resources and the mandate given to them by the public.
8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.
9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.
10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.
11. Public health institutions should ensure the professional competencies of their employees.
12. Public health institutions and their employees should engage in collabora- tions and affiliations in ways that build the public’s trust and the institution’s effectiveness.
BOX 6-4 Principles of the Ethical Practice of Public Health*
Reprinted with permission from the Public Health Leadership Society: Public Health Code of Ethics, American Public Health Association (APHA), 2002. Available at http://phls.org/CMSuploads/Principles-of-the-Ethical-Practice-of-PH-Version-2.2-68496.pdf.
133CHAPTER 6 Application of Ethics in the Community
Created by Deborah C. Conway, Assistant Professor of Nursing, School of Nursing, University of Virginia.
Because finding affordable housing was difficult, 26-year-old Terry White lived with her 6-month-old son, Tommy, and his father, Billy Smith, in one room of the landlord’s own house. Ms. White was morbidly obese and was diagnosed with bipolar disease; Mr. Smith had served time for drug dealing and was out on parole and staying straight. Neither had finished high school. Mr. Smith’s past drug use had rendered him unable to do much manual labor because of heart damage, but on occasion he would work in construction to support the family.
Public health nurse Jim Lewis had received a referral on Tommy when he was diagnosed with failure to thrive (FTT) 2 months earlier. Ms. White, who had had two children removed from her custody by Child Protective Services (CPS) in the past, and Mr. Smith seemed to adore their baby, so much so that Ms. White would hold the baby all day long. In the past 2 months, the nurse had taught Ms. White about infant nutrition and gotten her enrolled in the Women, Infants, and Children (WIC) nutrition program; as a result, Tommy had increased his rate of physical growth and was above the 5% level of his growth percentile. Yet he was not meeting his gross motor milestones per Denver Developmental Screening Test II (DDST II) testing. Mr. Lewis thought that Tommy was not allowed to play on the floor enough to progress in sitting, pushing his shoulders up, or crawling. Most of their small room was taken up with the bed and the boxes that stored their belongings. There wasn’t really space for “tummy time” or play. When not in the room, the family would take the bus to a discount store and spend the day walking around to get a change of scene.
One week Ms. White told the nurse she was not taking her medications for bipolar disease anymore because they caused her to gain weight. The next week she confided that Mr. Smith had had a “dirty” urine specimen check and would have to return to prison in the near future. The following week Mr. Lewis found
the family living in a run-down motel since their landlord evicted them following a disagreement. Ms. White was agitated and told the nurse that they had only $100. Mr. Smith was going to have to return to prison that week, and the motel bill was already $240. Ms. White knew she would be homeless soon without Mr. Smith’s support but refused to talk with her social worker about her needs. She asked the nurse not to tell anyone about her situation because she was afraid CPS would take Tommy from her. It was clear to Mr. Lewis that Ms. White might not know what would happen to Tommy after they left this motel. 1. Considering the principle of truth telling, what are Mr. Lewis’ professional
responsibilities to Ms. White, to Tommy, and to the social worker assigned to this family?
2. Using the generic ethical decision-making framework discussed earlier in the chapter and considering the deontological ethical decision-making process, answer the following questions. A. How should Mr. Lewis respond to Ms. White’s request to not tell anyone
about their situation? B. What communication, about truth telling, if any, should the nurse initiate
with the social worker? With others? C. Consistent with the principle of truth telling, how can the nurse involve
Mr. Smith in the ongoing support and involvement with his family? 3. Using virtue ethics, what actions would you take to resolve any moral dilem-
mas you have about the safety of Tommy in this family situation? If you do not tell anyone about the possible dangers to the child, what moral principles come into play? If you do tell the social worker about the situation and the child is removed from the mother, what moral principles come into play for you?
4. What ethical dilemmas may you experience if you are the nurse in this case? How can you deal effectively with these potential dilemmas?
BOX 6-5 Case #2: Applying Virtue Ethics, Truth Telling, and the Deontological Ethical Decision-Making Process
The APHA notes the critical need to shift from a nation focused on treating individual illness to one that also promotes population-based health services that encourage preventive and early intervention practices. Also, the field of genetics has increasingly become an important ethical focus in public health; two new Healthy People 2020 objectives relate to genomics (G HP2020-1, G HP2020-2). The clinical case in Box 6-5 discusses the applicatioin of virtue ethics, truth telling and the deonto- logical ethical decision-making process.
Codes and Standards of Practice Several codes and standards of practice address advocacy. Four are noted here. Advocacy is addressed in codes of ethics put forth by the ANA (2015) and the Public Health Leader- ship Society (PHLS, 2002), as well as by the ANA (2013) in Standard 17, Public Health Nursing: Scope & Standards of Practice and the PHLS Skills for the Ethical Practice of Public Health (Thomas, 2004). The American Association of Col- leges of Nursing (AACN) has developed a document entitled Recommended Baccalaureate Competencies and Curricular Guidelines for Public Health Nursing that added specific public health nursing education competences to their competencies for baccalaureate education. Several of the competencies include a recommendation to include specific content related to ethics and public health nursing (AACN, 2013).
According to the ANA (2015) Code of Ethics for Nurses, “The nurse promotes, advocates for, and protects the rights, health, and, safety of the patient” (p. 9). The focus of the inter- pretive statements regarding advocacy is the nurse’s responsibil- ity to take action when the client’s best interests are jeopardized by questionable practice on the part of any member of the health team, the health care system, or others.
The Public Health Code of Ethics (PHLS, 2002) and the PHLS Skills for the Ethical Practice of Public Health (Thomas, 2004) state that public health should advocate for disenfran- chised community members, aiming to ensure that the basic resources necessary for health are accessible to all. The PHLS’s code addresses two important issues: that the voice of the com- munity should be heard and that the marginalized or under- served in a community should receive “a decent minimum” (p. 4) of health resources.
According to the ANA Public Health Nursing: Scope & Stan- dards of Practice (2013), public health nurses have a moral mandate to establish ethical standards when advocating for health care policy. Specifically, Standard 7 says that public health nurses should practice ethically.
Conceptual Framework for Advocacy One framework that can be used to define helpful behaviors for advocacy is to contrast social justice and market justice
134 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
1. Act in the client’s best interests. 2. Act in accordance with the client’s wishes and instructions. 3. Keep the client properly informed. 4. Carry out instructions with diligence and competence. 5. Act impartially and offer frank, independent advice. 6. Maintain client confidentiality.
BOX 6-6 Ethical Principles for Effective Advocacy
(Dorfman et al, 2005). As noted earlier in this chapter, it is important to recognize the potential conflict of individuals versus society. With communitarianism, individual rights need to be balanced with social responsibilities. When using a frame- work that contrasts social justice and market justice, the biggest barrier to achieving social justice is the competing concept of market justice. Market justice is grounded in the assumption that the best way to meet the needs of individuals in a society is to avoid regulations. The focus is on individual, not shared, needs (Table 6-2). A focus on market justice, rather than social justice, influences public dialogue about public health needs. It is important that existing values and beliefs in the society be understood in order to frame the public health message appro- priately in terms of social justice values that relate to changes that they seek. Health care professionals must develop media
Adapted from Dorfman L, Wallack L, Woodruff K: More than a message: framing public health advocacy to change corporate practices. Health Educ Behav 32:320–336, 2005.
Market Justice Values Social Justice Values
Self-determination and self- discipline
Shared responsibility
Individual values and self-interest Interconnection and cooperation among individuals in a community
Personal efforts key to desired benefits
Community shares responsibility for providing basic benefits
Limited responsibilities for good of the community
Important obligations for the collective good
Limited government intervention Government involvement is necessary Voluntary focus on individual
moral behavior Community well-being supersedes
individual focus on well-being
TABLE 6-2 Contrast of Social Justice and Market Justice as an Advocacy Framework
Park EJ: The development and implications of a case-based computer program to train ethical decision-making. Nurs Ethics 20:943–956, 2013.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
One of the six tenets of Quality and Safety Education for Nurses (QSEN) is patient-centered care (Barton et al, 2009). This chapter has discussed many ways in which an understanding of basic principles of ethics can guide safe and effective nursing practice. Some key aspects of patient-centered care in public health nursing include being certain that the information provided to individuals, families, and communities is accurate and reflects the most current evidence, and that it is presented in a timely fashion. Community health education should take into account the age, gender, and cultural and religious backgrounds of those who receive the information. Giving health information that does not meet these criteria can be unsafe and clearly does not reflect attention to quality nursing care. One of the QSEN competencies related to patient-centered care is as follows: Recognize the patient or desig- nee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs. Specific aspects of patient-centered care related to communication are as follows: • Knowledge: Integrate understanding of multiple dimensions of patient-
centered care: information, communication, and education. • Skills: Communicate patient values, preferences, and expressed needs to
other members of the health care team.
• Attitudes: Respect and encourage individual expression of patient values, preferences, and expressed needs (Barton et al, 2009, p. 315).
Specific aspects of patient-centered care related to the public health dilemma of serving the good of the population versus serving the good of the individual are as follows: • Knowledge: Explore ethical and legal implications of patient-centered care. • Skills: Recognize the boundaries of therapeutic relationships (Barton et al,
2009, p. 315). • Attitudes: Acknowledge the tension that may exist between patient rights
and the organizational responsibility for professional ethical care. Patient-centered ethical activity: Public health is more concerned about the
good of the collective group than of the individual. In order to think more closely about quality and safety, debate with a classmate about whether children should be required to have all of the Centers for Disease Control and Prevention vac- cines before they can enter school or remain the school. At the present time, some parents are choosing not to give their children all the recommended immunizations because of fear of side effects of the vaccines. To support your argument see http://www.cdc.gov/vaccines/schedules/index.html for what is required. See web articles such as www.responsibility-project.libertymutual.com for the parents’ point of view.
skills to compete effectively with adversaries in public debate and learn to frame their advocacy initiatives.
Practical Framework for Advocacy Bateman (2000) takes a practical approach to advocacy. He places the advocate’s core skills (i.e., interviewing, assertiveness and force, negotiation, self-management, legal knowledge and research, and litigation) within the context of six ethical prin- ciples for effective advocacy, as shown in Box 6-6. His focus is on the individual client, although the focus could also apply to groups and communities.
Regarding the first ethical principle, Bateman (2000) is sensi- tive to the ethical conflict between clients’ best interests and the best interests of groups, communities, or societies but does not elaborate on this conflict. The second ethical principle, which puts the client in charge, works in tandem with the first prin- ciple. It goes like this: “This is what I think we can do. What do you want me to do?” (Bateman, 2000, p. 51). Of course, the advocate can refuse the request if self or others may be harmed. By following the third ethical principle, the client is empowered to make knowledgeable decisions. The fourth ethical principle addresses standards of practice. The fifth ethical principle addresses fairness and respect for persons (population-centered
135CHAPTER 6 Application of Ethics in the Community
nursing is more collaborative in nature than independent nursing). The last ethical principle, confidentiality, ensures that information will be shared only on a need-to-know basis.
Advocacy: Issues that Have Ethical Implications Advocacy and Bioterrorism Before the terrorist attacks in the United States on September 11, 2001, the subject of terrorism was not a major focus in philosophical discussions (terrorism, in Stanford Encyclopedia of Philosophy, 2007). The September 11th attack, however, brought a frightening new awareness of the vulnerability of individuals and groups in our society and the need for advocacy. Although some countries have been forced to live with the knowledge of this type of vulnerability for years, today’s reality of global terrorism means that nurses must thoughtfully reflect on and debate ethical issues that arise with the threat, action, and aftermath of terrorism. They also must carefully consider their own responsibilities in terms of moral obligation to respond and make themselves available in a crisis that threatens the well-being of a community.
As noted at the beginning of this chapter, population- centered nursing is concerned with protecting, promoting, pre- serving, and maintaining health while preventing disease. These goals that address the promotion of good and prevention of harm are intimately related to ethics and bioterrorism. It is often difficult to balance goals for the protection of the public and protection of the individual, as evidenced by an incident in which airport security personnel ordered a 4-year-old disabled child to remove his leg braces to go through a metal detector, even though his mother told the screeners that the child could not walk without the braces (Rubin, 2010). As a nurse, it is often hard when confronted with terrorism or a disaster to determine whether the needs of one’s family or the needs of one’s clients predominate. Silva and Ludwick (2003) provide a helpful framework related to the need for advocacy in bioterrorism, using the principles of nonmaleficence, beneficence, and dis- tributive justice. These principles can guide nurses as they learn to speak out against violence and terrorism, work with agencies in the community for short-term and long-term efforts to do good and avoid harm, and participate in policy debates that attempt to determine fair distribution of scarce resources to fight terrorism globally. The ANA Center for Ethics and Human Rights maintains a helpful list of resource informa- tion addressing biodefense at http://www.nursingworld.org/ MainMenuCategories/ThePracticeofProfessionalNursing/ EthicsStandards/CEHR.aspx.
Advocacy and Health Care Reform In the current focus on health care reform, it is critical that nurses advocate for reform that embodies ethical considerations that have been discussed in this chapter. Dr. Mary Wakefield, Admin- istrator of the Health Resources and Services Administration (HRSA), noted that not only should nurses participate in imple- menting new directions for health care, but that it is important that they help to envision these new directions (Wakefield, 2008). Nurses can be an important voice in advocating for access to consistent, effective, efficient health care for all in our society. Wakefield says that educating the public can be a unique chal- lenge because clever sound bites and attack ads in the media can lure consumers into thinking that the status quo is the best option. Nurses are an important part of the health care industry and are respected by the public; they can make meaningful con- tributions toward health care reform through advocating for clients and families. The signing of the 2010 health care bill by President Obama, after many years of controversial attempts at health care reform, provides an excellent opportunity for nurses to advocate for tying health care for all to ethics and social justice.
Ethical Use of Social Media As the trend for using social media grows in both personal and professional arenas the implications for establishing boundaries for its use by health care professionals also grow. As Baker (2013, p. 501) says, “If the risks (of using social media) are managed well, social media can be a positive force for patient advocacy and education, as well as a resource for evidence-based practice and research.” She points out that nurses should practice within defined professional boundaries that center around four key elements: (1) promoting the dignity of the clients, (2) seeking client independence and working for their best interests, (3) abstaining from inappropriate involvement with clients, and (4) refraining from personal gain at the expense of the client. Ethical dilemmas arise when nurses act in ways that are not consistent with their professional boundaries. Baker (2013) points out that it is important to think through ethical concerns that are associated with social networking. This can be espe- cially important when the nurse lives and works in a small community. For example, consider the public health nurse who goes to church with clients, attends the same parent-teacher meetings, and shops at the same stores as they do. Is it appropri- ate for her to then “friend” these clients on a social media site? Chapter 19 discusses rural health, and the issue of close rela- tionships between nurses and clients is described there.
LINKING CONTENT TO PRACTICE
Throughout this chapter, there has been application of the content related to ethics in public health nursing and the many documents that influence the role of public health nurses. These include the ANA Scope and Standards of Public Health Nursing, the ANA Code of Ethics, the core functions of public health as outlined by the Institute of Medicine, and the Healthy People 2020 objectives. Ethics is also an integral part of the Core Competencies for Public Health Professionals. Skill 8 in the section on analytic/assessment skills says that a
public health professional uses “ethical principles in the collection, mainte- nance, use, and dissemination of data and information” and skill 2 under leader- ship and systems thinking says a professional “incorporates ethical standards of practice as the basis of all interactions with organization, communities, and individuals” (Council on Linkages between Academic and Public Health Practice, 2010).
Council on Linkages Between Academic and Public Health Practice: Core competencies for public health professionals, Washington, DC, 2010. Public Health Foundation/Health Resources and Services Administration.
136 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
P R A C T I C E A P P L I C A T I O N The retiring director of the division of primary care in a state health department had recently hired Ann Green, a 34-year-old nurse with a master’s degree in public health, to be director of the division. Ms. Green’s work involved the monitoring of mil- lions of dollars of state and federal money as well as the super- vising of the funded programs within her division.
Ms. Green received many requests for funding from a par- ticular state agency that served a poor, large district. The poor people of the district primarily consisted of young families with children and homebound older adults with chronic illnesses. Over the past 3 years, the federal government had allocated considerable money to the state agency to subsidize pediatric primary care programs, but no formal evaluation of these pro- grams had occurred.
The director of the state agency was a physician who had been in this position for over 20 years. He was good at obtaining funding for primary care needs in his district, but the statistics related to the pediatric primary care program seemed
implausible—that is, few physical examinations were performed on the children, which had resulted in extra money in the budget. This unspent federal money was being used to supple- ment home health care services for the indigent homebound older adults in his district. The thinking of the physician was that he was doing good by providing some needed services to both indigent groups in his district. Ms. Green felt moral dis- comfort because she did not have either the money or the personnel to provide both services. What should she do? A. What facts are the most relevant in this scenario? B. What are the ethical issues? C. How can Ms. Green resolve the issues?
(The preceding case and answers are adapted and para- phrased from a real practice application shared by J.L. Chapin on the inappropriate distribution of primary health care funds [in Silva M, editor: Ethical Decision Making in Nursing Admin- istration. Norwalk, CT, 1990, Appleton & Lange].)
Answers can be found on the Evolve site.
K E Y P O I N T S • Nursing has a rich heritage of ethics and morality, beginning
with Florence Nightingale. • During the late 1960s, the field of bioethics began to emerge
and influence nursing. • Ethical decision making is the component of ethics that
focuses on the process of how ethical decisions are made. • Many different ethical decision-making frameworks exist;
however, underlying each of them is the problem-solving process.
• Ethical decision making applies to all approaches to ethics: utilitarianism, deontology, principlism, virtue ethics, caring and the ethic of care, and feminist ethics.
• Cultural diversity makes ethical decision making more challenging.
• Moral distress can lead to a personal sense of failure in pro- viding nursing care and may lead to work and/or career dissatisfaction.
• Classical ethical theories are utilitarianism and deontology. • Principlism consists of respect for autonomy, nonmalefi-
cence, beneficence, and justice. • Other approaches to ethics include virtue ethics, caring and
the ethic of care, and feminist ethics. • The core functions of public health nursing (i.e., assessment,
policy development, and assurance) are all grounded in ethics.
• Healthy People 2020 objectives address workforce competen- cies, training in essential public health services, and continu- ing education.
• The 2015 Code of Ethics for Nurses contains nine statements that address the moral standards that delineate nursing’s values, goals, and obligations.
• The 2002 Public Health Code of Ethics contains 12 state- ments that address the moral standards that delineate public health’s values, goals, and obligations.
• Advocacy is the act of pleading for or supporting a course of action on behalf of a person, group, or community.
• Effective advocacy incorporates ethical principles and concepts.
• The Code of Ethics for Nurses, the Public Health Code of Ethics, Skills for the Ethical Practice of Public Health, and Public Health Nursing: Scope & Standards of Practice all address advocacy.
• Public health advocacy is composed of both products and processes.
• The products of advocacy are decreased morbidity and mortality.
• The processes of public health advocacy include, but are not limited to, identifying problems, collecting data, developing and endorsing regulations and legislation, enforcing policies, and assessing the policy process.
• Advocacy related to bioterrorism, health care reform, and ethical use of social media is important for community and public health nurses.
137CHAPTER 6 Application of Ethics in the Community
REFERENCES American Association of Colleges of
Nursing (AACN): Recommended Baccalaureate Competencies and Curricular Guidelines for Public Health Nursing. Washington, DC, 2013, AACN.
American Nurses Association (ANA): Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD, 2015, Nursebooks.org.
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Baker JD: Social networking and professional boundaries. AORN J 97:501–506, 2013.
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Beauchamp TL, Childress JF: Principles of Biomedical Ethics, ed 6. New York, 2008, Oxford University Press.
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Bernheim RG, Childress JF, Bonnie RJ, et al: Essentials of Public Health Ethics. Burlington, MA, 2015, Jones & Bartlett.
Callahan D: Universalism and particularism fighting to a draw. Hastings Cent Rep 30:37, 2000.
Callahan D: Principlism and communitarianism. J Med Ethics 29:287–291, 2003.
Callahan D, Jennings B: Ethics and public health: forging a strong relationship. Am J Public Health 92:169, 2002.
Carlock C, Spader C: Communication and understanding: best vs distress. Nurs Spectr, October 8, 2007. Retrieved December 2014 from: http://news.nurse.com/ apps/pbcs. dll/article?AID= 2007710080311.
Council on Linkages between Academic and Public Health Practice: Core Competencies for Public Health Professionals. Washington, DC, 2010, Public Health Foundation/Health Resources and Services Administration.
Coursin CC: Inequalities affecting access to healthcare: a philosophical reflection. Int J Hum Caring 13:7–15, 2009.
Denhardt RB, Denhardt JV: The new public service: serving rather than steering. Public Admin Rev 60:549–552, 2000.
Dorfman L, Wallack L, Woodruff K: More than a message: framing public health advocacy to change corporate practices. Health Educ Behav 32:320–336, 2005.
Eriksson K: Caring science in a new way. Nurs Sci Q 15:61, 2002.
Fowler MDM, editor: Guide to the Code of Ethics for Nurses: Interpretation and Application. Silver Spring, MD, 2008, American Nurses Association.
Gilligan C: In a Different Voice: Psychological Theory and Women’s Development. Cambridge, MA, 1982, Harvard University Press.
Gjengedal E, Ekra EM, Hol H, et al: Vulnerability in health care— reflections on encounters in every
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Hellsten S: Theories of distributive justice. In Chadwick R, editor: Encyclopedia of Applied Ethics, vol 1. New York, 1998, Academic Press, pp 815–827.
Holstein MB: Bringing ethics home: a new look at ethics in the home and the community. In Holstein MB, Mitzen PB, editors: Ethics in Community-Based Elder Care. New York, 2001, Springer.
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C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Think about the differences in duties between a nurse
working in a critical care facility and a nurse working in a community care or public health setting. How might these differences lead to differences in ethical problems and deci- sion making?
2. Interview a long-retired nurse about the most important ethical issues that this nurse faced when practicing in the community. Next, interview a nurse actively practicing in the community about the most important ethical issues that this
nurse is now facing. Compare and contrast the ethical issues in the two interviews and place each within a historical context.
3. In a local or national newspaper, read one or more articles that discuss health care public policy with which you agree or disagree. Compose a letter to the editor analyzing why you agree or disagree with the policy but only after you take into account any of your own biases or vested interests.
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7
Cultural Diversity in the Community
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Describe the process for developing cultural competence to
meet the health care needs of culturally diverse individuals, communities, and organizations.
2. Describe major facilitators and barriers to providing quality health care for diverse populations.
3. Identify culturally competent nursing interventions to promote positive health outcomes for culturally diverse clients.
4. Evaluate the role of the public health nurse in providing culturally competent nursing care.
5. Use a case scenario to chart the five elements of cultural competence as described by Campinha-Bacote.
6. Use electronic resources to locate current databases about culturally competent practices that reduce health disparities.
K E Y T E R M S biological variations, p. 143 communication, p. 145 cultural accommodation, p. 159 cultural awareness, p. 154 cultural blindness, p. 157 cultural competence, p. 151 cultural conflict, p. 157 cultural desire, p. 155 cultural diversity, p. 142
cultural encounter, p. 155 cultural imposition, p. 157 cultural knowledge, p. 154 cultural nursing assessment, p. 161 cultural preservation, p. 158 cultural relativism, p. 157 cultural repatterning, p. 159 cultural skill, p. 154 culture, p. 141
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz
• Case Studies • Glossary • Answers to Practice Application
Cynthia E. Degazon, RN, PhD Dr. Cynthia E. Degazon is professor emerita at Hunter College, City University of New York. She received a BS in nursing from Long Island University, and an MA in Community Health nursing and a PhD from New York University. For 20 years she has prepared undergraduate and graduate nurses to provide culturally competent care to ethnically diverse populations. Dr. Degazon has given many national and international presentations, authored several scholarly publications, and served on the editorial board of the Journal of Cultural Diversity.
Dr. Bobbie Perdue is Professor of Nursing at South Carolina State University in Orangeburg, South Carolina. She is professor emerita at Syracuse University. Her teaching career in nursing spans 43 years and includes the teaching of associate degree, baccalaureate, and master degree nursing students. She received a BSN from Vanderbilt University, an MSN in child-psychiatric mental health nursing from Wayne State University, and a PhD in nursing research and theory development from New York University.
Bobbie J. Perdue, RN, PhD
140 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
C H A P T E R O U T L I N E Culture, Race, and Ethnicity
Culture Race Ethnicity
Cultural Diversity Cultural Variations among Selected Groups Immigrants and Cultural Diversity
Cultural Diversity and Health Disparities Disparities in Health Social Determinants of Health Health Equity Social Justice
Marginalization Health Literacy Health Disparities and Socioeconomic Status
Cultural Competent Nursing Interventions Cultural Competence Developing Provider Cultural Competence Barriers to Developing Cultural Competence Culturally Competent Nursing Interventions Developing Organizational Cultural Competence Positive Health Outcomes Associated with Cultural
Competence Cultural Nursing Assessment
K E Y T E R M S — cont’d culture brokering, p. 159 culture shock, p. 158 disparities, p. 150 environmental control, p. 145 ethnicity, p. 142 ethnocentrism, p. 157 foreign-born, p. 147 health equity, p. 150 health disparities, p. 150 health literacy, p. 150 immigrants, p. 147 interpreter, p. 148 lawful permanent residents, p. 147 legal immigrants, p. 147 marginalization, p. 150
non-immigrants, p. 148 perception of time, p. 144 personal space, p. 143 prejudice, p. 156 quality of care, p. 153 race, p. 142 racism, p. 156 refugees, p. 147 social determinants of health, p. 150 social justice, p. 150 social organization, p. 145 socioeconomic status, p. 151 stereotyping, p. 156 unauthorized immigrants, p. 148 —See Glossary for definitions
Caring for culturally diverse groups has been a focus of nursing from its beginning. As early as 1893, under the leadership of Lillian Wald, nurses in New York City started public health nursing and provided home care to inner city people, particu- larly immigrants, who could neither read nor write the English language (Anderson and McFarlane, 2010). Because nurses were not from the same cultural background as the immigrants, they had to deal with the cultural differences between themselves and the persons in their care. Today, the U.S. culture reflects a greater diversity of cultures from all over the world and assuring that individuals from these diverse cultures receive equity in health care is as much a challenge for nurses as it was during Lillian Wald’s era. Such assurance is viewed as a moral impera- tive to reduce health disparities.
Data from the U.S. Census Bureau (2010) showed that (72.4%) of the U.S. population defined themselves as a member of a non-Hispanic white ethnic group followed by African Americans (12.6%), Asian Americans (4.8%), American Indians/Alaskan Natives (0.9%), Native Hawaiian and other Pacific Islanders (0.2%), some other race (6.2%), and two or more races (2.9%). Hispanic origin was considered to be a sepa- rate concept from race but accounted for 16.4% of the
population with those predominantly identified as white or as some other race. Data also showed a decrease from the 2000 census when the white population accounted for 75.1%. This pattern of a decreasing white population is attributed to rapidly growing Hispanic populations, a strong increase in the Asian populations, a modest increase in Americans of African descent, and an increase in persons who identify as white in combination with another race.
Culture and language have a significant influence on health, belief systems, health practices, and health outcomes. As social determinants of health, they affect how clients and nurses per- ceive illness, and causes of and treatment of diseases. They contribute to the behaviors and attitudes that clients have about health care and the providers who care for them. As a result of this diversity, significant differences in beliefs and practices about health and illness have become apparent in health care systems. Nurses who want to incorporate their client’s beliefs of health and illness when intervening to promote and maintain wellness face many challenges.
Nurses need to understand the sociocultural views that affect perceptions of an illness, as well as the pathophysiology of the illness. According to the American Association of Colleges of
141CHAPTER 7 Cultural Diversity in the Community
summarizes factors that may influence individual differences within cultural groups.
In response to the needs of its members and the environ- ment, culture provides tested solutions to life’s problems and guides our thinking, discourse, attitudes, and actions. In the present health care system, nurses have the chief responsibility for translating health information so that clients can under- stand it and engage in more effective strategies to achieve posi- tive health outcomes. Understanding the beliefs and practices these clients bring to the clinical setting, their responses to health and illness, and the type of health care they expect to receive are important data that nurses should draw on when developing a plan of care for clients.
Individuals learn about their culture during the process of socialization and language development (Box 7-2). Parents and other family members are the primary sources for the transfer of traditions and teaching explicit and implicit behaviors of the culture. Schools, community, and cultural organizations are secondary sources of socialization. Explicit behaviors are straightforward and do not leave room for misinterpretation of what the person wants to communicate. Implicit behaviors are less exact and include the use of body language to communicate rather than persons saying verbally what is on their mind. An example of an explicit message is “No smoking is permitted” and an implicit message is: “Thank you for not smoking” (Figures 7-1 and 7-2).
Race Concepts of race and ethnicity within American society play a strong role in understanding human behavior and health. In everyday language, these two concepts are often used inter- changeably. Nurses are expected to understand and appreciate the meaning of each concept as each relates to providing cultur- ally competent health care to persons of diverse cultures.
Nursing (2014), the nursing workforce is overwhelmingly white (83%): African Americans account for 6%, Asian or Pacific Islanders 6%, Hispanics 3%, American Indian/Alaskan Natives 1%, Native Hawaiian/Pacific Islanders 1%, and 1% “other” nurses. There is also a small cadre of minority students enrolled in nursing schools (Phillips and Malone, 2014) even though clients are often more satisfied with nursing care when they have an ethnic connection with the provider of that care. Minority clients, in contrast to their white counterparts, are at greater safety risk in health care facilities as measured by the incidence of medical errors, length of hospital stay for a specific illness, and the number of laboratory tests ordered (Beacham et al, 2009; Smedley et al, 2002).
This chapter provides nurses with strategies to use in provid- ing culturally competent care to diverse clients (individuals, aggregates, families, and communities) who may not share the nurse’s culture. Although the chapter is population-focused, it emphases knowledge development in the care of clients from five culturally diverse marginalized groups: African Americans, Asian Americans, Hispanic Americans, Native American/ Alaskan Natives, and immigrants.
There is much cultural and ethnic diversity present within and among these marginalized groups; they are consistently identified in the literature as more vulnerable, have less access to health care, receive a poorer quality of health care, have higher rates of chronic illnesses, and shorter life expectancies than Anglo-white groups (Agency for Healthcare Research & Quality, 2014; Agency for Healthcare Research & Quality, 2012). Many groups other than racial and ethnic groups also differ from the expected norms relative to place of origin, sexual ori- entation, gender identity, educational background, literacy, income, and language. Individuals who are members of these subcultures are marginalized by the dominant health care culture as well. However, evidence is beginning to show a nar- rowing of the health gap among these groups for some of the access and quality measures.
CULTURE, RACE, AND ETHNICITY Culture Culture is a set of beliefs, values, and assumptions about life that are widely held among a group of people and is transmitted intergenerationally (Leininger, 2002a). The term culture encom- passes a broad range of concepts. It is an individual concept, a group phenomenon, and an organizational reality. Culture per- vades all aspects of life and of health care. Culture determines how health care information is processed, received, and distrib- uted; how rights and protections are exercised; what is consid- ered to be a health problem; how symptoms and concerns of the problem are expressed; who provides treatment for the problem; and what type of treatment should be given (Giger, 2012; Purnell and Paulanka, 2012; Spector, 2012). Culture is applicable not only to minority groups, but also to majority groups such as white Americans of European descent (i.e. Irish, Italian, and Russian). Individuals are usually members of more than one culture. Each individual should be viewed as a unique human being with differences that are respected. Box 7-1
Except where noted with an asterisk, from Orque M: Orque’s ethnic/ cultural system: a framework for ethnic nursing care. In Orque MS, Bloch B, Monrroy LSA, editors: Ethnic Nursing Care. A Multicultural Approach. St. Louis, 1983, Mosby.
• Age • Religion • Dialect and language spoken • Gender identity roles • Socioeconomic background • Geographic location in the country of origin • Geographic location in the current country • History of the subcultural group with which clients identify in their current
country of residence • History of the subcultural group with which clients identify in their country
of origin • Amount of interaction between older and younger generations • Degree of assimilation in the current country of residence • Immigration status* • Conditions under which migration occurred
BOX 7-1 Factors Influencing Individual Differences Within Cultural Groups
142 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
Race is a biological variation within population groups based on physical markers derived from genetic ancestry such as skin color, physical features, and hair texture. It is a charac- teristic that allows for some groups to be separated, treated as superior, and given access to power and other valued resources, while others are treated as inferior and have limited access to power and resources. Race differences include areas of growth and development, skin color, enzymatic differences, susceptibil- ity to disease, and laboratory test findings. Individuals may be of the same race but of different cultures. For example, African Americans, who may have been born in Africa, the Caribbean, North America, or elsewhere, are a heterogeneous group, but they may be considered culturally homogeneous by persons who think of African Americans as one group. Monolithic thinking means that the many cultural differences of individu- als from these diverse geographic regions may be overlooked because of the similar racial characteristics (Degazon, 1994).
FIG 7-1 The sign is from a culture that values directness in com- munication. (© 2012 Photos.com, a division of Getty Images. All rights reserved. Image 91883504.)
FIG 7-2 The sign is from a culture that values indirectness in communication. (© 2012 Photos.com, a division of Getty Images. All rights reserved. Image 122153579.)From Randall DE: Culturally Competent HIV Counseling and
Education. McLean, VA, 1994, Maternal and Child Health Clearinghouse.
Think about the first time you had contact with someone you realized was culturally different from you.
Briefly describe the situation/event. How old were you? What were your feel- ings? What were your thoughts?
What did your parents and other significant adults say about those who were culturally different from you or your family? What adjectives were used? What attitudes were conveyed?
As you got older, what messages did you receive about minority groups from members of your family, school, recreation facilities, and church?
As an adult, when you hear others talk about culturally different people, what images do they conjure up for you? What knowledge source is evident in the comment of the person? Do the views of the person reinforce or con- tradict the views that you hold today? Give an example.
What parts of your culture make it difficult to work with clients from different cultural groups?
What parts of your culture facilitate your work with clients from different cultural groups?
BOX 7-2 Early Cultural Awareness
Individuals who belong to the Caucasian race also experience this same over-generalization of individuals along racial/ethnic lines.
Ethnicity Ethnicity, in contrast to race, is the shared feeling of people- hood among a group of individuals and relates to cultural factors such as nationality, geographic region, culture, ancestry, language, beliefs, and traditions (Giger, 2012) (Figure 7-3). These ethnicity and racial patterns have been developed in a socioeconomic context with historical and political underpin- nings. They are equally influenced by education, income, and cross-cultural experiences. Race and ethnicity account for much of the health disparities in the United States. Members of an ethnic group are likely to give up aspects of their identity and society when they adopt characteristics of another group’s iden- tity. However, when there is a strong ethnic identity, the indi- vidual maintains the values, beliefs, behaviors, practices, and ways of thinking of their group. Ethnic disparities in health care are explained largely by differences in English fluency whereas racial disparities in health care are best explained by delayed care due to a lack of knowledge by caregivers about culture and ethnic values, norms and thinking outside of their reference group, lack of insurance, and lack of transportation.
CULTURAL DIVERSITY Cultural diversity refers to the degrees of variation that is rep- resented among populations based on lifestyle, ethnicity, race, interest, across place, and place of origin across time. It includes other aspects of variation among people, such as social class, gender identity, sexual orientation, physical abilities/disabilities and care beyond multiculturalism. Cultural diversity also refers to the changing populations of the world as it becomes more of a global village. It is about understanding and embracing each other’s differences and similarities.
143CHAPTER 7 Cultural Diversity in the Community
FIG 7-3 In countries around the world, there are distinct differ- ences in people who represent the same cultural group. (Copy- right © 2013 Thinkstock. All rights reserved. Image # 117003112).
protective agency in her state. The mother had to disprove the allegation to the agency’s social worker before her child could be released into her care. Other common and obvious varia- tions include eye shape, hair texture, adipose tissue, shape of earlobes, thickness of lips, and body configuration. A common enzyme deficiency is glucose-6-phosphate dehydrogenase (G6PD), which is responsible for lactose intolerance in many ethnic groups (Giger, 2012).
The findings that DNA composition for any two humans across race is 99.9% genetically identical and that difference between races occur only in 1 in 1000 people diminishes the ethnocentric debate about the importance of race. Another factor making race less important is the increasing numbers of interracial marriages that result in interracial children whose physical and genetic pool dilute the racial characteristics of their parents. Racial categories originated from a shared genealogy due to geographic isolation. In today’s global village, this isola- tion has been broken down and there are more mixed groups. In the United States, children of biracial parents are usually assigned the race of the mother. The Levels of Prevention Box gives examples of cultural strategies for primary, secondary, and tertiary levels of prevention.
Cultural Variations among Selected Groups Each culture has an organizational structure that distinguishes it from others and provides the direction for what members of the cultural group determine is appropriate or inappropriate behavior. The organizational elements of health culture have been described in nursing by Andrews and Boyle (2012), Giger (2012), Leininger (2002b), Purnell and Paulanka (2012), and Spector (2012). As part of the nursing process, nurses are expected to accurately assess a client’s health needs based on information about seven primary cultural elements: biological variations, personal space, time, environmental control, social organizations, communication patterns, nutrition, and religion (Table 7-1). Usually, the assessment takes place in the initial nurse–client interview. It is important that nurses use this infor- mation to develop a client-centered care plan. Once this infor- mation is gathered, the nurse should schedule a second interview with the client to determine ways to individualize culturally congruent care so that it is acceptable to the client.
Biological Variations Biological variations are the physical, biological, and physio- logical characteristics that exist between racial groups and dis- tinguish one race from another. These characteristics occur in areas of growth and development, skin color, enzymatic differ- ences, susceptibility to disease, and laboratory test findings (Andrews and Boyle, 2012; Giger, 2012). For example, Western- born neonates are slightly heavier at birth than those born in non-Western cultures. Variations in growth and development may be influenced by environmental conditions such as nutri- tion, climate, and disease. Mongolian spots are bluish discolor- ations that are sometimes present on the skin of African American, Asian, Hispanic, and Native American/Alaskan Native babies. These spots may be mistaken for bruises. When nurses encounter situations involving unfamiliar biological variations, they may create embarrassing situations. Consider the following scenario: The school nurse observed a bluish dis- coloration on the thigh of a Filipino child that she mistook for a bruise. The nurse reported her observation to the child
LEVELS OF PREVENTION
Primary Prevention Provide health teaching about balanced diet and exercise. Based on the details of the individual’s culture, the teaching should include members of the family and identification of culturally appropriate foods and the means for preparing them.
Secondary Prevention Teach clients and/or family to monitor blood pressure. Teach about diet, keeping in mind the client’s cultural preferences. Talk about health beliefs and cultural implications, such as the use of alternative therapies; make sure alternative therapies are compatible with any medications that may be prescribed.
Tertiary Prevention If blood pressure cannot be controlled by diet and/or exercise, refer the client to a culturally appropriate medical practitioner for medication and supervision; advise the client to engage in a cardiac program that will oversee diet and exercise.
Hypertension, Stroke, and Heart Disease Related to Cultural Differences
Personal Space Personal space is the physical distance maintained between individuals during an interaction (Giger, 2012). The amount of space varies among individuals and between cultures. When this space is violated, the nurse or the client may experience discom- fort. There are four zones of interpersonal space—intimate space (direct contact to 1.5 feet), personal distance (1.5 to 4 feet), social distance (4 to 12 feet), or public distance (greater than 12 feet)—that may be observed when nurses care for clients. Cultural groups also have spatial preferences. To illus- trate, Hispanic cultures tend to be comfortable with less space because individuals like to touch some persons with whom they
144 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
African Americans Asians Hispanics American Indian/ Native Alaskans
Verbal Communication
Asking personal questions of someone that you have met for the first time is seen as improper and intrusive.
High level of respect for others, especially those in positions of authority.
Expression of negative feelings is considered impolite.
Speak in a low tone of voice and expect the listener to be attentive.
Nonverbal Communication
Direct eye contact in conversation is often considered rude.
Direct eye contact with elders and authority figures may be considered disrespectful.
Avoidance of eye contact is usually a sign of attentiveness and respect.
Direct eye contact is often considered disrespectful. Avoidance of eye contact should not be interpreted as inattentiveness or evasiveness.
Touch Very affectionate and expressive. Touching of one’s hair by another is often considered offensive.
It is not customary to shake hands with persons of the opposite sex.
Very affectionate and use hand, face, and body gestures to express self. Touching is often observed between two persons in conversation.
Modesty. A light touch of the person’s hand instead of a firm handshake is often used when greeting a person.
Family Organization
Usually have close extended family networks; women play key roles in health care decisions.
Usually have close extended family ties; emphasis may be on family needs rather than individual needs.
Usually have close extended family ties; all members of the family may be involved in health care decisions.
Usually have close extended family; emphasis tends to be on family rather than on individual needs. Decision making may vary among tribes.
Time Perception Often present oriented. Often present oriented. Often present oriented. Often past oriented Environmental
Control Harmony of mind, health,
body, and spirit with nature. Balance between the “yin” and
“yang” energy forces. Balance and harmony
among mind, body, spirit, and nature.
Harmony of mind, body, spirit, and emotions with nature.
Alternative Healers
“Granny,” “root doctor,” voodoo priest, and spiritualist.
Acupuncture, acupressure, acumassage, herbalist, moodang.
Curandero, espiritualista, Santero priest, yerbero, faith healers.
Medicine man, shaman.
Self-care Practices
Poultices, herbal medicine, oils, teas, massage, hot baths, and roots.
Hot and cold foods, herbal medicine, teas, soups, cupping, burning, rubbing, pinching.
Hot and cold foods, herbal teas.
Herbs, corn meal, medicine bundle.
Biological Variations
Sickle cell anemia, Mongolian spots, keloid formations, inverted “T” waves, lactose intolerance, skin color.
Thalassemia, alcohol intolerance, drug interactions, Mongolian spots, lactose intolerance, skin color.
Mongolian spots, lactose intolerance, skin color.
Cleft uvula, lactose intolerance, skin color, lumbar pigmented spots, and epicanthal eye folds, Mongolian spots.
TABLE 7-1 Cultural Variations among Selected Groups
are speaking. In the Filipino culture individuals may view touch- ing strangers as inappropriate; therefore, nurses who wish to be culturally appropriate may elect to stand farther away from Filipinos than from Hispanics. On the other hand, clients who are comfortable with closer distances may experience discom- fort when nurses stand farther away, interpreting the behavior as rejecting. Nurses should take cues from clients to place them- selves in the appropriate spatial zone and avoid misinterpreta- tion of clients’ behavior as they handle their spatial needs.
Perception of Time Perception of time refers to past, present, and future time as well as to the duration of and period between events. Some cultures assign greater or lesser value to events that occur in the past, the
present, or the future. If members of a cultural group tend to be future oriented, they often will delay immediate gratification until future goals are accomplished. For example, some future- oriented persons who value longevity may engage in health pro- motion activities to moderate their dietary intake and engage in exercise activities to minimize future health risks. In contrast, some present-oriented cultural groups may place greater empha- sis on the here and now and view information about their present set of circumstances as more important than what will happen in the future. Other cultures believe that their ancestral lineage determines their current health status. When nurses discuss health promotion and disease prevention strategies with persons who have a present orientation, they should focus on the imme- diate benefits these clients will gain rather than emphasizing
From Office of Immigration Statistics, Office of Management, Department of Homeland Security: 2008 yearbook of immigration statistics, Washington, DC, 2008, U.S. Government Printing Office. *Australia, New Zealand, and the nearby islands.
145CHAPTER 7 Cultural Diversity in the Community
financial support in times of crises. The significance of kinship in the formation of family relations varies across cultures. Some cultures adopt individuals who are unrelated or remotely related as family members. Some Hispanic and Asian cultures place the needs of the family above those of the individual. In the American Indian/Alaskan Native family, members honor and respect their elders and look to them for leadership, believing that wisdom comes with increasing age. When working with clients who prefer family decision making over individual choice, nurses should be aware that it may be counterproductive to exclude family involvement—particularly mothers and grandmothers—in the health care decision making. At the same time, nurses should advocate for the individual, making sure that when families make decisions, the individual’s needs have been considered.
Communication Communication is the means by which culture is shared. Both verbal and nonverbal communications are learned in one’s culture. Communication is the most significant problem that presents itself in working with cross-cultural groups. Cross- cultural variations in verbal style can range from pronuncia- tion, word meaning, voice quality, and humor, to nonverbal communication with eye contact, gesture, touch, body posture, facial expression, and silence. In all forms of communication, maintain respect for individuals. Often in cultures where the elderly are held in high esteem, they are addressed in a formal manner. Communicating trust is also important because it facilitates the nurse–client interaction and determines the extent to which the client will share information with the nurse (Morgan et al, 2006).
The following example involving a nurse giving instructions to Asian clients about taking anti-tuberculin drugs illustrates the need to understand cultural communication. The clients responded with a smile and a nod. The nurse interpreted this response to mean that the clients understood the instructions and had accepted the treatment protocol. A week later, when the clients returned for a follow-up visit, the nurse discovered that the medications had not been taken. The nurse knew that acceptance by and avoidance of confrontation or disagreement with those in authority are important behaviors in Asian culture. Interventions were adjusted accordingly: the nurse repeated the medication instructions and gave the clients an opportunity to raise questions and concerns and to repeat the instructions that were given; the nurse also discussed the cul- tural meaning and treatment of tuberculosis. Other factors influencing communication include forms of address such as the use of first names or surnames, and whether it is polite to wait until a person finishes speaking or to talk over each other.
Nutrition For many cultures, the preparation and eating of food is a social activity and members of the group come together to celebrate life and comfort with one another. Almost all family rituals, including birth, baptisms, graduations, marriages, retirements, and deaths, include food as part of the ceremony. Many of these practices may have their origin in religious (for example, Muslims avoid pork and foods cooked with alcohol) as well as
future outcomes. That is not to say that clients cannot or will not learn about preventing future complications of illness, but nurses need to connect their teaching to the “here and now.” It is impor- tant to listen carefully to what the clients say in order to gather information about their time orientation. In cultures that focus on a past orientation (e.g., the Vietnamese culture), individuals may be less concerned about planning ahead and focus more on wishes and memories of their ancestors (Giger, 2012). In a past- oriented culture, time is viewed as being more flexible than in a present-oriented culture. It has less of a fixed point, and indi- viduals may not be offended by being late or early for appoint- ments. Nurses socialized in the Western culture may view time as money and equate punctuality with correctness and being responsible. Working with clients who have a different time per- ception than the nurse can pose a dilemma for the nurse who wishes to be culturally competent and accountable for helping her client receive adequate health care. Nurses should clarify the clients’ perceptions to avoid misunderstanding; however, nurses should explain the importance of keeping appointments from the Western perspective. For example, the nurse can communi- cate a willingness to be flexible in scheduling appointments and explain to clients that the time will be set aside, specifically for them. Along with culture, socioeconomic status and religion may influence the client’s perception of time.
Environmental Control Environmental control refers to the person’s relationship with nature and efforts to plan and direct factors in the environment that affect them. Different cultures can be distinguished on the basis of one of three views of nature and the role of environment in everyday life: (1) nature controls the environment, (2) nature and the environment work in harmony to promote health and wellness, and (3) the environment has mastery over nature. In cultures that perceive individuals as having mastery over the environment, one can expect that a client with the diagnosis of cancer will be willing to engage in a rigorous treatment, include chemotherapy, radiation, and laser therapy to beat the disease. Persons who value harmony with the environment (e.g., African Americans, Asians, and American Indian/Alaskan Natives) may perceive cancer as disharmony with other forces and that medi- cine can only relieve the symptoms rather than cure the disease. They would look to the mind, body, and spirit connection, for healing comes from within, to find treatments for the malig- nancy. Naturalistic solutions, such as herbs, acupuncture, and hot and cold treatments would be their treatment of choice to resolve the suffering associated with the cancerous condition. Individuals from cultures that view the environment as domi- nant over nature (e.g., Hispanics) may believe that they have little or no control over the serious illness for which they have been diagnosed. These individuals are less likely to engage in illness management interventions that are harsh and that they cannot trust to yield a positive health outcome.
Social Organization Social organization refers to the way in which families are struc- tured to carry out role functions. Members depend on the extended family and kinship networks for emotional, social, and
146 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
cultural (for example, African Americans may have a large meal with family and friends after church on Sunday) traditions. The culture domain of nutrition includes much more than having adequate food to sustain dietary requirements.
Efforts to understand dietary patterns of clients should go beyond relying on membership in a defined group. Knowing the client’s nutritional practices enables nurses to develop dietary regimens that do not conflict with their cultural food requirements. Health care teams that prescribe an American diet to a Hispanic or an Asian client whose mealtime and food choices may be different from American food patterns may be negligent. Specific foods have been developed for several sub- cultures such as Vietnamese, Cuban, Puerto Rican, Navajo, Japanese, and Jewish.
When engaging in mutual goal setting with the client and a nutritionist to change harmful dietary practices, the team might need to consult culturally oriented magazines before prescrib- ing particular food items. A number of popular magazines such as Essence, Ebony, and Latina have created healthier dishes from revised old family recipes for Hispanic and African American families. These dishes are tasty and resemble old traditions, yet they are nutritious. Although the foods may differ culturally, excesses often lead to similar risk factors. Box 7-3 identifies several questions that nurses should ask when conducting a nutritional assessment.
Many of clients’ health lifestyle choices are associated with their nutritional practices. As a result, before nurses begin a dietary intervention, they should perform a nutritional assess- ment to determine food preferences, rituals, and taboos. For many cultures, eating is a social activity and people get together for celebration and to comfort each other. Table 7-2 depicts various food preferences that are present among some cultural groups in American society and the associated risk factors when there is excessive use. Efforts to understand dietary patterns of clients should go beyond relying on membership in a defined group. Knowing the client’s nutritional practices makes it pos- sible for nurses to develop treatment regimens that will not conflict with their cultural food practices.
Religion The expression of spiritually is a component of health and illness coping for most people. The Joint Commission requires
1. Does the food have nutritional value based on My Plate? 2. What is the social significance of food in the family? Has the family
adopted foods from other cultural groups? 3. What foods are most frequently purchased for family consumption? Who
decides and from where is the food purchased? 4. What foods, if any, are prohibited for the family? 5. What variables play a significant role in food selection (cost, variability,
family rituals, religion, family tradition, celebrations)? 6. How often does the family prepare food at home? Who prepares the food?
How is it prepared? 7. How much food is eaten? When is it eaten and with whom? 8. Are fresh fruits and vegetables easily accessible for purchase in the
community? 9. What spices do the family use in the preparation of the food? What are
the family favorite recipes? 10. What are the characteristics of restaurants and other eating facilities that
the family uses outside of the home?
BOX 7-3 Assessment of Dietary Practices and Food Consumption Patterns
From Andrews MM, Boyle JS: Transcultural Concepts in Nursing Care, ed 6. Philadelphia, 2012, JB Lippincott; Giger JN: Transcultural Nursing: Assessment and Intervention, ed 6. St Louis, 2012, Mosby.
Cultural Group Food Preferences Nutritional Excess Risk Factors
African Americans Fried foods, greens, bread, pork, rice, foods with high sodium and starch content
Cholesterol, fat, sodium, carbohydrates, calories
Obesity, coronary heart disease, hypertension, cancer, diabetes, and HIV/AIDS
Asians Soy sauce, rice, pickled dishes, raw fish, tea, balance between yin (cold) and yang (hot) concepts
Cholesterol, fat, sodium, carbohydrates, calories
Coronary heart disease, liver disease, cancer of the stomach, ulcers
Hispanics Fried foods, beans and rice, chili, carbonated beverages, high-fat and high-sodium foods
Cholesterol, fat, sodium, carbohydrates, calories
Obesity, coronary heart disease, diabetes
American Indian/ Alaskan Natives
Blue corn meal, beans, squash, game and fish Carbohydrates, calories Depression, suicide, diabetes, malnutrition, tuberculosis, infant and maternal mortality
TABLE 7-2 Food Preferences and Associated Risk Factors in Selected Cultural Groups
that health professionals conduct a spiritual assessment on indi- viduals. Prayer and religion play a dominant role in protecting health and supporting healing in many cultural traditions. Among all the ethnic groups in the United States, African Amer- icans are most likely to report a formal religious affiliation (Pew Forum on Religion & Public Life, 2008). Among Hispanics, Roman Catholic and Pentecostal beliefs and practices are preva- lent. Hispanics who practice Pentecostal beliefs may engage in prayer and believe in miraculous healing.
Muslims are the most racially diverse group and the second largest and fastest growing religion in the world. In the United States, the majority of Muslims are white (37%), African Ameri- can (24%), Asian (20%), mixed race (15%), and Latino (4%). Muslims are considered either Sunni or Shia Muslim. Muslims face Mecca (which is northeast) when they pray, and when death is imminent they want their faces turned toward Mecca. Sunni Muslims pray five times a day and Shiite Muslims pray three times a day. Muslims gather for corporate worship on Fridays. Tradition says that Muslims pray on the floor, but during illness they may pray in bed. Exceptions from tradi- tional Muslim practices can sometimes be permitted during
147CHAPTER 7 Cultural Diversity in the Community
(13.5%); 36% of immigrant-headed households use at least one major welfare program (primarily food assistance and Medic- aid) compared to 23% of the U.S.-born population. They com- prise 16% of the total adult workforce with more than 54% of the adults in the labor force having completed high school (Camarota, 2012). These immigrants bring with them unique cultural, health care, and religious backgrounds (Figure 7-4).
There are four categories of foreign-born. The first category is legal immigrants, also known as lawful permanent resi- dents. This group constitutes about 85% of the immigrant population. They are not citizens but are legally allowed to live and work in the United States, usually because they fulfill labor demands or have family ties. Legal immigrants usually have a five-year waiting period living in the United States after receiv- ing “qualified” immigration status before they are eligible to receive entitlements such as Medicaid and CHIP (Camarota, 2012). The second category of foreign-born consists of refugees and persons seeking asylum. The Refugee Act of 1980 provided a uniform procedure for refugees (based on the United Nations definition) to be admitted to the United States (U.S. Depart- ment of Health and Human Services, 2001). This included refu- gees from Cuba, Vietnam, Laos, Cambodia, and Russian Jewish refugees. These are people who seek protection in the United States because of fear of persecution (on the basis of race, reli- gion, nationality, political view, or membership in a certain
pregnancy, breast feeding, illness, or travel; but the nurse should always ask the client because some Muslims may observe the practices even though they may have received permission for an exception.
Some African Americans practice Muslim traditions although most belong to a Christian faith. Many African Ameri- cans find comfort and support in their spiritual beliefs, believe God is responsible for health, and view health professionals as God’s instruments for healing. African Americans with Haitian background may practice voodoo in conjunction with a tradi- tional religion.
Most Jews observe the holidays of Rosh Hashanah and Yom Kippur. Many Jews observe Sabbath, which extends from sundown on Friday until sundown on Saturday. Jews of Euro- pean origin are called Ashkenazi Jews; Middle Easterners and non-European Jews are called Sephardic.
Chinese and other Asian people often practice Eastern reli- gions such as Confucianism, Buddhism, and Taoism (Lai and Sunrood, 2009). Confucianism emphasizes respect for the elderly and people in authority. Practitioners believe that moral conduct and maintaining harmonious relationships are the keys to life. The five most important attributes are benevolence, righteousness, loyalty, filial piety, and virtue. The Buddhist principles embrace three attributes: mercy, thriftiness, and humility. Buddhists believe that people receive good fortune for doing the right thing and misfortune for doing the wrong thing. Taoism embraces selflessness and emotional calm. The most important thing to them is to be in harmony with nature. An important element of health is outdoor exercise for peace of mind and outside air. Part of achieving good health is to adjust the thinking and the body to fit in with the natural rhythm of the universe.
Immigrants and Cultural Diversity Immigrants to the United States are born in countries or ter- ritories external to the United States and migrate to the United States, contributing to its vast diversity. Place of origin for the immigrant is distinguished from nationality, which refers to the place where the individual has or had citizenship. For example, if individuals were born in the Dominican Republic, they may be naturalized citizens, but their ethnicity is likely to be His- panic with a Dominican place of origin. It is estimated that the U.S. population consists of 39 million (foreign-born) immi- grants accounting for 12% of the total population of which 11.7 million have illegal status (Congress of the United States, 2012). Foreign-born refers to all residents who were not a U.S citizen at birth, regardless of their current legal or citizen status or those whose parents were not U.S. citizens. More than two thirds of the foreign-born population lives in or around major metropolitan areas in four states: Nevada, Texas, California, and Arizona (Congress of the United States, 2012). Their employ- ment tends to be associated with the region of the world from which they came. For example, persons from South America may be in construction- or agriculture-related occupations (21%), while persons from Asia tend to be associated with pro- fessional or technical occupations (39%). The foreign-born are likely to be poorer (23%) than the U.S.-born population
FIG 7-4 A child from Nepal living in the United States. The child has a black dot on her forehead to protect her from the “evil eye.”
148 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
hearing, and dental problems. Many of these conditions are either preventable or treatable if managed correctly. Nurses need to know the major health problems and risk factors that are spe- cific to the immigrant populations for whom they provide care. Nurses need to understand the difficulty of the acculturation process for immigrant families and to treat individuals in the context of the culture from which they come. Often children and adolescents adjust to the new culture more easily than adults. This can lead to a shift in the balance of power between adults and children, contributing to family conflict and at times vio- lence. Inability of elders to acculturate may play a large part in their lack of adherence to health care guidelines. When conduct- ing a health history, nurses should be alert for warning signs of family stress and tension. Remember that older family members can help translate their culture, beliefs, religious practices, dietary habits, support systems, and risk factors for the health care pro- vider. They can also assist with decision making and provide support to enable the person or group seeking care to change behaviors and increase their health promotion practices.
Similarly, understanding the role of the community in the care of immigrants is important. Communities can help clients (and thus providers) with communication, crisis intervention, housing, and emotional and other forms of support. Nurses need to carefully assess the community and learn what strengths, resources, and talents are available.
Nurses need knowledge about the traditional healing prac- tices that immigrants use. Many of these practices have thera- peutic value and can be blended with traditional Western medicine (Figure 7-5). The key is to know what practices are being used so the blending can be done knowledgeably. Com- munity members are excellent sources of this information, and nurses working with immigrant populations should use the community assessment, group work, and family techniques described in other chapters to partner with immigrant clients.
Culturally appropriate nursing actions that can be imple- mented to increase authenticity, accuracy, and approachabil- ity when working with immigrant populations include the following: 1. Self-awareness: Recognize the values, beliefs, and practices
that comprise your own culture. Nurses, like clients, are influenced by culture, values, and language.
2. Identify the client’s preferred or native language. When nurses do not speak or understand the client’s language, they must obtain assistance from an interpreter to ensure that full and effective communication occurs. Health care institu- tions must provide clients with an interpreter. The inter- preter should have knowledge of the client’s culture and medical terminology. Interpreters should be trained, quali- fied, and hired to ensure that they have met minimum stan- dards to provide accurate and safe interpretation. Using family members, friends, and staff who are not trained as health/medical interpreters can create errors in understand- ing and communicating, pose grave risks for the client and liability to the health care institution. While both an interpreter and a translator interpret and translate informa- tion from one language to another, there are significant differences between the two. A translator is usually
group) if they were to return to their homeland. Refugees are immediately eligible to receive Temporary Assistance for Needy Families, Supplemental Security Income, and Medicaid. The third category of foreign-born is the non-immigrants; these are people admitted to the United States for a limited duration and for a specified purpose. Non-immigrants include students, tourists, temporary workers, business executives, career diplo- mats, their spouses and children, artists, entertainers, and reporters. The fourth category of foreign-born is unauthorized immigrants, or undocumented or illegal aliens. These persons may have crossed a border into the United States illegally, or their legal permission to stay in the United States may have expired. Unauthorized immigrants are eligible to receive emer- gency medical services, immunizations, treatment for the symp- toms of communicable diseases, and access to school lunches only. They are not eligible for federal public benefits through the Affordable Care Act. Between 2007 and 2012, increased apprehensions by the U.S. Border Patrol accounted for a smaller number of persons entering the United States illegally than in the previous decade (Pew Research Center, 2013). A description of the immigrant populations and what benefits they are eligi- ble to receive can be found in A Description of Immigrant Popu- lation: An Update (Congress of the United States, 2012).
National debate about immigration policy has intensified, particularly about amnesty for illegal aliens, since the events of September 11, 2001. As a result, a variety of immigration laws have been enacted (Changes in Immigration Law, 2013). These changes reflect tightened and more restrictive visa procedures as well as greater scrutiny given to all visas and entry docu- ments. The complex issues involved with the foreign-born population and health care accessibility restrict the opportunity for public health nurses to provide culturally competent care to this population.
Misperceptions abound about the economic value of allow- ing immigrants to enter, or to stay in, the United States. It is estimated that immigrants increase the gross domestic product by 37 billion dollars each year because of their presence in the labor force and contributions in skills, education and capital investments by adding workers to the pool (Immigration Policy Center, 2012), The dilemma for communities, however, is that immigrants typically pay federal taxes yet the services they receive are paid for by the states and localities. Although federal matching funds for Medicaid are not available to the states for immigrants, some states have found compelling public health reasons to use their own funds to cover even undocumented immigrant children, pregnant women with low incomes, dis- abled persons, and older adults (Camarota, 2012).
There are other health care issues in addition to financial constraints on providing health care for immigrants. Some of these are language barriers; differences in social, religious, and cultural backgrounds between the immigrant and the health care provider; and the use of traditional healing or folk health care practices that may be unfamiliar to U.S. health care providers. Providers may lack knowledge about high-risk diseases in the specific immigrant groups for whom they care. For example, some groups are more at risk for hepatitis B (with its attendant effects on the liver), tuberculosis, intestinal parasites, and visual,
149CHAPTER 7 Cultural Diversity in the Community
4. Get to know the community where the immigrant client lives. Read about the culture of your clients. Take a course. Volunteer to participate in the acculturation process of the community (e.g., to give talks, hold forums with free-flowing and two-way communication), and learn who the formal and informal resources are.
5. Get to know some of the traditional practices and remedies used by families and communities. Coordinate health teach- ing seminars with traditional healing courses for the com- munity so you can work with, not against them.
6. Learn how cultural subgroups explain common illnesses or events. In cultures where the body and mind are seen as one entity or in cultures in which there is a high degree of stigma associated with mental illness, people or individuals somati- cize their feelings of psychological distress. In somatization, psychological distress is experienced as a physical illness.
7. Try to see things from the viewpoint of the client, family, and community and accommodate rather than squash the cli- ent’s view.
8. Conduct a cultural assessment focusing on what is working, what is not working, and changes that need to be made to accommodate cultural norms and promote positive health behaviors.
associated with translating written documents such as medical records and legal documents; in contrast, the inter- preter is associated with verbal communication that focuses on accurate expression of equivalent meanings rather than on word-to-word equivalence.
Many nurses cite linguistic barriers as the largest issue they encounter when trying to provide culturally competent care for linguistically different clients (Starr and Wallace, 2009). Experiences of success that nurses report when working with an interpreter include proper use of interpret- ers to assure that clients understand health care instructions; provision of linguistically appropriate educational material; ability to communicate in the client’s language to provide health care instructions; and ensuring proper use of instruc- tions. Experiences of difficulty include language barriers preventing appropriate communications; lack of available interpreters overall and for specific languages; and lack of appropriate translation by interpreter. Nurses can minimize some of these difficulties by learning basic words and sen- tences of the most commonly spoken languages in the com- munity and observing client reactions when asking them questions. Also, nurses should provide written material in the client’s primary language, so that family members can reinforce information when at home with the client. The How To Box provides guidelines for using an interpreter.
3. Learn the health-seeking behaviors of your client and their family members. In asking the client about family members, you might try using a simple genogram, which places family members on a diagram. Ask who the family members are, where they live, and who is missing or deceased. You might also ask them to talk about holiday celebrations: who comes, who is missing, what do they do?
FIG 7-5 Mi-yuk kook (seaweed soup) is a Korean dish eaten by postpartum women to stop bleeding and to cleanse body fluids. It is also eaten every birthday.
HOW TO Guidelines for Selecting and Using an Interpreter 1. The interpreter must interpret everything that is said by all the
people in the interaction and inform the public health nurse if the content might be perceived as insensitive or harmful to the dignity of the client.
2. The interpreter conveys the content, the spirit of what is said without omitting or adding.
3. The educational level and the socioeconomic status of the inter- preter are important. The nurse should know that the interpreter understands the community’s interpretation of the disease and the nurse should understand the community’s health care prac- tices around the disease.
4. The nurse needs to evaluate the interpreter’s style, approach to clients, and ability to develop a relationship of trust and respect.
5. The gender and/or age of the interpreter may be of concern; in some cultures, women may prefer a female interpreter and men may prefer a male, and older clients may want a more mature interpreter. Avoid using children as interpreters, particu- larly when the client is an adult.
6. Identify the client’s country of origin and language or dialect spoken before selecting the interpreter. For example, Chinese clients speak different dialects depending on the region in which they were born.
7. Observe the client for nonverbal messages such as facial expressions, gestures, and other forms of body language. If the client’s responses do not fit with the question, the nurse should check to be sure that the interpreter understood the question.
8. Make phrase charts and picture cards available. 9. Increase accuracy in transmission of information by asking the
interpreter to translate the client’s own words, and ask the client to repeat the information that was communicated.
10. The interpreter must maintain confidentiality of all information and interactions. At the end of the interview, review the mate- rial with the client and the interpreter to ensure that nothing has been missed or misunderstood.
150 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
mainstream in social, economic, cultural, or political life. Mar- ginalization is brought about by policies, practices, and pro- grams that have relegated these populations to the fringe of society and which prevents them from meaningfully participat- ing in society. Examples of these vulnerable populations include but are not limited to groups excluded due to race/ethnicity, homelessness, immigrants with linguistic challenges, drug abuse, sexual orientation, economics, and gender, which are devalued and not granted certain privileges that are given to others. In some instances, vulnerable populations may be con- sidered an equivalent term for marginalization.
Health Equity Health equity is concerned with providing social justice in health so that individuals are not disadvantaged from achieving the highest possible standard of health based on membership in a group that has historically been disadvantaged (Braveman, 2014). It is the principle underlying a commitment to reduce and ultimately eliminate disparities in health. Achieving health equity requires giving recognition to social barriers as well as barriers that have their origins in genetics, economics, and life- style factors that contribute to inequality of health. Health ineq- uities are avoidable treatment between groups of people. They are reflected in differences in length of life, quality of life, rates of disease and disability, severity of disease, access to treatment among groups of people, and death.
Social Justice Social justice is concerned with values of impartiality and objectivity at a systems or governmental level and is founded on principles of fairness, equity, respect for self and human dignity, and tolerance. Practicing social justice is acting in accor- dance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation.
Health Literacy The Centers for Disease Control and Prevention (CDC) define health literacy as the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health care decisions. Low health literacy negatively influences understand- ing of medical information (such as illness condition, treatment plan), obtaining health care services, managing chronic condi- tions, and use of medication and avoidance of medication errors, and places individuals at a safety risk. Low literacy is more common among the elderly, minority populations, immi- grants, individuals with lower socioeconomic status, and the medically underserved. Individuals with low health literacy are adversely affected by low educational skills, cultural barriers to health care, and by nurses who use language that the patient does not understand. Often these individuals may have a differ- ent perspective about their illness and what to do about it. The pattern in which they present their illness might be different from the pattern persons with high literacy skills would use to present their illness. When caring for persons with low literacy skills, nurses should ask the client to repeat instructions to assess the client’s level of literacy, repeat information as needed,
HEALTHY PEOPLE 2020
Goal: Eliminate health disparities among different segments of the population as defined by gender, race or ethnicity, education, income, disability, living in rural areas, and sexual orientation.
Selected Objectives • AHS-1: Increase the proportion of persons with health insurance. • AHS-2: Increase the proportion of insured persons with clinical preventive
services coverage. • AHS-3: Increase the proportion of persons with a usual primary care
provider. • AHS-6: Increase the proportion of persons who have a specific source of
ongoing care. • AHS-7: Reduce the proportion of individuals who are unable to obtain or
delay in obtaining necessary medical care, dental care, or prescription medicine.
Goals and Objectives of Healthy People 2020 Related to Cultural Issues
CULTURAL DIVERSITY AND HEALTH DISPARITIES Disparities in Health Disparities are used to describe incongruent elements. Health disparities are associated with inequity in social structures based on particular characteristics such as ethnicity, race, immi- grant status, gender, age, and sexual orientation (Levine et al, 2011). Health disparities stem from characteristics historically linked to discrimination. They are also expressed in differences in morbidity and mortality rates among population groups linked to factors such as race or ethnicity, religion, socioeco- nomic status, gender, mental health, sexual orientation, place of origin, and residence. Health disparities are monitored annually by various departments within The U.S. Department of Health and Human Services as part of the national goal to achieve health equity for all within the United States (see the Healthy People 2020 box related to health disparities).
Social Determinants of Health Social determinants of health are the circumstances in which people are born, grow up, live, work, age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces such as economic stability (indi- cators such as poverty and unemployment), education (indica- tors such as reading levels, graduation rates, and enrollment in higher education), social and community context (indicators such as family structure and social cohesion), health and health care (indicators such as access to health services and access to primary care), and neighborhood (indicators such as quality of schools and housing, access to healthy foods, and incidences of crime and violence) (Healthy People 2020, 2013).
Marginalization Marginalization of vulnerable populations occurs when a segment of the population has been excluded from the
151CHAPTER 7 Cultural Diversity in the Community
communication problems. Nevertheless, research on health dis- parities has shown that individuals from minority racial and ethnic groups are disproportionately likely to develop severe health problems and to experience lower quality care and poor outcomes in relation to health problems even after controlling for socioeconomic status, insurance status, and age (Agency for Healthcare Research & Quality, 2014; 2013).
There is danger in believing that only individuals in the lower socioeconomic rung use cultural behaviors such as folk (natural and magico-religious) practices. More individuals in Western cultures, including health professionals, are integrating folk practices with the biomedical system to promote, protect, and restore their health. Acceptance of this is reflected in courses being offered in universities, the arrival of newer disciplines in health care such as homeopathic medicine, and more accep- tance of traditional medicine (such as acupressure and acu- puncture). Nurses can consult and seek guidance from non-Western practitioners to better understand how clients and families integrate cultural concepts with other aspects of client care to meet their clients’ total health care needs.
CULTURAL COMPETENT NURSING INTERVENTIONS Cultural Competence Transcultural nursing recognizes and appreciates differences in health care values, beliefs, and customs. Transcultural theorists subscribe to the belief that nurses must acquire knowledge, skill, and attitudes in cultural competence and be committed to change to ensure positive outcomes, eliminate health dispari- ties, and increase client satisfaction.
A number of governmental agencies such as the U.S. Depart- ment of Health and Human Services, state regulations, and private and quasi-governmental regulators such as The Joint Commission have attempted to address the need for cultural competence through various standards and legislation. For instance, standards of practice for culturally competent nursing care were developed by a task force of the expert panel for Global Nursing and Health of the American Academy of Nursing in concert with members of the Transcultural Nursing Society to help nurses apply these standards universally in the arenas of clinical practice, research, education, and administration (American Academy of Nursing Expert Panel, 2010). The 12 standards address core values inherent in professional nursing practice and include behaviors, attitudes, and skills requisite for cultural competence. These standards are described in Box 7-4.
Both of the accreditation bodies for nursing education, the Accreditation Commission for Education in Nursing (ACEN) and the Commission on Collegiate Nursing Education (CCNE), address the need for cultural competence as essential content in nursing education. State Boards of Nursing are requiring cultural competence education in nursing schools and recent legislation in many states includes requiring cultural competency training for health care providers to receive licensure or relicensure.
Cultural competence entails a combination of culturally congruent behaviors, practice attitudes, and policies that allow nurses to use interpersonal communication, relationship skills,
allow the client time to process the information, use face-to-face communication whenever possible, make the information per- sonally relevant, give reasons for short-term benefits for taking the specific action, and provide sufficient follow-up for each person (CDC, 2009).
Health Disparities and Socioeconomic Status The relationship between health disparities and socioeconomic status is reflected in life expectancy, infant death rates, low birth rates, and many other health measures (Agency for Healthcare Research & Quality, 2013). Members of minority groups may be marginalized, preventing them from enjoying the same opportunities and resources for education, occupation, income earning, and property ownership that the dominant group has, thus relegating them to the fringe of society. Between 2007 and 2011 the poverty rate in the United States was 14.3% (Macartney et al, 2013), but there were differences in poverty rates associated with membership in various racial/ethnic groups. Table 7-3 indicates that there are more white families than minorities below the poverty level. However, the propor- tion of poor families in a minority group is greater. For example, 11.6% of white families are living in poverty, whereas 25.8% of African Americans, 23.2% of Hispanics, and 27% of American Indian/Alaskan Natives are doing so. Consequently, minority families are disproportionately represented on the lower tiers of the socioeconomic ladder. The mortality rate among individuals from lower socioeconomic status is signifi- cantly higher than among those from higher income levels (Cheng and Kindig, 2012).
Poor economic achievement is also a common characteristic found among populations at risk, such as single-parent head of households, the homeless, migrant workers, and refugees. Nurses should be able to distinguish between cultural and socioeconomic issues. Attributing behaviors stemming from socioeconomic deficits to behaviors embedded in cultural origins can result in misinterpretations of the client’s motiva- tion to adhere to treatment regimens. Data suggest that when nurses and clients come from the same social class, it is more likely that they operate from the same health belief model, and consequently there is less opportunity for misinterpretation and
From U.S. Census Bureau: Income, Poverty, and Health Insurance Coverage in the US: 2010 and Macartney S, Bishaw A, Fontenot K: Poverty rates for selected detailed race and Hispanic groups by state and place: 2007–2011.
Ethnic Groups Percent of Total Populations
Percent of Poverty Rate
Non-Hispanic Whites 42.4% 11.6% Blacks 12.6% 25.8% Asians 4.8% 11.7% Hispanics 16.4% 23.2% American Indian/
Alaskan Natives .09% 27.0%
Native Hawaiians 0.02% 17.6%
TABLE 7-3 Poverty Rates by Ethnic Groups
152 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
once thought to be all that was needed for nurses to effectively care for their client. In contrast, cultural sensitivity suggests that the nurse has basic knowledge of the client’s culture but does not use the information to devise a plan of care that reflects the client’s total cultural needs. Nurses should be aware of the social determinants of health in the environment that prevent indi- viduals from achieving good health.
It is generally accepted that culturally competent nursing care is guided by the following principles (American Academy of Nursing Expert Panel, 2010): 1. Care must be client centered, that is, designed for the specific
client, family, or community. 2. Care must be based on the uniqueness of the client’s culture
and incorporate the cultural norms and values of the client in the management of the care plan.
3. Self-empowerment strategies of the client are identified and viewed as strengths to facilitate client decision making and self-care management in health and illness situations. Cultural competence is also one of the core attributes of
public health nurses (Quad Council, 2011). Nurses work toward becoming culturally competent for a number of reasons. First, nurses who come from a culture different from that of the client may not be knowledgeable about the client’s culture. Nurses come from a variety of cultural backgrounds and have their own cultural traditions. Each nurse has unique cultural experi- ences that give meaning and understanding to his or her behav- ior. Because of differences between the client’s cultural system and the nurse’s cultural system, when the client and the nurse interact they may have different understandings about the meaning of the health issue and different ideas about what to do to promote and protect health. In these circumstances, nurses who value and practice cultural competence use com- munication and relational strategies that respect clients’ values, expectations, and goals without diminishing the nurses’ own values, expectations, and goals. To illustrate, a recent Mexican immigrant who speaks little English goes to a community health center because of a urinary tract infection. The nurse understands that she must use strategies that would allow her to effectively communicate with the client. She also understands that the client has the right to receive effective care that is based upon culturally informed nursing science, to judge whether she has received the care she wanted, and to follow up with appro- priate action if she did not receive the expected care. Nurses must be culturally competent to modify nursing interventions that are specific to the needs of cultural and ethnic groups.
Second, care that is not culturally competent may further increase the gap in racial and health disparities between minor- ity and majority populations. Failure to effectively respond to the health care needs and preferences of culturally and linguisti- cally diverse individuals may (1) increase barriers to equitable access to care, (2) inhibit effective communication between the client and the nurse, and (3) create obstacles in gathering assess- ment data, thus limiting the development and implementation of effective treatment plans.
Third, nurses use culturally competent practice to improve the quality, cost, and safety of care and health outcomes. The health care industry focuses on cost-effectiveness to balance
and behavioral flexibility to work effectively in cross-cultural situations. Cultural competence allows nurses to partner with the client to deliver health promotion, disease prevention, and health restoration (Campinha-Bacote, 2011; Leininger, 2002a). Culturally competent nurses respect individuals from different cultures, value diversity, and function effectively when caring for clients from other cultures. Cultural competence reflects a higher level of knowledge than cultural sensitivity, which was
Adapted from American Academy of Nursing Expert Panel: Standards of practice for culturally competent nursing care, 2010. Available at http://www.tcns.org/files/Standards_of_Practice_for_Culturally_ Compt_Nsg_Care-Revised.pdf. Accessed February 25, 2014.
Standard 1. Social justice: Nurses use principles of social justice to guide them as they advocate for the patient, family, community, and other health care professionals.
Standard 2. Critical reflection: Nurses critically reflect on their own values, beliefs, and cultural heritage to determine the influence of these qualities and issues on providing culturally congruent nursing care.
Standard 3. Knowledge of cultures: Nurses understand the perspectives, tradi- tions, values, practices, and family systems of culturally diverse individuals, families, communities, and populations for whom they care, as well as having knowledge of the complex variables that affect the achievement of health and well-being.
Standard 4. Culturally competent practice: Nurses use cross-cultural knowl- edge and culturally sensitive skills when implementing culturally congruent nursing care.
Standard 5. Cultural competence in health care systems and organizations: Health care organizations provide the structure and resources for nurses to evaluate and meet the cultural and language needs of their culturally diverse clientele.
Standard 6. Patient advocacy and empowerment: Nurses recognize the impact that health care policies, delivery systems, and resources have on their populations and advocate on the patients’ behalf for inclusion of their cultural beliefs and practices in all dimensions of their health care.
Standard 7. Multicultural workforce: Nurses engage in activities to ensure multicultural workforce health care settings, such as those that strengthen recruitment and retention in hospitals and academic settings.
Standard 8. Education and training in culturally competent care: Nurses shall have knowledge and skills to ensure that the delivery of patient care is culturally congruent and includes global health care agendas that mandate formal education and clinical training as well as ongoing continuing educa- tion for all practicing nurses.
Standard 9. Cross-cultural communication: Nurses use culturally appropriate verbal and nonverbal communication skills to identify patient’s values, beliefs, practices, perceptions, and unique health care needs.
Standard 10. Cross-cultural leadership: Nurses influence individuals, groups, and systems to achieve positive health outcomes of culturally competent care for diverse populations.
Standard 11. Policy development: Nurses have the knowledge and skills to work with public and private organizations, professional associations, and communities to develop policies and standards for comprehensive imple- mentation and evaluation of culturally competent care.
Standard 12. Evidence-based practice and research: Nurses use tested inter- ventions shown to be effective for the culturally diverse populations that they serve. The nurse also engages in research to test the effectiveness of interventions appropriate for specific culturally diverse clients.
BOX 7-4 Standards of Practice for Culturally Competent Nursing Care
153CHAPTER 7 Cultural Diversity in the Community
and care practices for its diverse populations and providers. Insurance companies, health maintenance organizations, and other private health entities have developed initiatives in cul- tural competence for their providers and engage in cultural competence strategies to improve patient satisfaction and patient care outcomes.
Sixth, in an effort to decrease the risk of liability from mal- practice claims and to increase client satisfaction, health care providers and health care organizations are engaging in cultural negotiations. For example, a communication strategy focused on increasing productive health care services for clients was initiated. The strategy utilizes a nurse–client partnership and underscores openness, mutual respect, and flexibility when communicating.
Developing Provider Cultural Competence Cultural competence is an ongoing life process in which the nurse is challenged to break with the old and engage in new ways of thinking and performing.
Nurses develop cultural competence through the critical reflective use of self-awareness skills, communications skills, relationship-building skills, and intervention skills that promote mutual respect for differences in the use of participatory deci- sion making. In developing cultural competence, nurses may be guided by two principles suggested by Leininger (2002a): (1) maintain a broad objective and open attitude toward individu- als and their cultures, and (2) avoid seeing all individuals as alike. Because there are varying degrees of cultural competence, not all nurses will achieve the same level of development con- currently. For example, Starr and Wallace (2009) reported that public health nurses in a southeastern public health department rated themselves higher on cultural thoughts (cultural aware- ness and sensitivity) than on cultural competence behaviors. Over all, the nurses reported a moderate level of cultural com- petence that was increased through online and class room courses.
In an early model developed by Orlandi (1992), three stages to developing cultural competence were depicted (culturally incompetent, culturally sensitive, and culturally competent). Table 7-4 shows that each stage has three dimensions—cognitive
cost and quality (Agency for Healthcare Research & Quality, 2012). Quality of care means that the client has access to health care and that the care is delivered by culturally competent nurses to help clients achieve positive health outcomes. Care that is not focused on the clients’ values, expectations, and goals is likely to increase cost and diminish quality. For example, when clients are using both folk medicine and traditional Western medicine and nurses fail to assess and use this informa- tion in teaching, the clients may not get the full benefits of the treatment protocol. Positive outcomes, which are indicators of quality, may not be met. When quality is compromised, addi- tional resources that typically increase costs may be needed to achieve the desired health care outcomes.
Fourth, legal regulations and accreditation mandates specify that culturally competent health care must be provided so that health disparities can be reduced and ultimately eliminated. For example, the specific Healthy People 2020 objectives for persons of different cultures need to be met (USDHHS, 2010). To accomplish these objectives, the client’s lifestyle and personal choices must be considered beyond the cursory ways that health care providers have interacted with clients in the past. Clients may present their symptoms vastly differently from the way they are presented in medical and nursing text books; they may present with different threshold for seeking care or expectations about their care. They may have beliefs about the origin and treatment of disease that affect their willingness to adhere to the treatment regimen, and they may have limited English pro- ficiency and low health literacy.
For example, American health care professionals frequently view excessive drinking as a sign of disease and alcoholism as a mental illness. However, in the American Indian/Alaskan Native culture, these signify a disharmony between the individual and the spirit world, and biomedical interventions alone may not be adequate to reduce alcoholism within this culture. American Indians and Alaskan Natives have an alcohol-related death rate that is two times higher than it is in the general population. This is particularly devastating among American Indian males in the 35 to 49 age group, and contributes to a loss of 6.4 more years of potential life compared with those in the general population (CDC, 2008). The national goal is to reduce this disparity. However, many American Indian/Alaskan Natives view alcohol consumption as an acceptable way to participate in family cel- ebrations and tribal ceremonies, and refusal to drink with family may be viewed as a sign of rejection. West (1993, p. 234) suggested that nurses understand the possible ramifications of not having culturally competent staff available to care for the American Indian/Alaskan Native population. She stated, “If the government sends Indians to a health clinic where personnel do not understand the holistic health practices of Indians and where young white people serve as caregivers and authority figures, failure is likely to result.” To have successful outcomes, nurses who develop population-based programs to reduce alcohol-related deaths must be willing to respect the cultural uniqueness of Native Americans and to explore individuals’ life experiences to find the underlying causes of their behaviors.
Fifth, to gain a competitive edge in the marketplace, the private sector is incorporating culturally competent policies
From Orlandi MA: Defining cultural competence: an organizing framework. In Orlandi MA, editor: Cultural Competence for Evaluators. Washington, DC, 1992, U.S. Department of Health and Human Services.
Culturally Incompetent
Culturally Sensitive
Culturally Competent
Cognitive Oblivious Aware Knowledgeable Affective Apathetic Sympathetic Committed to
change Psychomotor
(skills) Unskilled Lacking some
skills Highly skilled
Overall effect Destructive Neutral Constructive
TABLE 7-4 The Cultural Competence Framework: Stages of Competence Development
154 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
assets and barriers and appropriate intervention strategies. A confrontation might have ensued that would not have been helpful to the client or the nurse. Nurses should champion the cause for clients seeking health care to have health care profes- sionals respect their cultural traditions.
Cultural Knowledge Cultural knowledge refers to the process of searching for and obtaining a sound educational understanding about culturally diverse groups (Campinha-Bacote, 2011). Emphasis is on learn- ing about the clients’ worldview from an emic (native) perspec- tive as it pertains to health beliefs and practices, cultural values, and disease incidence and prevalence. For example, cultural knowledge indicates that Middle Eastern women might not attend prenatal classes without encouragement and support from the nurse (Meleis, 2005). Attendance at prenatal classes is about the future of the baby while the mother’s main focus may be on the present and what is happening in the immediate environment. The nurse’s understanding of the client’s concept of time would decrease misinterpretation that the mother might undermine efforts to promote a healthy baby, and allows the nurse to select strategies to ensure the client’s cooperation in providing the best care for the baby. In contrast, knowledge of Nigerian culture indicates that while women will start pre- natal care as soon as pregnancy is confirmed, they view preg- nancy and birth as natural events and may not continue to attend prenatal classes throughout the prenatal phase (Ogbu, 2005). Although the behavior of the women from these two countries may be the same, the rationale for their action is dif- ferent. Leininger (2002a) points out that nurses who lack cul- tural knowledge may develop feelings of inadequacy and helplessness because they are often unable to effectively help their clients.
Although it is unrealistic to expect that nurses will have knowledge of all cultures, they should know how and where to obtain information that impacts the individual with whom they have frequent interaction. Missing or inadequate knowledge of the client’s culture can contribute to negative situations such as client’s inadequate use of health resources. Because cultural competence is a requirement in nursing education, students are now exposed to a variety of individuals who hold membership in cultures that are different from their own. Students therefore have an opportunity to assess gaps in their cultural knowledge about how to care for individuals, families, and communities from diverse groups. Students also learn that clients are a rich source of information about their own culture. The Evidence- Based Practice box provides an example of learning how to meet the needs of a cultural group that is different from that of the nurse.
Cultural Skill Cultural skill is the third element of developing cultural com- petence. Cultural skill refers to the ability of nurses to effectively integrate cultural awareness and cultural knowledge when con- ducting a cultural assessment as well as a culturally based physi- cal assessment and to use the data to meet the specific client’s needs (Campinha-Bacote, 2011). Culturally skillful nurses elicit
(thinking), affective (feeling), and psychomotor (doing)—that have an overall effect on nursing outcomes. The most effective outcomes are knowledgeable, committed to change, and highly skilled. The most destructive outcomes are oblivious, apathetic, and unskilled.
A widely used model to explain the process of cultural com- petence was created by Campinha-Bacote (2011). The most recent model depicts five elements of cultural competence: (1) cultural awareness, (2) cultural knowledge, (3) cultural skill, (4) cultural encounter, and (5) cultural desire.
Cultural Awareness Cultural awareness refers to the self-examination and in-depth exploration of one’s own biases, stereotypes, and prejudices as they influence behavior toward other cultural groups (Campinha-Bacote, 2011). Culturally aware nurses are con- scious of culture as an influencing factor on differences between themselves and others, and are receptive to learning about the cultural dimensions of diverse clients. They understand the basis for their own behavior and how it helps or hinders the delivery of competent care to persons from cultures other than their own (American Academy of Nursing Expert Panel, 2010). Culturally aware nurses recognize that health is expressed dif- ferently across cultures and that culture influences an individ- ual’s responses to health, illness, disease, and death. Culturally competent care can be delivered in a variety of modes consistent with the client’s health values. For example, at a community outreach program, a nurse was teaching a racially mixed group the screening protocol for breast and cervical cancer detection. An African American woman in the group refused to give the return demonstration for breast self-examination. When encouraged to do so, she said, “My breasts are much larger than those on the model. Besides, the models are not like me. They are all white.” After hearing the client’s comments, the nurse realized that she did not take into account the significance of breasts based on ethnicity and culture, the size of the breast, and had made no reference in her talk to the influence of culture or race on screening for breast and cervical cancer.
The nurse then talked with the client, asked for her recom- mendations, and encouraged her to return the demonstration. The nurse coached the client through the self-examination process while pointing out that regardless of breast size, shape, and color, the technique is the same for feeling the tissue and squeezing the nipple to make certain that there is no discharge. Because this nurse was culturally aware, she neither became angry with herself or the client nor imposed her own values on the client. Rather, she elicited a discussion with the client about her beliefs, attitudes, and feelings about screening for cancer that may have been influenced by her culture. The nurse under- stood that she had to tailor her teaching material to the needs of diverse client groups. Subsequently, she advocated for her agency to purchase a model of an African American woman’s breast to be used in future health education programs with African American women.
If the nurse had not been culturally aware, she might have misunderstood the client’s concerns and acted in a defensive manner. Such an interaction would have failed to identify client
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that focuses on caring, compassion, presence, caring conscious- ness, and empathy. There are two types of cultural encounters: direct (face-to-face) and indirect. An example of a direct cul- tural encounter occurs when nurses learn directly from their Puerto Rican clients about spicy foods that they avoid during periods of breastfeeding. Indirect cultural encounters occur when nurses share these assessment findings with other nurses to help them develop their knowledge to effectively care for other Puerto Rican clients who are breastfeeding. The most important encounters are those in which nurses engage in effec- tive communication, use appropriate language and literacy level, and learn about clients’ life experiences and the signifi- cance of these experiences for health (Leininger, 2002a). In some communities, nurses may have few opportunities to work directly with persons of other cultures. Thus, when nurses come in contact with clients who are culturally different from the nurse, they should adapt general cultural concepts to the situ- ation until they are able to learn directly from the clients about their culture. Developing cultural competence also comes from reading about, taking courses on, and discussing different cul- tures within multicultural settings. Successful cultural encoun- ters embrace. Continuously interact with patients from diverse backgrounds to validate, refine, or modify existing values, beliefs and practices about a cultural group and to develop cultural desire, cultural awareness, cultural skill, and cultural knowledge (Figure 7-6).
Cultural Desire Cultural desire is the fifth element needed in the process of developing cultural competence. It refers to nurses’ intrinsic motivation to want to engage in the previous four elements necessary to provide culturally competent care (Campinha- Bacote, 2012). It is based on the humanistic value of caring for the individual. Nurses who wish to become culturally compe- tent do so because they want to, rather than because they are directed to do so. They demonstrate a sense of energy and enthusiasm about the possibility of providing culturally com- petent nursing interventions. Unlike the other elements, cul- tural desire cannot be directly taught in the classroom or in other educational or work settings. Nurses are more likely to demonstrate cultural desire when the environment at all levels of the organization reflects a philosophy that values cultural competence for all its clients.
Campinha-Bacote (2011) recommends that nurses who want to develop cultural competence should not fear making mistakes, but should internalize and incorporate into their own worldview selected beliefs, values, practices, life-ways, and problem-solving skills of other cultures with which they have the most frequent encounters. Several measures of the cultural competence construct have been reported in the nursing literature: the Interpersonal Process of Care survey (IPC-18, Chart Form: Stewart et al, 2007) and the Cultural Competent Assessment (CCA–25; Doorenbos et al, 2005). The IPC survey consists of two subscales that are used to determine disparities in interpersonal care, predict patient outcomes, and examine outcomes of quality improvement efforts to reduce health care disparities. The CCA consists of two subscales that
from clients their perception of the health problem, discuss treatment protocol, negotiate acceptable options, select inter- ventions that incorporate alternative treatment plans, and col- laborate with all stakeholders. For example, culturally competent nurses use appropriate touch during conversation and modify the physical distance between themselves and others while meeting mutually agreed upon goals.
Cultural Encounter Cultural encounter is the fourth element essential to becoming culturally competent. Cultural encounter refers to the process that permits nurses to seek opportunities to directly engage in cross-cultural interactions with clients of diverse cultures to modify existing beliefs about a specific cultural group and pos- sibly avoid stereotyping (Campinha-Bacote, 2011). Culture encounters, a key element in becoming culturally competent, have their roots in the nurse–client interpersonal relationship
From Jacobs A, Kemppainen JK, Taylor JS, et al: Beliefs about diabetes and medication adherence among Lumbee Indians living in rural southeastern North Carolina. J Transcult Nurs 25:167–175, 2014.
The purpose of this descriptive correlation designed study was to assess the personal beliefs about the causes and meaning of having diabetes among members of the Lumbee Indian tribe living in rural southeastern North Caro- lina. The sample consisted of 40 adult men and women. A mixed method approach to consist of qualitative and quantitative data was used to conduct this study.
The participant responses indicated a moderate belief in the efficacy of diabetes treatment, a moderate belief in their ability to understand a coherent model of diabetes, and a low level of emotional distress related to having diabetes. Two major themes emerged from the open-ended questions about the causes of diabetes: (1) genetic predetermination and (2) lifestyle practices. Although participants believed that their prescribed diabetes medications were a necessary part of controlling their illness, several expressed fatigue and “felt worn out” with having to persist with their treatment expectations. Limitations were that the sample only included persons who were seeking health care treatment for diabetes and did not include those who were not scheduled for an appointment at the clinic during the data collection period, or included those who did not have access to health care.
Nurse Use Nurses should be aware that their Lumbee Indian clients may not always have a high degree of confidence in conventional treatment regimens nor under- stand the unpredictable course of diabetes. Nurses should work with these clients to provide culturally congruent education using appropriate communi- cation to increase clients’ knowledge about current treatment regimens. Nurses should incorporate culturally specific strategies that will empower clients to take a more active role in their illness management, dispel the attitude that a diagnosis of diabetes is genetically predetermined, link con- crete behaviors to disease progression and outcomes, and demonstrate to clients how attainable decreases in blood sugar can reduce the risk of long- term consequences. Such strategies would help eliminate negative percep- tions that may interfere with the health care delivery process. The researchers suggested that by using a broad systems approach, nurses will increase the availability of Native American health care providers who can serve as role models for the community as well as become activists for developing com- munity infrastructure to support healthy lifestyles.
EVIDENCE-BASED PRACTICE
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group, leading to an expectation that they will always behave in ways that reinforce the stereotypical notion. Other groups are stereotyped as “industrious and hard working,” while some groups are stereotyped as negative and noncompliant. To illus- trate, a nurse who believes that young African American women are sexually permissive may label a woman in this group who is complaining of abdominal pain as having symptoms of a sexually transmitted disease. Clients who perceive they are being stereotyped may respond with anger and hostility. This in turn perpetuates the stereotype and creates barriers to health- seeking behavior. To minimize the use of stereotypes, nurses should rely on their ability to conduct good health assessment and engage in culturally competent discussions.
Prejudice Prejudice is the emotional manifestation of deeply held beliefs (stereotypes) about a group. These beliefs are directed toward a person who is a member of that group, and who is presumed to have the qualities ascribed to the group. Prejudice is not based on reason or experience but rather on negative or favor- able preconceived feelings. These feelings are often precursors for discriminatory acts based on prejudging, limited knowledge about, misinformation about, fear of, or limited contact with individuals from that group. Those who are prejudiced wish to deny the individuals, on the basis of race, skin color, ethnicity, or social standing, the opportunity to benefit fully from soci- ety’s offerings of accessible health care, education, good jobs, and community activities.
Racism Racism is a form of prejudice that occurs through the exercise of power by individuals and institutions against people who are
examine nurses’ cultural diversity experience, cultural aware- ness and sensitivity, and performance of cultural competence behaviors.
Barriers to Developing Cultural Competence Nurses fail to provide culturally competent nursing care for a variety of reasons: they may have had minimal opportunity to learn about cross-cultural nursing; their supervisors may encourage them to increase productivity at the expense of quality; or they may be pressured by colleagues who are not knowledgeable about cultural concepts and are offended when others use the concepts. These and similar issues may result in nurses engaging in behaviors such as stereotyping, prejudice and racism, ethnocentrism, cultural imposition, cultural con- flict, and culture shock.
Stereotyping Stereotyping is ascribing certain beliefs and behaviors about a given racial and ethnic group to an individual without assessing for individual differences. Stereotyping blocks the willingness of a person to be open and to learn about specific individuals or groups. When information is not immediately available, nurses may generalize about an individual’s group behavioral pattern as a guide until they have had time to observe and assess the client’s behavior. This can be a problem, and it may lead to a nurse’s unwillingness to incorporate new and specific data about the client. New information may be distorted to fit with preconceived ideas. The generalizing that was a beginning point for under- standing the individual becomes a final point. The individual is thus stereotyped on the basis of the group’s ascribed behavior.
Stereotypes can be either positive or negative. For example, Asians are often positively stereotyped as the “model” minority
FIG 7-6 A Hispanic nursing student interacting with African American men at a nutritional center. To interact in a culturally com- petent manner, the student needs to have awareness of and knowledge about the differences between her culture and the men’s culture and the skill to portray this in her behavior toward them.
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means that the behavior is both apparent and purposeful. The nurse is aware of personal biases and beliefs and integrates them into a plan of action to negatively manage client problems. With overt unintentional, the behavior is apparent but not purpose- ful, and no harm is intended, although harm may result. Covert intentional means that the behavior is subtle and purposeful but the person tries to avoid being viewed as prejudicial or racist. Covert unintentional means that the person’s behavior is neither apparent nor purposeful. The person is unaware of the behavior. Regardless of the type of prejudice or racism, the behavior is harmful to the client. Examples of each type of prejudice and racism are presented in Box 7-5.
Ethnocentrism Ethnocentrism, or cultural prejudice, is the belief that one’s own cultural group determines the standards by which another group’s behavior is judged. The implication is that one’s own standards are better than and superior to the other person’s standards. Ethnocentric nurses favor their own professional values and find unacceptable that which is different from their culture. Their inability to accept different worldviews often leads them to devalue the experiences of others, judge them to be inferior, and treat those who are different from themselves with suspicion or hostility (Andrews and Boyle, 2012).
Ethnoculturalism is in contrast to cultural blindness, in which there is an inability to recognize the differences between one’s own cultural beliefs, values, and practices and those of another culture. The tendency is to believe that the recognition of racial, ethnic, religious, or gender difference is itself prejudi- cial and discriminatory. Hence, nurses who state that they treat all clients the same, regardless of cultural orientation, are dem- onstrating cultural blindness.
Cultural Imposition Cultural imposition is the belief in one’s own superiority, or ethnocentrism, and is the act of imposing one’s cultural beliefs, values, and practices on individuals from another culture. Nurses impose their values on clients when they forcefully promote biomedical traditions while ignoring the clients’ valuing of non-Western treatments such as acupuncture, herbal therapy, or spiritualistic rituals. A goal for nurses is to develop an approach of cultural relativism, whereby they recognize that clients have different approaches to health, and that each culture should be judged on its own merit and not on the nurse’s per- sonal beliefs.
Cultural Conflict Cultural conflict is a perceived threat that may arise from a misunderstanding of expectations when nurses are unable to respond appropriately to another individual’s cultural practice because of unfamiliarity with the practice (Andrews and Boyle, 2012). Although cultural conflicts are unavoidable, the nursing goal is to manage conflicts so that they do not affect the delivery of culturally competent nursing care. Knowing how conflict is managed in the particular culture can minimize the conflict. It is important, when resolving the conflict, that all persons involved in the conflict have a way to “save face.”
judged to be inferior on the basis of intelligence, morals, beauty, inheritance, and self-worth. Individuals are denied certain opportunities (e.g., jobs, housing, education, and health care) typically enjoyed by the larger group because of some charac- teristic over which they have no control. When racism is acted upon, it results in perceived or actual harm to the individual. Three types of racism exist: individual, institutional, and cul- tural. Individual racism refers to discriminatory behavior or acts directed toward individuals or groups because of identified characteristics, such as skin color, hair texture, and facial fea- tures. Institutional racism refers to discriminatory behavior or acts by an institution, as expressed in policies, priority setting, hiring, and resource allocation practices that are directed toward individuals and groups and restrict their access to opportunities or resources. Institutional racism provides the structure for racism at the individual level to be accepted and condoned. Cultural racism refers to discriminatory behavior or acts directed by the dominant group toward another cultural group. The cultural group is depicted in derogatory or stereotypical ways because of, for example, language or dress. All forms of racism can have individual, as well as community and popula- tion, effects.
The Tuskegee Syphilis Study is a well-known example of racism (Gamble, 1997). This study was conducted by the U.S. Public Health Service to observe the effects of syphilis on African American men over a period of 40 years, beginning in 1932. When African American men with syphilis were recruited for the study, they were told that they were being treated for “bad blood,” and treatment for syphilis was withheld intention- ally so that the study on the deleterious effect of syphilis could be completed. As a result, hundreds of men lost their lives because of discriminatory policies that promoted substandard health care. The consequence of such racism has contributed to the long-held beliefs by some African Americans that health research might be designed to harm them and that accessible health care for African Americans might be part of a research study, especially government-sponsored programs. In 2005, Dwayne, Isaac, and Laveist reported that a telephone survey revealed that no differences by race existed between African Americans and whites in knowledge about the Tuskegee study. There were significant race differences in medical care that the researchers attributed to broader historical and personal experi- ences of African Americans. Perceived racism by cultural groups can have physiological and psychological negative health out- comes that include high blood pressure, stroke, engaging in risky behaviors such as smoking and substance abuse, depres- sion, and low self-esteem. Nurses too may be recipients of prej- udicial or racist acts (Fielo and Degazon, 1997), but they do not have to accept such behavior from clients. Rather, they should set limits, discuss the behavior with other colleagues when appropriate, and avoid personalizing the behavior.
One way to depict the effects of prejudice and racism is to use a two-dimensional matrix: overt versus covert, and inten- tional versus unintentional. Locke and Hardaway (1992) depict four types of prejudice and racism that result from this matrix: overt intentional, covert intentional, overt unintentional, and covert unintentional. Overt intentional prejudice or racism
158 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
Overt Intentional Prejudice/Racism Two homeless women, one African American and the other Irish, are clients at the oncology clinic at the free neighborhood health care center. Both of the women have a history of ovarian cancer and are experiencing financial difficulty from time to time due to the cost of medical care associated with the illness. Although the African American client has been homeless longer, both clients have health issues associated with diminished quality of life and functional status related to the length of the illness, the progression of the illness, and the seriousness of the illness. The nurse as case manager referred the Irish client to the social services department to inquire about available resources but did not refer the African American client. The nurse reasoned that minority clients have direct contact with some local and national government programs, know about available resources, and have experience negotiating the social system for themselves and their family. In contrast, the nurse reasoned that because the Irish woman had no prior experience negotiating government programs, she needed to advocate for her client. The nurse did not assess the health-seeking behaviors of either client before coming to these conclusions, stereotyped both women, and intentionally used her informational power to help one client while denying assistance to the other client.
Overt Unintentional Prejudice/Racism The community health nurse was assigned to make an initial home visit to two clients recently discharged from the hospital with a diagnosis of hypertension. The nurse performed physical assessments on both clients. He developed an extensive culturally relevant teaching plan with the Filipino client that included information on sodium restriction and its effect on kidney functioning, ways to integrate cultural foods into the diet, and support in lifestyle changes. With the Puerto Rican client, the nurse performed a routine physical assessment and did not discuss the client’s culturally special dietary requirements. The nurse rea- soned that the Puerto Rican client was not capable of understanding such complex information and would most likely seek information from her curandera (a folk practitioner) to manage the hypertension. At the end of the visit, the nurse said to this client, “Take care of yourself. See you next time.” This nurse did not realize that he had stereotyped the client and that his nursing interventions were
minimal. He believed that he had delivered patient-centered care and the dif- ference in his assessment and implementation approach reflected his under- standing of cultural competence theory.
Covert Intentional Prejudice/Racism A Native American nurse works in a home health agency that serves an ethni- cally diverse community. The nurse has observed that her assigned clients are always among the poorest and live in the unsafe ZIP code areas of the com- munity. Her nonminority nurse colleagues are not assigned to clients residing in those ZIP codes. In a recent staff meeting, the Native American nurse expressed discomfort about the assignment patterns that she had observed with her nursing supervisors. Upon hearing her observations, the supervisors looked at the nurse in a surprised and skeptical manner and asked her to give a specific example. This is an example of covert racism because the nursing supervisors were aware of the informal policy that they assign minority nurses to clients residing in designated minority neighborhoods. The nursing supervisors were aware of this long-standing practice to assign minority nurses to minority clients and Caucasian nurses to Caucasian clients but would never admit to it. The supervisors thought that the best way for minority clients to be the recipi- ents of culturally competent care was to assign a minority nurse to care for their own.
Covert Unintentional Prejudice/Racism Ashley is the seven-year-old daughter of a lesbian middle-class couple. The school nurse is frustrated that Ashley’s parents refuse to disclose the father and insist on altering the demographic form to include the two mothers as parents. Ashley frequently shows up to the nurse’s office with stomach upsets and the nurse attributes the upsets to the parents’ sexual orientation. The school nurse has not conducted an in-depth assessment of the child’s chief complaint. This is unusual behavior for the school nurse as she has been cited for her thorough assessments of children that have resulted in early diagnosis and treatment of disorders for this age group. This school nurse is unaware that her intolerance for the parents’ sexual orientation and family’s lifestyle has contributed to her decision to provide a cursory assessment for Ashley.
BOX 7-5 Types of Prejudice and Racist Behaviors
Culture Shock Culture shock is the feeling of helplessness, discomfort, and disorientation experienced by an individual attempting to understand or effectively adapt to a cultural group whose beliefs and values are radically different from the individual’s culture. When nurses experience culture shock, it may be a normal reac- tion to a client’s beliefs and practices that are not allowed or approved in the nurse’s own culture (Andrews and Boyle, 2012). Culture shock is brought on by anxiety that results from losing familiar signs and symbols of social interaction. As nurses change their practice environments and leave the safety of the hospital for community settings, they may experience height- ened discomfort and feelings of powerlessness to confront dif- ferences between themselves and clients. This is especially true when nurses have little knowledge or exposure to the culture from which the client comes. For example, nurses who are unfa- miliar with “cupping” may experience culture shock when Cambodians use this practice to relieve headaches, to reduce stress and sinus tension, or to delay the onset of colds. Being aware of the clients’ own cultural beliefs and having knowledge of other cultures may help nurses to be more accepting of cul- tural differences.
Culturally Competent Nursing Interventions In culturally competent nursing interventions nurses integrate their professional knowledge with the client’s knowledge and practices to maintain, protect, and restore the client’s health. Leininger (2002a) developed a nursing intervention framework to increase culturally competent care; this framework suggests three modes of action, based on negotiation between the client and nurse, which guide the nurse to deliver culturally compe- tent care: cultural preservation, cultural accommodation, and cultural repatterning. When these decisions and actions are used with cultural brokering, the nurse is able to provide holis- tic care for culturally diverse clients (individual, family, or community).
Cultural Preservation Cultural preservation refers to assistive, supportive, facilitative, or enabling nurse actions and decisions that help the clients of a particular culture to retain and preserve traditional values, so they can maintain, promote, and restore health. For example, acupuncture, an ancient Chinese practice of inserting needles in specific points on the skin through which life energy flows, is used to relieve pain or cure diseases by restoring balance of
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when cultural values and beliefs are respected while at the same time there is a cocreation of interventions with the client to provide for a healthier pattern than before the changes were developed. For example, a culturally competent school nurse who works with Mexican Americans knows of the high inci- dence of obesity among women 20 years and older. Using this information, she developed a health education program for Mexican teenagers in the local high school. While respecting their cultural traditions, the nurse discussed weight manage- ment strategies with the teenagers. The nurse understood the teenagers’ cultural issues pertaining to food and knew how to negotiate with them. She discouraged the use of fried foods (such as tortillas), sour cream, and regular cheese and encour- aged and demonstrated the use of baked tortillas and salsa as dip and topping. In another example, a nurse discovered during her instructions on diabetes self-management that pregnant Haitian women were visiting an herbalist to obtain teas so they would not have to take insulin. The nurse asked for the names of the herbs in the teas that they were drinking and scheduled a conference with the pharmacist to discuss the specific ingre- dients in the herbs as well as ways that they might help clients meet their cultural needs. The nurse found out that one of the herbs contributed to high blood pressure, a problem that many of the women were experiencing. She negotiated with the women not to take the tea with the specific herb. The nurse understood the importance of supernatural causes of illness in the Haitian culture and sought cooperation from the herbalist. Another example of cultural repatterning occurs when nurses assist older Chinese clients to use low-sodium soy sauce, rather than soy sauce with high sodium, in their cooking as a means to more effectively manage their hypertension. Similarly, nurses should guide African Americans to eat more broiled and less fried foods.
Culture Brokering Culture brokering is advocating, mediating, negotiating, and intervening between the client’s culture and the biomedical health care culture on behalf of clients. Nurses as culture brokers act as go-betweens or advocates between groups of persons or persons of different cultural backgrounds to reduce conflict or produce change to facilitate client access to health care. As client advocates, nurse brokers are positioned to understand both cultures (the client’s culture and the culture of the health care system) and resolve or lessen problems that result when indi- viduals in either culture do not understand the other person’s values. To illustrate, migrant workers tend to have high occu- pational mobility; many are poor and have limited formal edu- cation. They may seek health care only when they are ill and cannot work. Nurses who staff mobile health care vans often come in contact with migrant workers and usually take the opportunity to teach these individuals about prevention, health maintenance, environmental sanitation, and nutrition because it may be the only opportunity they will ever have to care for that particular migrant worker. These public health nurses also advocate for the rights of the migrant worker to receive quality health care. In this instance mobile health care nurses who provide manpower for the health mobile care van clinic may
yin and yang (Spector, 2012). This practice is being accepted by increasing numbers of Western practitioners as a legitimate treatment for many health problems. Thus, when Western prac- titioners integrate modalities such as acupuncture in the plan of care to maintain and protect the health of Asian clients who subscribe to the practice, they are providing care that is consis- tent with the clients’ beliefs and values and helping to preserve their culture.
In another example, the nurse helps maintain cultural family values of Ms. Rodriquez, a 73-year-old Filipino woman who was discharged from hospital to home care after surgery for cancer of the large intestine. During the home visit, the nurse discussed with the client and her husband about making a referral to have a home health aide assist with physical care and light house- keeping chores. The family was gracious but seemed hesitant to accept the referral. The nurse knew that in the Filipino family the older daughter is expected to be the caregiver for her mother and father. She asked the couple if they would like to discuss the situation with their daughters. Both the client and her husband seemed pleased with the idea, and the nurse promised to get back to them the next day. When the nurse returned for her visit, Ms. Rodriquez’s older daughter was present and told the nurse that she would manage without additional help. The three daughters had made a schedule to take turns caring for their parents. The nurse accepted and supported the family’s decision and told them that if they decided at a later time to accept the services of a home health aide, they should call the agency. The nurse then gave the family the telephone number of the agency, and scheduled the next follow-up visit with them.
Cultural Accommodation Cultural accommodation refers to assistive, supportive, facili- tative, or enabling nurse actions and decisions that help clients of a particular culture accept nursing strategies, or negotiate with nurses to achieve satisfying health care outcomes. Nurses may support and facilitate successful use of home burial of placenta alongside interventions from the biomedical health care system. For example, the delivery nurse was very helpful when Ms. Sanchez asked her not to discard a piece of the amni- otic sac that was present on her grandbaby’s face immediately after birth. Ms. Sanchez asked the nurse to give it to her instead. The grandmother believed that being born with a piece of the amniotic sac on the face was a visible sign that something special was going to happen in the person’s life. The grand- mother explained that after she dried the piece of the amniotic sac, she would keep it in a safe place. She would also spend extra time protecting the baby to prevent her from being harmed. Although the delivery room nurse was not knowledgeable about this practice, she was assistive and gave the grandmother the piece of the sac as she requested.
Cultural Repatterning Cultural repatterning refers to assistive, supportive, facilitative, or enabling nurse actions and decisions that help clients of a particular culture to change or modify a cultural practice for new or different health care patterns that are meaningful, satis- fying, and beneficial. Successful repatterning is likely to occur
160 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
practice; (3) being culturally innovative refers to the use of cultural symbols and notions of health and well-being to convey health promotion messages, working with established social institutions in the community; and (4) being cultural transfor- mative refers to using principles of social activism and change to unearth power relationships and partnering with communi- ties to alter aspects of the basic social structure. The assertion by these authors that social activism can and should be a part of social competence underscores the commitment that orga- nized nursing has to address social justice issues rooted in larger systems problems of inequality and discrimination. Nurses, as providers, are expected to develop cultural competence to change the dynamic of the nurse–client relationship. As leaders, nurses are expected to use leadership skills to advocate for social justice by promoting community empowerment, liberation, and relief of suffering and human oppression.
Betancourt et al (2003) presented a three-tier cultural com- petence framework—clinical, organizational, and structural— through which culturally competent strategies can be implemented to reduce health disparities. According to Betan- court, the rationale for these three levels of focus is that all three levels contribute to disparate health outcomes; therefore they must all be addressed to level the playing field and equalize health outcomes. Social cultural barriers to culturally compe- tent care in this model are clinical barriers (poor provider com- munication, provider stereotyping and discrimination, and misunderstanding of culture perspective on health issues), organizational barriers (the lack of minorities in institutional leadership and the health care workforce), and structural (lack of interpreter services, bureaucratic intake processes, and dif- ficulties accessing specialty care for minorities). Interventions to overcome these barriers are suggested for each level. Struc- tural interventions include improving access to processes within the delivery health care system that includes expanding inter- preter services and health teaching; organizational interven- tions include increasing diversity within the workforce and the health care leadership; and clinical interventions include working to enhance provider knowledge of the relationship between sociocultural factors and health beliefs and behaviors, and equipping providers with tools and skills to manage these factors appropriately.
Institutional level interventions could include agency engage- ment with the broader community, increased access to care for socioeconomically disadvantaged groups, and selection of interventions that are culturally appropriate. This macro level model provides direction for agencies that want to adopt cul- turally competent practices as part of their operational proce- dures and to facilitate provider level culturally competent care. When describing these broad-base interventions, cultural com- petence becomes an umbrella term to address the many indi- vidual level skills, attitudes, and knowledge and organizational level structures, policies, and protocols that come together in a profession, organization, or community to provide effective care to culturally diverse populations.
How well do culturally competent interventions fare in improving positive health outcomes for culturally diverse clients? Many studies demonstrate a beneficial effect on
contact the migrant health services for follow-up or referral care for the migrant workers who received health care from the mobile health care van.
LINKING CONTENT TO PRACTICE
As has been discussed throughout the chapter, culturally competent nursing care uses many of the standards, guidelines, and competencies from key nursing and public health documents. For example, the Council on Linkages (Council on Linkages, 2010) has a set of skills related to cultural competency and a set related to communication that are consistent with the information in this chapter. Likewise, the Quad Council further develops and applies the skills of the Council on Linkages related to both cultural competency and communication to public health nursing practice. As an example, the Council on Linkages states that a necessary skill in public health is to consider “the role of cultural, social, and behavioral factors in the accessibility, availability, acceptability and delivery of public health services.” The Quad Council states that “public health nurses should consider the role of cultural, social, and behavioral factors in the accessibility, availability, acceptability and delivery of public health nursing services.” Each of the competencies in the Council on Linkages core competencies is applied directly to public health nursing prac- tice by the Quad Council (2011). Also, the American Academy Expert Panel on Global Nursing and Health (2010) identifies 12 standards that serve as a resource and guide for nurses in practice, administration, education, and research by underscoring cultural competence as a priority of care for the populations that they serve.
Developing Organizational Cultural Competence Cultural competence barriers extend beyond the individual health care provider. Institutions and agencies can facilitate cul- tural competence. For example, a number of organizations sub- scribe to the nine cultural competence strategies that Lie and colleagues (2010) targeted at the institutional level: (1) provid- ing interpreter services, (2) establishing recruitment and reten- tion policies to increase ethnic minority representation, (3) providing training in cultural competence and sensitivity, (4) coordinating with traditional healers in the community, (5) using community health workers, (6) carrying out culturally competent health promotion that incorporates cultural notions of health and well-being, (7) including families and community members in care and decision making, (8) facilitating provider immersion into another culture and administrative and orga- nizational accommodation, such as providing a welcoming environment, and (9) ensuring linguistic appropriateness of materials and information. By incorporating culturally compe- tent behaviors that are embedded in the culture of the organiza- tion into the cultural competence framework, institutions have expanded the reach of their resources into the community and are addressing social determinants of health care.
Tripp-Reimer et al (2001) described another organizational cultural competence intervention model. They described four levels of systems interventions: (1) being culturally neutral refers to the standard practice typically developed by whites for whites; (2) being culturally insensitive refers to addressing issues of accessibility of services by using bilingual and bicul- tural health informational material that incorporates surface- level cultural knowledge, such as dietary preferences into
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satisfaction has been the subject of recent research activity in nursing. The majority of studies of the effectiveness of cultur- ally competent nursing interventions are descriptive. Few studies have employed a randomized clinical trial design. Fisher et al (2007) identified 38 nursing interventions that used some form of culturally oriented interventions to target racial and ethnic disparities. Kulbok et al (2012) cited several examples from the evidence-based nursing literature of public health nursing using the technique of participatory practice, defined as the building of partnerships with community members to assess, plan, analyze data, and implement sustainable health promotion and prevention programs to reach marginalized populations in vulnerable communities. For instance, Andrews et al (2007) used participatory methods to assess an African American population living in an impoverished neighborhood. To gain in-depth insights about the community’s assets and needs, the research team involved community advisory board members and community health workers to assist them in con- ducting a series of community forums and interpreting the data gathered at the forums. Anderson and her research team (2007) were able to identify multilevel factors related to smoking pat- terns of the community. Thomas et al (2009) worked with a tribal community council to attain culturally sensitive knowl- edge of the tradition, history, and strength of that community in projects to reduce substance abuse. McQuiston et al (2005) used ethnographic community participatory strategies to set up a nominal group process to obtain important cultural aspects of health when assessing health disparities in a Latino popula- tion. Zandee et al (2010) described how public health nursing students used cultural competence principles to better under- stand the cultural background of the communities in which they were placed. By partnering with community health workers, the students were able to improve their cultural competence.
CULTURAL NURSING ASSESSMENT A cultural nursing assessment is “a systematic identification and documentation of the culture care beliefs, meanings, values, symbols, and practices of individuals or groups within a holistic perspective, which includes the worldview, life experiences, environmental context, ethno history, language, and diverse social structure influences” (Leininger, 2002b, pp. 117-118). A cultural assessment is the basis for providing culturally compe- tent health care and helps to ensure that nurses will understand and respect the client’s beliefs, values, and health care practices and take these cultural data into consideration when creating a treatment plan for the client. A cultural assessment should focus on those aspects relevant to the presenting problem, necessary intervention, and participatory education. Nurses use the infor- mation gathered to help them identify and understand clients’ beliefs and practices about health and illness. By adopting a relativistic approach, nurses avoid judging or evaluating the clients in terms of their own culture.
A nonjudgmental approach toward the client’s culture is facilitated through having a skill set that includes understand- ing, eliciting, listening, explaining, acknowledging, recom- mending, and negotiating. It is vital that nurses listen to clients’
provider knowledge, provider attitudes, and provider skills. Favorable patient satisfaction measures and improvement in adherence to follow-up among client assignees to intervention group providers have also been reported. Interventions that focus on the avoidance of bias, gender concepts of culture, and client-centeredness demonstrate promise as lasting strategies to decrease health disparities. These strategies include availability and access to assessment of problems in their social and cultural context, selection of culturally and socially acceptable interven- tions, and increased accountability to recipients of services and their community. Institutional level interventions could include agency engagement with the broader community, increased access to care for socially disadvantaged groups, and selection of interventions that are culturally appropriate. These four macro level modes provide direction to agencies that want to adopt culturally competent practices as part of their operational procedure and to facilitate provider level culturally competent care. When describing these broad-based interventions, cultural competence becomes an umbrella term to address the many individual level competencies, skills, attitudes, and knowledge, and organizational level competencies, structures, policies, and protocols that come together in a profession, organization, or community to provide effective care to culturally diverse populations.
Positive Health Outcomes Associated with Cultural Competence Nurse clinicians and educators are beginning to understand how to provide critical learning environments and workplaces for students, faculty, and practitioners to apply the concepts of cultural competence in their practice in order to improve the effectiveness of their actions. The majority of nurses continue to believe that they are less confident and inadequately prepared to provide sustained culturally competent care to clients from diverse cultures (Esposito, 2014). It is important to dis- seminate cultural competence outcomes in nursing through public health and research conferences, staff development pro- grams, continuing education programs, and the student nursing associations.
Sealey et al (2006) examined the cultural competence of nurse educators in Louisiana and found that very few of the nurse educators had formal preparation to teach transcultural nursing and that they felt uncomfortable attempting to do so. A study conducted on community-based nurses’ perceptions of cultural competence offers some encouragement (Starr and Wallace, 2009). The study indicated that about 85% of clients participating in the study perceived that nursing care today contains key components of decision making, communication, and interpersonal styles that reflect cultural components, 57% indicated that their communication style was culturally competent, 61% rated their decision-making choices as reflec- tive of cultural competence behaviors, and about 70% said their interpersonal style was indicative of cultural competence behaviors.
Evidence-based cultural competence practice in nursing connecting culturally competent health care goals with the pro- fessional values of nursing and patient care outcomes and
162 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES The six quality and safety competencies for nurses that were identified in the Quality and Safety Education for Nurses (QSEN) project are patient-centered care, teamwork and collaboration, evidence-based practice, quality improve- ment, safety, and informatics. While each of these is important and pertinent to the nursing actions taken with people from cultural groups other than that of the nurse, perhaps the most significant is that of patient-centered care. The chapter presents many guidelines and principles for aiding nurses in providing culturally competent care. One of the areas in which patient-centered care is lacking occurs when the nurse and the patient are not communicating effectively. The lack of communication may occur when they speak different languages, have different cultural practices and expectations that lead them to hear messages differently or when the persons being served simply do not understand what the nurse is saying and are reluctant to acknowledge this. Nurses must observe for both verbal and nonverbal cues that a message is either understood or not understood. When the latter occurs, the nurse should take action to clarify the message. This may include asking someone from that cultural group to assist or to enlist the aid of an interpreter. See: Issel LM, Bekemeier B: Safe practice of population-focused nursing care: Development of a public health nursing concept, Nursing Outlook, 58(5):226- 232, 2010.
The following applies the QSEN competency of client-centered interventions that reflect cultural competence.
Targeted Competency: Client-Centered Intervention—Recognize the client or designee as the source of control and full partner in providing compassionate and coordinated interventions based on respect for the client’s preferences, values, and needs.
Important aspects of client-centered intervention include: • Knowledge: Describe strategies to empower clients or families in all
aspects of the health care process • Skills: Communicate client values, preferences, and expressed needs to
other members of the health care team • Attitudes: Willingly support client-centered care for individuals and groups
whose values differ from your own.
Client-Centered Care Question Competence in providing client-centered interventions involves not only effec- tive interviewing of individual clients, but developing an awareness of their context. As a community-based clinician, it is helpful to familiarize yourself with the cultural context of your clients. Learning about community resources can sometimes be helpful in learning about the cultural context. You have just been hired as a visiting nurse in a Hispanic community. What community resources could you explore to assist you in providing effective client-centered care?
Answer • You might explore community centers. Where are they? How well frequented
are the community centers? Which programs are most popular? Which com- munity center programs are health-oriented?
• Are community members very involved with one or more churches? You might familiarize yourself with elements of this faith tradition.
• Are there community elders who are publically recognized as leaders in the community? Can you meet with them to understand how the community has changed and evolved over time?
perceptions of their problem and, in turn, that nurses explain to clients their own perceptions of the problem. Nurses and clients should acknowledge and discuss similarities and differ- ences between the two perceptions to develop recommenda- tions and suggestions for management of problems. A variety of tools are available to assist nurses in conducting cultural assessments (Andrews and Boyle, 2012; Leininger, 2002b). The focus of such tools varies, and selection is determined by the dimensions of the culture to be assessed.
During an initial contact with clients, nurses should perform a general cultural assessment to obtain an overview of the clients’ characteristics. Nurses ask clients about their ethnic background, language, education, religious affiliation, dietary practices, family relationships, hospital experiences, occupa- tion and socioeconomic status, cultural beliefs, and language. Nurses also want to know about clients’ distinctive features, perceptions of the health issue, causation, treatment, antici- pated results, and the impact the issue might have on the client. Such basic data help nurses understand the clients from the clients’ points of view and recognize their uniqueness, thus avoiding stereotyping. Data for an in-depth cultural assess- ment should be gathered over a period of time and not restricted to the first encounter with the client. This gives both the client and the nurse time to get to know each other, and it is especially beneficial for the client to see the nurse in a helping relationship. An in-depth cultural assessment should be con- ducted in two phases: a data collection phase and an organiza- tion phase.
The data collection phase consists of three steps: 1. The nurse collects self-identifying data similar to those col-
lected in the brief assessment. 2. The nurse raises a variety of questions that seek information on
the client’s perception of what brings them to the health care system, the illness, and previous and anticipated treatments.
3. After the nursing diagnosis is made, the nurse identifies cul- tural factors that may influence the effectiveness of nursing care actions. In the organization phase, data related to the client’s and
family’s views on optimal treatment choices are routinely exam- ined, and areas of difference between the client’s cultural needs and the goals of Western medicine are identified. Nurses may use Leininger’s (2002a) three actions (discussed previously in this chapter) to guide them in selecting and discussing cultur- ally appropriate interventions with clients.
The key to a successful cultural assessment lies in nurses being aware of their own culture. The nurse should consider the following suggestions when eliciting cultural information: • Be sensitive to the cues in the environment and be in tune with
the verbal and nonverbal communications before taking action. • Know about the resources in the community such as schools,
churches, hospitals, tribal councils, restaurants, taverns, and bars.
• Know the specific areas to focus on before beginning the cultural assessment.
• Select a strategy for gathering cultural data. Possible strate- gies include in-depth interviews, informal conversations,
163CHAPTER 7 Cultural Diversity in the Community
• Use a trained interpreter if the client has limited proficiency with English.
• Talk with formal and informal community leaders to gain a comprehensive understanding about significant aspects of community life.
• Be aware that all information has both subjective and objec- tive aspects, and verify and cross-check the information that is collected before acting on it.
• Avoid the pitfalls that may occur when making premature generalizations.
• Be sincere, open, and honest with yourself and the client.
observations of the client’s everyday activities or specific events, survey research, and a case method approach to study certain aspects of a client.
• Identify a confidante who will help “bridge the gap” between cultures. Be aware that in some cultures the woman’s husband or a close male family friend may be the person from whom the nurse may need to obtain the cultural information.
• Know the appropriate questions to ask without offending the client.
• Interview other nurses or health care professionals who have worked with the specific individual, family, or community to get their input.
P R A C T I C E A P P L I C A T I O N Mr. Nguyen, a 64-year-old man from rural Vietnam, entered the United States with his family 3 years ago through the refugee program. Mr. Nguyen was a farmer in his homeland, and since his arrival he has been unable to obtain a stable job that would allow him to adequately care for his family. His financial resources are limited, and he has no insurance. He speaks enough English to interact directly with people outside his family and community. His oldest daughter, Aeyoung, is enrolled in a 2-year program to become a registered nurse.
The Nguyen family attends the neighborhood church with other Vietnamese families. Mr. Nguyen has been attending the clinic at the hospital but refuses to discuss with his family, even with Aeyoung, the reason for these visits. Aeyoung became increasingly concerned as she observed her father to have insomnia, retarded motor activity, an inability to concentrate, and weight loss. However, Mr. Nguyen denied that he was not well. Aeyoung decided to discuss her concerns with a nurse, with whom she had developed an attachment, at the church. She invited the nurse to her home for lunch on a Saturday so she could meet her father and validate her impressions.
After several visits with the family, the nurse was able to establish a close enough relationship with Mr. Nguyen so that she could engage him in a discussion of his health. Because of her extensive work with other Vietnamese immigrants, the nurse was familiar with themes of loss and decided to focus her conversation with Mr. Nguyen on his adjustment to the new community living, gains and losses as a result of immigra- tion, and coping strategies. After several discussions with
Mr. Nguyen, he confided in the nurse that he feared that he was dying because he had been diagnosed with cancer of the small intestine. He further revealed that he had not shared the diag- nosis with the family because he did not want them to know of his “bad news.” Mr. Nguyen had refused treatment because he knew that people never get better when they have cancer; they always die. A. Which of the following actions best characterize the nurse’s
willingness to provide culturally competent care to Mr. Nguyen and his family? 1. Discuss with the client his understanding of his
diagnosis. 2. Discuss with the client the prognosis for a person diag-
nosed with cancer of the small intestine in the United States.
3. Discuss with the client the prognosis for a person diag- nosed with cancer of the small intestine in Vietnam.
4. Discuss the medical treatment and surgical intervention for cancer of the small intestine.
B. The way in which the nurse poses questions to Mr. Nguyen is very important and determines the kind of responses the client gives to the nurse. What types of questions should the nurse pose to Mr. Nguyen to get the best responses from him?
C. Which resources should a community health agency have available to assist Mr. Nguyen with his health care concerns? Answers can be found on the Evolve site.
K E Y P O I N T S • The U.S. population is becoming increasingly diverse, and
nurses and health care organizations need to learn more about the culture of individuals to whom they provide care and the impact of culture on health care.
• Culture is a learned set of behaviors that are widely shared among a group of people and helps guide individuals in problem solving and decision making processes.
• Cultural differences exist among groups and they may be observed in areas such as biological variations, personal
space, perception of time, environmental control, family organization, communication, nutrition, and religion.
• There are individual differences among people within a cul- tural group.
• Changes in immigration laws and policies have increased migration, contributing to changes in community demo- graphics and challenges for nurses to effectively communi- cate with their clients and help them understand the basic health information needed to make appropriate health
164 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
K E Y P O I N T S — cont’d decisions. When nurses do not speak or understand the cli- ent’s language, interpreters should be available to assist them in communicating with clients.
• In selecting an interpreter, nurses should not only consider the clients’ cultural needs but also respect their right to privacy.
• Members of minority groups are over-represented on the lower tiers of the socioeconomic ladder. Poor economic achievement is also a common characteristic among popula- tions at risk, such as the homeless, migrant workers, and refugees. Nurses should be able to distinguish between culture and socioeconomic class issues and not interpret behavior as having a cultural origin when in fact it is based on socioeconomic class.
• Clients who are excluded from full participation in the eco- nomic, social, and political life of the society may have more complex health issues and more difficulty accessing and receiving services from health care institutions.
• The social determinants of health are the circumstances in which people are born and grow up, live, work, and age, and the systems put in place to deal with illness. They are shaped by race, economics, education, the family structure, health, and access to health resources.
• Efforts to understand dietary practices should go beyond relying on the individual having membership in a specific group and include religious requirements.
• Culturally competent nursing care is designed for a specific client, reflects the nurse’s knowledge and the individual’s knowledge and practices, and is implemented with care and sensitivity. Such nursing care helps to improve health out- comes and reduce health care costs.
• Standards of practice have been developed to guide nurses around the world in the areas of clinical practice, research, education, and administration.
• Culturally competent nurses are empowered to provide equitable nursing care that is focused on meeting the physical, physiological, social, and cultural needs of the client.
• Culturally competent nurses are aware of their own cultures, use cultural knowledge, have cultural skill, and select cultur- ally appropriate interventions to care for the client holisti- cally. The most important aspect is cultural encounter with the client.
• Nurses must have the desire or intrinsic motivation to want to provide culturally competent nursing care.
• Barriers to providing culturally competent care include ste- reotyping, prejudice and racism, ethnocentrism, cultural imposition, cultural conflict, and culture shock.
• Culturally competent nurses may select from four modes of interventions when providing care: cultural preservation, cultural accommodation, cultural repatterning, and culture brokering.
• Organizations, institutions, and professional associations should have policies, procedures, and practices that support a climate in which nurses can deliver culturally competent care to clients whom they serve.
• Nurses should perform a cultural assessment on every client with whom they interact. Cultural assessments help nurses understand clients’ perspectives of health and illness and thereby guide them to implement culturally competent interventions. The needs of clients vary with their age, edu- cation, religion, and socioeconomic status.
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Select a culture that you would like to study. Go to the appro-
priate websites and gather information about the cultural group. Identify the group’s cultural beliefs and practices and health-seeking behaviors. Share what you have obtained from websites and ask the person to evaluate the informa- tion. Discuss this information with at least one member of that cultural group. Compare and contrast information obtained from the two sources. Describe how you would use this information in your clinical practice.
2. Discuss how you would interview older clients who are con- sidering giving up their independence and living in a nursing home. Prepare them for the likelihood that their health care providers are likely to be culturally diverse and may not share the same race or ethnicity. How will they engage in com- munication with the care provider about their health needs, family of origin, and important routine behaviors? How will they share their daily routine, dietary practices, and memo- ries of family and friends?
3. Identify an alternative health care practitioner in the com- munity of your clinical placement where you have been
assigned. Prepare six questions and use them as a guide to interview the alternative healer about cultural health beliefs, healing practice, and alternative biomedical explanation of illness systems.
4. Select from one of the standards of practice for culturally competent care (Office of Minority Health, Expert Panel for Global Nursing and Health of the American Academy of Nursing and the Transculutral Nursing Society, the Quad Council, and the Joint Commission) and examine the extent to which the public health agency in your community is in compliance with cultural competence standards as identified by one of these organizations. Report your findings to a culturally competent leader in the organization.
5. On the basis of Healthy People 2020 objectives, identify an at-risk aggregate in your community. Use the AHRQ website to access information for that year on the progress the com- munity has made toward decreasing a specific health dispar- ity. Work with the public health nurse to evaluate the effectiveness of the plan the community has developed to remedy the disparity.
165CHAPTER 7 Cultural Diversity in the Community
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Public Health Policy
Marcia Stanhope, PhD, RN, FAAN Dr. Marcia Stanhope is currently an Associate of the Tufts and Associates Search Firm, Chicago, Ill. She is also a consultant for the nursing program at Berea College, Kentucky. She has practiced community and home health nursing, has served as an administrator and consultant in home health, and has been involved in the development of two nurse-managed centers. At one time in her career, she held a public policy fel- lowship and worked in the office of a U.S. senator. She has taught community health, public health, epide- miology, policy, primary care nursing, and administration courses. Dr. Stanhope formerly directed the Division of Community Health Nursing and Administration and served as Associate Dean of the College of Nursing at the University of Kentucky. She has been responsible for both undergraduate and graduate courses in population-centered nursing. She has also taught at the University of Virginia and the University of Alabama, Birmingham. During her career at the University of Kentucky she was appointed to the Good Samaritan Foundation Chair and Professorship in Community Health Nursing, and was honored with the University Provost’s Public Scholar award. Her presentations and publications have been in the areas of home health, community health, and community-focused nursing practice, as well as primary care nursing.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Discuss the structure of the U.S. government and health
care roles. 2. Identify the functions of key governmental and quasi-
governmental agencies that affect public health systems and nursing, both around the world and in the United States.
3. Differentiate between the primary bodies of law that affect nursing and health care.
4. Define key terms related to policy and politics. 5. State the relationships between nursing practice, health
policy, and politics. 6. Develop and implement a plan to communicate with
policy makers on a chosen public health issue.
K E Y T E R M S advanced practice nurses, p. 182 Agency for Healthcare Research and Quality, p. 174 American Association of Colleges of Nursing, p. 184 American Nurses Association, p. 172 block grants, p. 169 boards of nursing, p. 177 categorical funding, p. 176 constitutional law, p. 176 devolution, p. 169 health policy, p. 168 judicial law, p. 177 law, p. 168 legislation, p. 177 legislative staff, p. 179
licensure, p. 179 National Institute of Nursing Research, p. 174 nurse practice act, p. 177 Occupational Safety and Health Administration, p. 173 Office of Homeland Security, p. 176 police power, p. 169 policy, p. 168 politics, p. 168 public policy, p. 168 regulations, p. 177 U.S. Department of Health and Human Services, p. 168 World Health Organization, p. 172 —See Glossary for definitions
A D D I T I O N A L R E S O U R C E S Evolve website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz
• Case Studies • Glossary • Answers to Practice Application
168 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
C H A P T E R O U T L I N E Definitions Governmental Role in U.S. Health Care
Trends and Shifts in Governmental Roles Government Health Care Functions
Healthy People 2020: An Example of National Health Policy Guidance
Organizations and Agencies that Influence Health International Organizations Federal Health Agencies Federal Non-Health Agencies State and Local Health Departments
Impact of Government Health Functions and Structures on Nursing
The Law and Health Care Constitutional Law Legislation and Regulation Judicial and Common Law
Laws Specific to Nursing Practice Scope of Practice Professional Negligence
Legal Issues Affecting Health Care Practices School and Family Health Home Care and Hospice Correctional Health
The Nurse’s Role in the Policy Process Legislative Action Regulatory Action The Process of Regulation Nursing Advocacy
Nurses are an important part of the health care system and are greatly affected by governmental and legal systems. Nurses who select the community as their area of practice must be especially aware of the impact of government, law, and health policy on nursing, health, and the communities in which they practice. Insight into how government, law, and political action have changed over time is necessary to understand how the health care system has been shaped by these factors. Also, understand- ing how these factors have influenced the current and future roles for nurses and the public health system is critical for better health policy for the nation.
Nurses have historically viewed themselves as advocates for the health of the population. It is this heritage that has moved the discipline into the policy and political arenas. To secure a more positive health care system, nurse professionals must develop a working knowledge of government, key governmental and quasi-governmental organizations and agencies, health care law, the policy process, and the political forces that are shaping the future of health care. This knowledge and the motivation to be an agent of change in the discipline and in the community are necessary ingredients for success as a population-centered nurse.
DEFINITIONS To understand the relationship between health policy, politics, and laws, one must first understand the definitions of the terms. Policy is a settled course of action to be followed by a govern- ment or institution to obtain a desired end (CDC, 2014). Public policy is described as all governmental activities, direct or indi- rect, that influence the lives of all citizens (Birkland, 2010). Health policy, in contrast, is a set course of action to obtain a desired health outcome for an individual, family, group, com- munity, or society (WHO, 2014). Policies are made not only by governments, but also by such institutions as a health depart- ment or other health care agency, a family, a community, or a professional organization.
Politics plays a role in the development of such policies. Politics is found in families, professional and employing agen- cies, and governments. Politics determines who gets what and when and how they get it (Birkland, 2010). Politics is the art of influencing others to accept a specific course of action. There- fore, political activities are used to arrive at a course of action (the policy). Law is a system of privileges and processes by which people solve problems based on a set of established rules; it is intended to minimize the use of force (Yourdictionary, 2014). Laws govern the relationships of individuals and organi- zations to other individuals and to government. Through politi- cal action, a policy may become a law, a regulation, a judicial ruling, a decision, or an order.
After a law is established, regulations further define the course of action (policy) to be taken by organizations or indi- viduals in reaching an outcome. Government is the ultimate authority in society and is designated to enforce the policy whether it is related to health, education, economics, social welfare, or any other society issue. The following discussion explains the role of government in health policy.
GOVERNMENTAL ROLE IN U.S. HEALTH CARE In the United States, the federal and most state and local gov- ernments are composed of three branches, each of which has separate and important functions (Truman, 2014). The execu- tive branch is composed of the president (or state governor or local mayor) along with the staff and cabinet appointed by this executive, various administrative and regulatory departments, and agencies such as the U.S. Department of Health and Human Services (USDHHS). The legislative branch (i.e., Con- gress at the federal level) is made up of two bodies: the Senate and the House of Representatives, whose members are elected by the citizens of particular geographic areas. There is a federal Division of Nursing, a section within the Health Resources and Services Agency (HRSA) of the USDHHS, that refines criteria
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Senator Wagner of New York initiated the first national health insurance bill. The Social Security Act of 1935 was passed to provide assistance to older adults and the unemployed, and it offered survivors’ insurance for widows and children. It also provided for child welfare, health department grants, and mater- nal and child health projects. In 1948 Congress created the National Institutes of Health (NIH), and in 1965 it passed very important health legislation creating Medicare and Medicaid to provide health care service payments for older adults, the dis- abled, and the categorically poor. These legislative acts by Con- gress created programs that were implemented by the executive branch. In March 2010, the most recent legislation passed and signed by President Obama to improve the health of the nation and access to care was the health reform law, the Patient Protec- tion and Affordable Care Act (US LAW, PL 111-148). See Chapter 3 for in-depth information (Kaiser Family Foundation, 2010a).
The U.S. Department of Health and Human Services (USDHHS) (known first as the Department of Health, Educa- tion, and Welfare [DHEW]) was created in 1953. The Health Care Financing Administration (HCFA) was created in 1977 as the key agency within the USDHHS to provide direction for Medicare and Medicaid. In 2002 HCFA was renamed the Center for Medi- care and Medicaid Services (CMS). During the 1980s, a major effort of the Reagan administration was to shift federal govern- ment activities to the states, including federal programs for health care. The process of shifting the responsibility for planning, deliv- ering, and financing programs from the federal level to the states is called devolution. Throughout the 1980s and 1990s, Congress has increasingly funded health programs by giving block grants to the states. Devolution processes including block granting should alert professional nurses that state and local policy has grown in importance to the health care arena. With the new health reform law, stimulus grants have been provided to state and local areas to improve health care access (HRSA, 2010).
The role of government in health care is shaped both by the needs and demands of its citizens and by the citizens’ beliefs and values about personal responsibility and self-sufficiency. These beliefs and values often clash with society’s sense of responsibility and need for equality for all citizens. A federal example of this ideological debate occurred in the 1990s over health care reform. The Democratic agenda called for a health care system that was universally accessible, with a focus on primary care and prevention. The Republican agenda sup- ported more modest changes within the medical model of the delivery system. This agenda also supported reducing the federal government’s role in health care delivery through cuts in Medicare and Medicaid benefits. The Democrats proposed the Health Security Act of 1993, which failed to gain Congress’s approval. In an effort to make some incremental health care changes, both the Democrats and the Republicans in Congress passed two new laws. The Health Insurance Portability and Accountability Act (HIPAA) allows working persons to keep their employee group health insurance for up to 16 months after they leave a job (U.S. Law 107-105, 1996). The State Child Health Improvement Act (SCHIP) of 1997 provides insurance for children and families who cannot otherwise afford health insurance (U.S. Law, 1997).
for nursing education programs as funded by Congress and affirmed by the President.
The judicial branch is composed of a system of federal, state, and local courts guided by the opinions of the Supreme Court. Each of these branches is established by the Constitution, and each plays an important role in the development and imple- mentation of health law and public policy.
The executive branch suggests, administers, and regulates policy. The role of the legislative branch is to identify problems and to propose, debate, pass, and modify laws to address those problems. The judicial branch interprets laws and their meaning, as in its ongoing interpretation of states’ rights to define access to reproductive health services to citizens of the states.
One of the first constitutional challenges to a federal law passed by Congress was in the area of health and welfare in 1937, after the 74th Congress had established unemployment compensation and old-age benefits for U.S. citizens (U.S. Law, 1937a). Although Congress had created other health programs previously, its legal basis for doing so had never been chal- lenged. In Stewart Machine Co. v. Davis (U.S. Law, 1937b), the Supreme Court (judicial branch) reviewed this legislation and determined, through interpretation of the Constitution, that such federal governmental action was within the powers of Congress to promote the general welfare. It was obvious in 2008 and beyond that unemployment benefits are important to the economy and to individuals who lose jobs during a national economic crisis (BLS, 2010).
Most legal bases for the actions of Congress in health care are found in Article I, Section 8 of the U.S. Constitution, includ- ing the following: 1. Provide for the general welfare. 2. Regulate commerce among the states. 3. Raise funds to support the military. 4. Provide spending power.
Through a continuing number and variety of cases and con- troversies, these Section 8 provisions have been interpreted by the courts to appropriately include a wide variety of federal powers and activities. State power concerning health care is called police power (Legal Information Institute, 2014). This power allows states to act to protect the health, safety, and welfare of their citizens. Such police power must be used fairly, and the state must show that it has a compelling interest in taking actions, especially actions that might infringe on indi- vidual rights. Examples of a state using its police powers include requiring immunization of children before being admitted to school and requiring case finding, reporting, treating, and follow-up care of persons with tuberculosis. These activities protect the health, safety, and welfare of state citizens.
Trends and Shifts in Governmental Roles The government’s role in health care at both the state and federal level began gradually. Wars, economic instability, and political differences between parties all shaped the government’s role. The first major federal governmental action relating to health was the creation in 1798 of the Public Health Service (PHS). Then in 1890 federal laws were passed to promote the public health of merchant seamen and Native Americans. In 1934
170 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
to individuals and families, frequently on the basis of factors such as financial need or the need for a particular service, such as hypertension or tuberculosis screening, immunizations for chil- dren and older adults, and primary care for inmates in local jails or state prisons. The Evidence-Based Practice box presents a study that examined the use of a state health insurance program.
With the latest health care reform, numerous debates occurred in the House of Representatives and the Senate until there was agreement that the Senate version of the bill would be passed. On March 30, 2010 President Obama signed into law the Health Care and Education Reconciliation Act of 2010, which made some changes to the comprehensive health reform law and included House amendments to the new law (Kaiser, 2010B). See Chapter 3 for further discussion.
This discussion has focused primarily on trends in and shifts between different levels of government. An additional aspect of governmental action is the relationship between government and individuals. Freedom of individuals must be balanced with governmental powers. After the terrorist attacks on the United States in September (World Trade Center attack) and October (anthrax outbreak) of 2001, much government activity was being conducted in the name of national security.
It is interesting to note that before September 11, 2001, the Congress and President, recognizing that the public health system infrastructure needed help, passed “The Public Health Threats and Emergencies Act” (PL 106-505) in 2000. This law “addresses emerging threats to the public’s health and autho- rizes the Secretary of HHS to take appropriate response actions during a public health emergency, including investigations, treatment, and prevention” (Katz et al, 2014, p. 133). This leg- islation is said to have signaled the beginning of renewed inter- est in public health as the protector for entire communities. In June 2002 the Public Health Security and Bioterrorism Pre- paredness and Response Act was signed into law (US Law 2002, PL 107-188), with $3 billion appropriated by Congress, to implement the following antibioterrorism activities: • Improving public health capacity • Upgrading of health professionals’ ability to recognize and
treat diseases caused by bioterrorism • Speeding the development of new vaccines and other
countermeasures • Improving water and food supply protection • Tracking and regulating the use of dangerous pathogens
within the United States (Katz et al, 2014) Yet there is considerable debate on just how much govern-
mental intervention is necessary and effective and how much will be tolerated by citizens. For example, in 2010 approximately 49% of citizens were against the new health care reform acts, and the Republicans were seen as being obstructionists. In 2014, 50% of citizens were for government intervention and 50% against (Debate.org, 2013).
Government Health Care Functions Federal, state, and local governments carry out five health care functions, which fall into the general categories of direct services, financing, information, policy setting, and public protection.
Direct Services Federal, state, and local governments provide direct health ser- vices to certain individuals and groups. For example, the federal government provides health care to members and dependents of the military, certain veterans, and federal prisoners. State and local governments employ nurses to deliver a variety of services
Financing Governments pay for some health care services; the 2011 per- centage of the bill paid by the government was about 46.3%, and this is projected to increase to 47.6% by the year 2015. The government also pays for training some health personnel and for biomedical and health care research (NCHS, 2014). Support in these areas has greatly affected both consumers and health care providers. Federal governments finance the direct care of clients through the Medicare, Medicaid, Social Security, and SCHIP programs. State governments contribute to the costs of Medicaid and SCHIP programs. Many nurses have been edu- cated with government funds through grants and loans, and schools of nursing in the past have been built and equipped using federal funds. Governments also have financially sup- ported other health care providers, such as physicians, most significantly through the program of Graduate Medical Educa- tion funds.
The federal government invests in research and new program demonstration projects, with NIH receiving a large portion of the monies. The National Institute of Nursing Research (NINR) is a part of the NIH and, as such, provides a substantial sum of money to the discipline of nursing for the purpose of develop- ing the knowledge base of nursing and promoting nursing ser- vices in health care (NINR, 2014).
Information All branches and levels of government collect, analyze, and dis- seminate data about health care and health status of the citizens.
The purpose of this study was to examine the changes in access to care, use of services, and quality of care among children enrolled in Child Health Plus (CHPlus), a state health insurance program for low-income children that became a model for the State Child Health Insurance Program (SCHIP). A before-and-after design was used to evaluate the health care experience of children the year before and the year after enrollment in the state health insurance program. The study consisted of 2126 children from New York State, ranging from birth to 12.99 years of age. Results indicated that the state health insurance program for low-income children was associated with improved access, use, and quality of care. The development and implementa- tion of SCHIP was an outcome of the soaring costs of health care and the fact that there were 11 million uninsured children in the United States at the time of the study. It was the largest public investment in child health in 30 years.
Nurse Use This study supports the value of health policy and the need to evaluate the effectiveness of policy in accomplishing the purposes of the policy.
EVIDENCE-BASED PRACTICE
From U.S. Department of Health and Human Services: Healthy People 2010: understanding and improving health, ed 2, Washington, DC,2000, U.S. Government Printing Office.
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The Sheppard-Towner Act made nurses available to provide health services for women and children, including well-child and child-development services; provided adequate hospital services and facilities for women and children; and provided grants-in-aid for establishing maternal–child welfare programs. The act helped set precedents and patterns for the growth of modern-day public health policy. It defined the role of the federal government in creating standards to be followed by states in conducting categorical programs such as the Women, Infants, and Children (WIC) and Early Periodic Screening and Developmental Testing (EPSDT) programs. The act also defined the position of the consumer in influencing, formulating, and shaping public policy; the government’s role in research; a system for collecting national health statistics; and the integrat- ing of health and social services. This act established the impor- tance of prenatal care, anticipatory guidance, client education, and nurse–client conferences, all of which are viewed today as essential nursing responsibilities.
Public Protection The U.S. Constitution gives the federal government the author- ity to provide for the protection of the public’s health. This function is carried out in numerous venues, such as by regulat- ing air and water quality and protecting the borders from the influx of diseases by controlling food, drugs, and animal trans- portation, to name a few. The Supreme Court interprets and makes decisions related to public health, such as affirming a woman’s rights to reproductive privacy (Roe v. Wade), requiring vaccinations, and setting conditions for states to receive public funds for highway construction/repair by requiring a minimum drinking age.
HEALTHY PEOPLE 2020: AN EXAMPLE OF NATIONAL HEALTH POLICY GUIDANCE In 1979 the surgeon general issued a report that began a 30-year focus on promoting health and preventing disease for all Amer- icans (DHEW, 1979). In 1989, Healthy People 2000 became a national effort with many stakeholders representing the per- spectives of government, state, and local agencies; advocacy groups; academia; and health organizations (USDHHS, 1991).
Throughout the 1990s states used Healthy People 2000 objec- tives to identify emerging public health issues. The success of this national program was accomplished and measured through state and local efforts. The Healthy People 2010 document focused on a vision of healthy people living in healthy com- munities. Healthy People 2020 has four overarching goals, which can be found in the Healthy People 2020 box; this box compares the goals of Healthy People documents from 2000 to 2020.
ORGANIZATIONS AND AGENCIES THAT INFLUENCE HEALTH International Organizations In June 1945, following World War II, many national govern- ments joined together to create the United Nations (UN). By charter, the aims and goals of the UN deal with human rights,
Organization Data Sources
International United Nations http://www.un.org/
Demographic Yearbook World Health
Organization http://www.who.int/en/ World Health Statistics Annual
Federal Department of
Health and Human Services
http://www.hhs.gov National Vital Statistics System National Survey of Family Growth National Health Interview Survey National Health Examination Survey National Health and Nutrition Examination Survey National Master Facility Inventory National Hospital Discharge Survey National Nursing Home Survey National Ambulatory Medical Care Survey National Morbidity Reporting System U.S. Immunization Survey Surveys of Mental Health Facilities Estimates of National Health Expenditures AIDS Surveillance Nurse Supply Estimates
Department of Commerce
http://www.commerce.gov U.S. Census of Population Current Population Survey Population Estimates and Projections
Department of Labor
http://www.dol.gov Consumer Price Index Employment and Earnings
TABLE 8-1 International and National Sources of Data on the Health Status of the U.S. Population
An example is the annual report Health: United States, 2013, compiled each year by the USDHHS (NCHS, 2014). Collecting vital statistics, including mortality and morbidity data, gather- ing of census data, and conducting health care status surveys are all government activities. Table 8-1 lists examples of avail- able federal and international data sources on the health status of populations in the United States and around the world. These sources are available on the Internet and in the governmental documents’ section of most large libraries. This information is especially important because it can help nurses understand the major health problems in the United States and those in their own states and local communities.
Policy Setting Policy setting is a chief governmental function. Governments at all levels and within all branches make policy decisions about health care. These health policy decisions have broad implica- tions for financial expenses, resource use, delivery system change, and innovation in the health care field. One law that has played a very important role in the development of public health policy, public health nursing, and social welfare policy in the United States is the Sheppard-Towner Act of 1921 (USDHHS, HRSA, 2010).
172 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
drugs; and establishing of world standards for antibiotics and vaccines. Assistance available to individual countries includes support for national programs to fight disease, to train health workers, and to strengthen the delivery of health services. The World Health Assembly (WHA) is the WHO’s policy-making body, and it meets annually. The WHA’s health policy work provides policy options for many countries of the world in their development of in-country initiatives and priorities; however, although WHA policy statements are important everywhere, they are guides and not law. The WHA’s most recent policy statement on nursing and midwifery was released in 2013, and the current worldwide shortage of professional nurses is now on the WHO agenda and is being addressed by country (WHA, 2011; WHO, 2010; WHO, 2013).
The World Health Report, first published in 1995, is WHO’s leading publication. Each year the report combines an expert assessment of global health, including statistics relating to all countries, with a focus on a specific subject. The main purpose of the report is to provide countries, donor agencies, interna- tional organizations, and others with the information they need to help them make policy and funding decisions. In the 2010 report, the WHO mapped out what countries can do to modify their financing systems so they can move more quickly toward this goal—universal coverage—and sustain the gains that have been achieved. The report builds on new research and lessons learned from country experience. It provides an action agenda for countries at all stages of development and proposes ways that the international community can better support efforts in low-income countries to achieve universal coverage and improve health outcomes (WHO, 2010).
The presence of nursing in international health is increasing. Besides offering direct health services in every country in the world, nurses serve as consultants, educators, and program planners and evaluators. Nurses focus their work on a variety of public health issues, including the health care workforce and education, environment, sanitation, infectious diseases, well- ness promotion, maternal and child health, and primary care. Dr. Naeema Al-Gasseer of Bahrain has served as the scientist for nursing and midwifery at the WHO; Marla Salmon, former dean of nursing at The University of Washington, chaired a Global Advisory Group on Nursing and Midwifery; and Linda Tarr Whelan served as the U.S. Ambassador to the UN Com- mission on the Status of Women. Virginia Trotter Betts, past president of the American Nurses Association (ANA), served as a U.S. delegate to both the WHA and the Fourth World Con- ference on Women in Beijing in 1995, where she participated on the negotiating team of the conference to develop a platform on the health of women across the life span. Many U.S. nurse leaders, such as Dr. Carolyn Williams, current author in this book, have been WHO consultants.
Federal Health Agencies Laws passed by Congress may be assigned to any administrative agency within the executive branch of government for imple- menting, supervising, regulating, and enforcing. Congress decides which agency will monitor specific laws. For example, most health care legislation is delegated to the USDHHS. However, legislation concerning the environment would most
world peace, international security, and the promotion of eco- nomic and social advancement of all the world’s peoples. The UN, headquartered in New York City, is made up of six principal divisions, several subgroups, and many specialized agencies and autonomous organizations. With the approval and support of the UN Commission on the Status of Women, five world confer- ences on women have been held. At these conferences, the health of women and children and their rights to personal, educational, and economic security as well as initiatives to achieve these goals at the country level were debated and explored, and policies were formulated (United Nations, 1975, 1980, 1985, 1995, 2000). The work of the UN and the world conferences continues with agendas to include the development of human beings, eradica- tion of poverty, protection of human rights, investment in health, education, training, trade, economic growth, and a continued emphasis on women (United Nations, 2014).
One of the special autonomous organizations growing out of the UN is the World Health Organization (WHO). Estab- lished in 1946, WHO relates to the UN through the Economic and Social Council to achieve its goal to attain the highest pos- sible level of health for all persons. “Health for All” is the creed of the WHO. Headquartered in Geneva, Switzerland, the WHO has six regional offices. The office for the Americas is located in Washington, DC, and is known as the Pan American Health Organization (PAHO).
The WHO provides services worldwide to promote health, it cooperates with member countries in promoting their health efforts, and it coordinates the collaborating efforts between countries and the disseminating of biomedical research. Its ser- vices, which benefit all countries, include a day-to-day informa- tion service on the occurrence of internationally important diseases; the publishing of the international list of causes of disease, injury, and death; monitoring of adverse reactions to
HEALTHY PEOPLE 2020
Healthy People 2000
Healthy People 2010 Healthy People 2020
Increase the years of healthy life for Americans
Reduce health disparities among Americans
Achieve access to preventive services for all Americans
Increase quality and years of healthy life
Eliminate health disparities
Attaining high quality, longer lives free of preventable disease, disability, injury, and premature death
Achieving health equity, eliminating disparities, and improving the health of all groups
Creating social and physical environments that promote good health for all
Promoting quality of life, healthy development, and healthy behaviors across all life stages
A Comparison of the Goals of Healthy People 2000, Healthy People 2010, and Healthy People 2020
From U.S. Department of Health and Human Services: Leading indicators.In Healthy People 2000, 2010, & 2020, Washington, DC, 1989,1999, 2010, U.S. Government Printing Office.
173CHAPTER 8 Public Health Policy
the health security of our nation (CDC, 2014A) The CDC seeks to accomplish its mission by working with partners throughout the nation and the world in the following ways: • To provide health security • To detect and investigate health threats • To tackle the biggest health problems causing death and
disability • To conduct research that will enhance prevention • To promote healthy and safe behaviors, communities, and
environments • To develop leaders and train the public health workforce,
including disease detectives • To develop and advocate sound public health policies • To implement prevention strategies • To promote healthy behaviors • To foster safe and healthful environments • To provide leadership and training
The outbreak of summer 2014 is an example of how the CDC fulfills its mission. The Shiga toxin-producing Escherichia coli outbreak linked to raw clover sprouts affected six states and 19 people, and 44% were hospitalized. Idaho was the state that was most likely the source of the outbreak. The CDC regu- larly collects data about foodborne illnesses through the National Notifiable Disease Surveillance System on a weekly basis through the CDC MMWR weekly report from states. Because of the recognized increase in cases, states were asked to report aggre- gate numbers of cases twice a week along with foodborne-related hospitalizations and complications. The CDC implemented an investigation to track the cases and worked with state and local health departments to perform the following: • Detect the possible outbreak • Define and find cases • Generate hypotheses about the likely source • Test the hypothesis • Find the point of contamination • Control the outbreak from further spread • Decide when the outbreak is over.
By August 2014, there had been about 19 cases beginning in June 2014. In 3 months there were cases in 6 states. Figure 8-1 presents a CDC map indicating cases per state (CDC, MMWR Dispatch, 2014b). The six states involved were California (1), Idaho (3), Michigan (1), Montana (2), Utah (1), and Wash- ington (11). By August 2014 CDC determined the outbreak to be over. Although few people were involved in this outbreak, the outcome could have been deadly to the persons who ate the sprouts. While the Ebola virus of West Africa continues to spread, the CDC is monitoring the effects of the virus as part of their global monitoring system. CDC has information and training materials ready for those who may need to use the materials (CDC, 2014c). The CDC has taken an active role in the recent outbreak of measles as a result of exposure to the virus at Disneyland in California. This outbreak resulted in 140 people from seven states being infected. On 1/23/2015, the CDC issued a health advisory to all public health and health care facilities nationwide (Zipprich et al, 2015).
National Institutes of Health. Founded in 1887, NIH today is one of the world’s foremost biomedical research centers, and the federal focus point for biomedical research in the United States.
likely be implemented and monitored by the Environmental Protection Agency (EPA), and that concerning occupational health by the Occupational Safety and Health Administration (OSHA) in the U.S. Department of Labor.
U.S. Department of Health and Human Services The USDHHS is the agency most heavily involved with the health and welfare of U.S. citizens. It touches more lives than any other federal agency. The following agencies have been selected for their relevance to this chapter.
Health Resources and Services Administration. The Health Resources and Services Administration (HRSA) has been a long- standing contributor to the improved health status of Americans through the programs of services and health professions educa- tion that it funds. The HRSA contains the Bureau of Health Professions (BHPr), which includes the Division of Nursing as well as the Divisions of Medicine, Dentistry, and Allied Health Professions. The Division of Nursing is the key federal focus for nursing education and practice, and it provides national leader- ship to ensure an adequate supply and distribution of qualified nursing personnel to meet the health needs of the nation.
At the 122nd meeting of the Division of Nursing’s National Advisory Council for Nursing Education and Practice (NACNEP), the participants discussed the role of public health nurses in participating in primary care in their communities. The speaker indicated several factors that need to be in place to support the public health nurse role: • Baccalaureate standard for entry into practice • Ongoing stable funding for health departments • Competitive salaries commensurate with responsibilities • Interventions grounded in and responsive to community
needs • Consideration of health determinants • Experience in health promotion and prevention • Long-term trusting relationships in the community (i.e., with
clients) • Established network of community partners • Commitment to social justice and eliminating health
disparities In the council’s twelfth report to Congress (USDHHS, 2013a)
the council recommended further investment by the govern- ment in public health nursing, arguing the need based on system changes and the Affordable Care Act implementation, greater need to connect public health and care delivery with front-line public health nurses, plus the economic benefits of supporting this investment. Through the input of the NACNEP, the Divi- sion of Nursing sets policy for nursing nationally.
Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention (CDC) serve as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and edu- cation activities designed to improve the health of the people of the United States. The mission of the CDC is to protect America from health, safety and security threats, both foreign and in the United States. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same. As such CDC increases
174 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
federal agency charged with improving the quality, safety, effi- ciency, and effectiveness of health care for all Americans. As one of 12 agencies within the USDHHS, AHRQ supports health services research that will improve the quality of health care and promote evidence-based decision making. AHRQ is committed to improving care safety and quality by developing successful partnerships and generating the knowledge and tools required for long-term improvement. The goal of AHRQ research is to promote measurable improvements in health care in America. The outcomes are gauged in terms of improved quality of life and client outcomes, lives saved, and value gained for what we spend (AHRQ, 2014a).
By examining what works and what does not work in health care, the AHRQ fulfills its missions of translating research find- ings into better client care and providing consumers, policy makers, and other health care leaders with information needed to make critical health care decisions. In 1999, Congress, through legislation, specifically directed AHRQ to focus on measuring and improving health care quality; promoting client safety and reducing medical errors; advancing the use of infor- mation technology for coordinating client care and conducting quality and outcomes research; and seeking to eliminate dis- parities in health care delivery for the priority populations of low-income groups, minorities, women, children, older adults, and individuals with special health care needs.
The AHRQ published protocols for care of clients with a variety of health problems. These protocols became the stan- dards of health care delivery. The agency continues to maintain a clinical practice guidelines clearinghouse for use by clinicians and others. In addition, the AHRQ had a project called “Put Prevention into Practice” to promote the use of standardized protocols for primary care delivery for clients across the age span (see Schedule of Clinical Preventive Services in AHRQ, 2014b). Today there is a program titled The Practice-Based Research Network that rapidly develops and assesses methods
The NIH is composed of 27 separate institutes and centers. The goal of NIH research is to acquire new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold. The NIH mission is to uncover new knowledge that will lead to better health for every- one. The NIH works toward that mission by conducting research in its own laboratories; supporting the research of nonfederal scientists in universities, medical schools, hospitals, and research institutions throughout the country and abroad; helping in the training of research investigators; and fostering communication of medical and health sciences’ information (NIH, 2010a).
In late 1985 Congress overrode a presidential veto, allowing the creation of the National Center for Nursing Research within the NIH. In 1993 the Center became one of the divisions of the NIH and was renamed the National Institute of Nursing Research (NINR). The research and research-related training activities previously supported by the Division of Nursing were transferred to the new Institute. The NINR is the focal point of the nation’s nursing research activities. It promotes the growth and quality of research in nursing and client care, provides important leadership, expands the pool of experienced nurse researchers, and serves as a point of interac- tion with other bases of health care research. The mission of NINR is to promote and improve the health of individuals, families, communities, and populations.
NINR supports and conducts clinical and basic research and research training on health and illness across the life span. The research focus encompasses health promotion and disease pre- vention, quality of life, health disparities, and end of life. NINR seeks to extend nursing science by integrating the biological and behavioral sciences, using new technologies to research ques- tions, improving research methods, and developing the scien- tists of the future (NINR, 2011).
Agency for Healthcare Research and Quality. The Agency for Healthcare Research and Quality (AHRQ) is the lead
FIG 8-1 The number of reported Escherichia coli cases linked to multistate outbreak, by state— United States, May to August, 2014 (From Centers for Disease Control and Prevention: Epidemiology of Escherichia coli outbreak, United States, Atlanta, 2014 USDHHS.)
1
1
1
11
2
3
175CHAPTER 8 Public Health Policy
Department of Agriculture The Department of Agriculture houses the Food and Nutrition Service, which oversees a variety of food assistance activities. This service collaborates with state and local government welfare agencies to provide food stamps to needy persons to increase their food purchasing power. Other programs include school breakfast and lunch programs, WIC, and grants to states for nutrition education and training. In 2013, WIC provided support for 53% of all infants born in the United States. Although these programs have been successful, the increasing use of the process of giving federal block grants to states (rather than implementing national programs) may threaten the effec- tiveness of these programs because of differences in how deci- sions are made at the state level on how to spend money on nutrition (USDA, 2013).
Department of Justice Health services to federal prisoners are administered within the Department of Justice. The Federal Bureau of Prisons is respon- sible for the custody and care of approximately 214,000 federal offenders (Bureau of Federal Prisons, 2014). The Medical and Services Division of the Bureau of Prisons includes medical, psychiatric, dental, and health support services with commu- nity standards in a correctional environment. Health promo- tion is emphasized through counseling during examinations, education about effects of medications, infectious disease pre- vention and education, and chronic care clinics for conditions such as cardiovascular disease, diabetes, and hypertension. The Bureau also provides forensic services to the courts, including a range of evaluative mental health studies outlined in federal statutes. Health care for prisoners is highly regulated because of a series of court decisions on inmates’ rights.
State and Local Health Departments Depending on funding, public commitment and interest, and access to other resources, programs offered by state and local health departments vary greatly. Many state and local health officials report that employees in public health agencies lack skills in the core sciences of public health, and that this has hindered their effectiveness. The lack of specialized education and skill is a significant barrier to population-based preventive care and the delivery of quality health care to the public. Public health workforce specialists report that the number of retirees expected in this decade will result in a major shortage of public health workers, including nurses. More often than at other levels of government, nurses at the local level provide direct services. Some nurses deliver special or selected services, such as follow-up of contacts in cases of tuberculosis or venereal disease or providing child immunization clinics. Other nurses have a more generalized practice, delivering services to families in certain geographic areas (PHF, 2010; University of Michigan Center of Excellence in Public Health Workforce Studies, 2013).
At the local and state levels, coordinating health efforts between health departments and other county or city depart- ments is essential. Gaps in community coordination are showing up in glaring ways as states and communities scramble to
and tools to ensure that new scientific evidence is incorporated into real-world practice settings (AHRQ, 2014c).
Centers for Medicare and Medicaid Services. One of the most powerful agencies within the USDHHS is the CMS, which administers Medicare and Medicaid accounts and guided payment policy and delivery rules for services for 100 million people in 2014 (CMS, 2014). In addition to providing health insurance, CMS also performs a number of quality-focused health care or health-related activities, including regulating of laboratory testing, developing coverage policies, and improving quality of care. CMS maintains oversight of the surveying and certifying of nursing homes and continuing care providers (including home health agencies, intermediate care facilities for the developmentally disabled, and hospitals). It makes available to beneficiaries, providers, researchers, and state surveyors information about these activities and nursing home quality.
Federal Non-Health Agencies Although the USDHHS has primary responsibility for federal health functions, several other departments of the executive branch carry out important health functions for the nation. Among these are the Defense, Labor, Agriculture, and Justice Departments.
Department of Defense The Department of Defense delivers health care to members of the military, to their dependents and survivors, to National Guard and reserve members, and to retired members and their families. The assistant secretary of defense for health affairs administers a variety of health care plans for service personnel: TriCare Prime (a managed care arrangement) and an option for fee-for-service plans called TriCare Standard as well as TriCare Extra with many other options available. In each branch of the uniformed services, nurses of high military rank are part of the administration of these health services (U.S. Department of Defense, 2014).
Department of Labor The Department of Labor houses OSHA, which imposes work- place requirements on industries. These requirements shape the functions of nurses and the types of health services provided to workers in the workplace. A record-keeping system required by OSHA greatly affects health records in the workplace. Each state has an agency similar to OSHA that also monitors and inspects industries, as well as the health services delivered to them by nurses.
Needlestick injuries and other sharps-related injuries that result in occupational bloodborne pathogen exposure continue to be an important public health concern, especially to health care workers. In response to this serious situation, Congress passed the Needle Stick Safety and Prevention Act, which became law on November 6, 2000. To meet the requirements of this act, OSHA revised its Bloodborne Pathogen Standard to become effective on April 18, 2002. This act clarified the respon- sibility of employers to select safer needle devices as they become available and to involve employees in identifying and choosing the devices. The updated standard also required employers to maintain a log of injuries from contaminated sharps (OSHA, 2008; 2011; OSHA, 2013).
176 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
THE LAW AND HEALTH CARE The United States is a nation of laws, which are subject to the U.S. Constitution. The law is a system of privileges and pro- cesses by which people solve problems on the basis of a set of established rules. It is intended to minimize the use of force. Laws govern the relationships of individuals and organizations to other individuals and to government. After a law is estab- lished, regulations further define the course of actions to be taken by the government, organizations, or individuals in reach- ing an agreed-on outcome. Government and its laws are the ultimate authority in society and are designed to enforce official policy whether it is related to health, education, economics, social welfare, or any other society issue. The number and types of laws influencing health care are ever increasing. Definitions of law (Catholic University of America, 2010) include the following: • A rule established by authority, society, or custom • The body of rules governing the affairs of people, communi-
ties, states, corporations, and nations • A set of rules or customs governing a discrete field or activity
(e.g., criminal law, contract law) These definitions reflect the close relationship of law to the community and to society’s customs and beliefs.
The law has had a major impact on nursing practice. Although nursing emerged from individual voluntary activities, society passed laws to give formality to public health and, through legal mandates (i.e., laws), positions and functions for nurses in community settings were created. These functions in many instances carry the force of law. For example, if the nurse discovers a person with smallpox, the law directs the nurse and others in the public health community to take specific actions. In another example, in a mumps outbreak, a nurse and other health professionals are required to report mumps cases. This reporting requirement helps with locating and treating cases so cases can be treated or isolated as they occur to prevent further spreading of disease. Three types of laws in the United States have particular importance.
Constitutional Law Constitutional law derives from federal and state constitutions. It provides overall guidance for selected practice situations. For example, on what basis can the state require quarantine or isola- tion of individuals with tuberculosis? The U.S. Constitution specifies the explicit and limited functions of the federal gov- ernment. All other powers and functions are left to the indi- vidual states. The major constitutional power of the states relating to population-centered nursing practice is the state’s right to intervene in a reasonable manner to protect the health, safety, and welfare of its citizens. The state has police power to act through its public health system, but it has limits. First, it must be a “reasonable” exercise of power. Second, if the power interferes or infringes on individual rights, the state must dem- onstrate that there is a “compelling state interest” in exercising its power. Isolating an individual or separating someone from a community because that person has a communicable disease has been deemed an appropriate exercise of state powers. The
address bioterrorism preparedness since September 11, 2001, and since such natural disasters as Hurricane Katrina. The United States had 220,000 people lose their homes in 2013 due to extreme storms and tornadoes in Oklahoma and another 100,000 from flooding in Colorado. Health departments are on the front line in such occurrences (see Chapter 46).
IMPACT OF GOVERNMENT HEALTH FUNCTIONS AND STRUCTURES ON NURSING The variety and range of functions of governmental agencies have had a major impact on the practice of nursing. Funding, in particular, has shaped roles and tasks of population-centered nurses. The designation of money for specific needs, or cate- gorical funding, has led to special and more narrowly focused nursing roles. Examples are in emergency preparedness, school nursing, and family planning. Funds assigned to antibioterror- ism cannot be used to support unrelated communicable disease programs or family planning.
The events of September 11, 2001, have had the public and the profession of nursing concerned about the ability of the present public health system and its workforce to deal with bio- terrorism, especially outbreaks of deadly and serious communi- cable diseases. For example, smallpox vaccinations were stopped in 1972, but immunity lasts for only 10 years; although there have been no reported cases since the early 1970s, almost no one in the United States retains their immunity. Thus, the population is vulnerable to a smallpox outbreak, and smallpox could be used as a weapon of bioterrorism. Two laboratories in the world retain a small amount of the smallpox virus. Because of these potential threats, the U.S. government has begun to increase production of the vaccine (NIH, 2010b). Few public health professionals are knowledgeable of the symptoms, treatment, or mode of trans- mission of this disease. Most health professionals, including reg- istered nurses (RNs), who currently work in the United States, have never seen a case of anthrax, smallpox, or plague—the three major biological weapons of concern in the world today. A few have now seen the effects of the Ebola virus. The USDHHS and the federal Office of Homeland Security have provided funds to address this serious threat to the people of the United States.
One of the first things being done is the rebuilding of the crumbling public health infrastructures of each state to provide surveillance, intervention, and communication in the face of future bioterrorism events and natural disasters. On December 19, 2006, President George W. Bush signed the Pandemic and All-Hazards Preparedness Act (PAHPA), which was intended to improve the organization, direction, and utility of preparedness efforts. PAHPA centralizes federal responsibilities, requires state-based accountability, proposes new national surveillance methods, addresses surge capacity, and facilitates the develop- ment of vaccines and other scarce resources (Morhard and Franco, 2013). On March 13, 2013, President Barrack Obama signed the Pandemic and All-Hazards Preparedness Reauthori- zation Act into law. The 2013 law reauthorizes funding for public health and medical preparedness programs that enable communities to build systems to support people in need during and after disasters (USDHHS, 2013B).
177CHAPTER 8 Public Health Policy
Judicial and Common Law Both judicial law and common law have great impact on nursing. Judicial law is based on court or jury decisions. The opinions of the courts are referred to as case law (Birkland, 2010). The court uses other types of laws to make its decisions, including previous court decisions or cases. Precedent is one principle of common law. This means that judges are bound by previous decisions unless they are convinced that the older law is no longer relevant or valid. This process is called distinguish- ing, and it usually involves a demonstration of how the current situation in dispute differs from the previously decided situa- tion. Other principles of common law such as justice, fairness, respect for individual’s autonomy, and self-determination are part of a court’s rationale and the basis upon which to make a decision.
LAWS SPECIFIC TO NURSING PRACTICE Despite the broad nature and varied roles of nurses in practice, two legal arenas are most applicable to nurse practice situations. The first is the statutory authority for the profession and its scope of practice, and the second is professional negligence or malpractice.
Scope of Practice The issue of scope of practice involves defining nursing, setting its credentials, and then distinguishing between the practices of nurses, physicians, and other health care providers. The issue is especially important to nurses in community settings, who have traditionally practiced with much autonomy.
Health care practitioners are subject to the laws of the state in which they practice, and they can practice only with a license. The states’ nurse practice acts differ somewhat, but they are the most important statutory laws affecting nurses. The nurse prac- tice act of each state accomplishes at least four functions: defin- ing the practice of professional nursing, identifying the scope of nursing practice, setting educational qualifications and other requirements for licensure, and determining the legal titles nurses may use to identify themselves. The usual and customary practice of nursing can be determined through a variety of sources, including the following: • Content of nursing educational programs, both general
and special • Experience of other practicing nurses (peers) • Statements and standards of nursing professional
organizations • Policies and procedures of agencies employing nurses • Needs and interests of the community • Updated literature, including research, books, texts, and
journals • Internet sites if it can be determined that the site is a profes-
sional source of information All of these sources can describe, determine, and refine the
scope of practice of a professional nurse. Every nurse should know and follow closely any proposed changes in the practice acts of nursing, medicine, pharmacy, and other related
state can isolate an individual even though it infringes on indi- vidual rights (such as freedom and autonomy), under the fol- lowing conditions (Lee et al, 2012): • There is a compelling state interest in preventing an
epidemic. • The isolation is necessary to protect the health, safety, and
welfare of individuals in the community or the public as a whole.
• The isolation is done in a reasonable manner. The legal and medical communities along with AIDS
(acquired immunodeficiency syndrome) activists rejected (and made the case) that the social quarantine of individuals with AIDS was unnecessary. Thus, individual freedom and auton- omy of the individual come before “compelling state interest” unless science warrants another conclusion (Swendiman and Elsea, 2010).
Legislation and Regulation Legislation is law that comes from the legislative branches of federal, state, or local government. This is referred to as Statute Law because it becomes coded in the statutes of a government (Birkland, 2010). Much legislation has an effect on nursing. Regulations are specific statements of law related to defining or implanting individual pieces of legislation or statute law. For example, state legislatures enact laws (statutes) establishing boards of nursing and defining terms such as registered nurse and nursing practice. Every state has a board of nursing. The board may be found either in the department of licensing boards of the health department or in an administrative agency of the governor’s office. Created by legislation known as a state nurse practice act, the board of nursing is made up of nurses and consumers. The functions of this board are described in the nurse practice act of each state and generally include licensing and examination of RNs and licensed practi- cal nurses; licensing and/or certification of advanced practice nurses; approval of schools of nursing in the state; revocation, suspension, or denying of licenses; and writing of regulations about nursing practice and education.
The state boards of nursing operationalize, implement, and enforce the statutory law by writing explicit statements (rules) on what it means to be an RN, and on the nurse’s rights and responsibilities in delegating work to others and in meeting continuing education requirements.
All nurses employed in community settings are subject to legislation and regulations. For example, home health care nurses employed by private agencies must deliver care accord- ing to federal Medicare or state Medicaid legislation and regulations, so the agency can be reimbursed for those services. Private and public health care services rendered by nurses are subject to many governmental regulations for quality of care, standards of documentation, and confidentiality of client records and communications. All state health depart- ments have a public health practice reference that governs the practice of nurses and others, and state public health laws that define the essential public health services that must be offered in the state as well as the optional services that may also be offered.
178 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
According to a published account a $4.5 million verdict was returned for the child’s pain and suffering. A defense motion to set aside the verdict was pending.
With permission from Medical Malpractice Verdicts,
Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville,
TN 37203-3411,2013 1-800-298-6288.
An integral part of all negligence actions is the question of who should be sued. When a nurse is employed and functioning within the scope of employment, the employer is responsible for the nurse’s negligent actions. This is referred to as the doc- trine of respondeat superior. By directing a nurse to carry out a particular function, the employer becomes responsible for neg- ligence, along with the individual nurse. Because employers are usually better able to pay for the injuries suffered by clients, they are sued more often than the nurses themselves, although an increasing number of judgments include the professional nurse by name as a co-defendant. In some instances, if the agency is found liable, the agency may in turn sue the nurse for negli- gence. At least, the nurse often loses the job.
Thus, it is imperative that all nurses engaged in clinical prac- tice carry their own professional liability insurance. Nurses may have personal immunity for particular practice areas, such as giving immunizations. In some states, the legislature has granted personal immunity to nurses employed by public agencies to cover all aspects of their practice under the legal theory of sov- ereign immunity (Cherry and Jacobs, 2013).
Nursing students need to be aware that the same laws and rules that govern the professional nurse govern them. Students are expected to meet the same standard of care as that met by any licensed nurse practicing under the same or similar circum- stances. Students are expected to be able to perform all tasks and make clinical decisions on the basis of the knowledge they have gained or been offered, according to their progress in their educational programs and along with adequate educational supervision.
LEGAL ISSUES AFFECTING HEALTH CARE PRACTICES Specific legal issues of nursing vary depending on the setting where care is delivered, the clinical arena, and the nurse’s func- tional role. The law, including legislation and judicial opinions, significantly affects each of the following areas of nursing prac- tice. Nurses responsible for setting and implementing program priorities need to identify and monitor laws related to each special area of practice.
School and Family Health Nurses employed by health departments or boards of education may deliver school and family health nursing. School health legislation establishes a minimum of services that must be pro- vided to children in public and private schools. For example, most states require that children be immunized against certain communicable diseases before entering school. Children must
professions. The nurse should always examine all legislation, rules, and regulations related to nursing practice. For example, a review of the pharmacy act will let the nurse know whether to question the right to dispense medications in a family plan- ning clinic in a local health department. Defining the scope of practice forces one to clarify independent, interdependent, and dependent nursing functions.
Just as practice acts vary by state, so do the evolving issues and tensions of scopes of practice among the health professions. In past years, several state legislatures (working closely with the National Council of State Boards of Nursing) embarked on a legislative effort to develop the Interstate Nurse Licensure Compact. The compact allows mutual recognition of generalist nursing licensure across state lines in the compact states. By 2014, 24 states had adopted the compact (NCSBN, 2014).
Professional Negligence Professional negligence, or malpractice, is defined as an act (or a failure to act) that leads to injury of a client. To recover money damages in a malpractice action, the client must prove all of the following: 1. That the nurse owed a duty to the client or was responsible
for the client’s care 2. That the duty to act the way a reasonable, prudent nurse
would act in the same circumstances was not fulfilled 3. That the failure to act reasonably under the circumstances
led to the alleged injuries 4. That the injuries provided the basis for a monetary claim
from the nurse as compensation for the injury Reported cases involving negligence and population-centered
nurses are rare. However, the following is an example:
Home Nurse Fails to Properly Supervise Bottle Feeding of Child With Tracheal Tube for Oxygen—Death—$4.5 Million Verdict
The plaintiff, a child, age sixteen months, suffered insuf- ficiency of her lungs and required a continuous supply of oxygen via a tracheal tube. She required constant supervi- sion by a home health nurse.
In January 2008, during the day a bottle of formula was given by the nurse. The formula entered the tracheal tube and lungs. After several minutes the nurse observed that the child had stopped breathing and began cardiopulmonary resuscitation. The child did not survive. It was determined that the child had suffered asphyxiation due to ingestion of vomited material.
The plaintiff claimed that the child had choked and gagged throughout the nurse’s resuscitation attempts and that CPR was not the correct method of resuscitating the child. The plaintiff claimed that the tracheal tube should have been cleared or changed.
The case was initially brought against the defendant nurse’s employer, the home care agency, and the hospital which had provided the tracheal tube. The claims against the hospital were discontinued and the matter proceeded to trial against the home care agency. The defendant did not contest liability.
179CHAPTER 8 Public Health Policy
required for all prisoners after they are sentenced. Regulations specify basic levels of care that must be provided for prisoners, and access to care during illness is a particular focus. Court decisions requiring adequate health services are based on con- stitutional law. If minimal services are not provided, it is a viola- tion of a prisoner’s right to freedom from cruel and unusual punishment. Such decisions provide a framework that strongly influences the setting of nursing priorities. For example, provid- ing care to the sick would take priority over wellness or health education classes.
THE NURSE’S ROLE IN THE POLICY PROCESS The number and types of laws influencing health care are increasing. Because of this, nurses need to be involved in the policy process and understand the importance of involvement of nursing to the clients they serve.
For nurses to effectively care for their client populations and their communities in the complex U.S. health care system, pro- fessional advocacy for logical health policy that considers equal- ity is essential. Professional nurses working in the community know all too well about the health care problems they and their clients encounter daily, and it is through policy and political activism that both big-picture and long-term solutions can be developed.
Although the term policy may sound rather lofty, health policy is quite simply the process of turning health problems into workable action solutions. Health policy is developed on the three-legged stool of access, cost, and quality. The policy process, which is very familiar to professional nurses, includes the following: • Statement of a health care problem • Statement of policy options to address the health problem • Adoption of a particular policy option • Implementation of the policy product (e.g., a service) • Evaluation of the policy’s intended and unintended conse-
quences in solving the original health problem Thus the policy process is very similar to the nursing process,
but the focus is on the level of the larger society and the adoption strategies require political action. For most profes- sional nurses, action in the policy arena comes most easily and naturally through participation in nursing organizations such as the ANA at the state level or the Association of Community Health Nursing Educators (ACHNE) or the Asso- ciation of State and Territorial Directors of Nursing (ASTDN) at the national or state level, and in certain specialty organiza- tions like the American Association of Specialty Nursing Organizations.
Legislative Action It is often helpful to review the legislative and political processes that may have been a part of high school education. It becomes important material to remember as a professional career is embarked upon.
The people within geographic jurisdictions elect their legis- lative representatives and senators. An important part of the legislative process is the work of the legislative staff. These
have had a physical examination by that time, and most states require at least one physical at a later time in their schooling. Legislation also specifies when and what type of health screen- ing will be conducted in schools (e.g., vision and hearing testing). These requirements are found in statutory laws of states. Some states are now requiring a simple dental examina- tion in schools for the purpose of referring children to a dental health professional if needed.
Statutes addressing child abuse and neglect make a large impact on nursing practice within schools and families. Most states require nurses to notify police and/or a social service agency of any situation in which they suspect a child is being abused or neglected. This is one instance in which the law man- dates that a health professional breach client confidentiality to protect someone who may be in a helpless or vulnerable posi- tion. There is civil immunity for such reporting, and the nurse may be called as a witness in a court hearing of the case.
Occupational health is another special area of practice that has specific legal requirements as a result of state and federal statutes. Of special concern are the state workers’ compensation statutes, which provide the legal foundation for claims of workers injured on the job. Access to records, confidentiality, and the use of standing orders are legal issues that have great practice significance to nurses employed in industries.
Home Care and Hospice Home care and hospice services rendered by nurses are shaped through state statutes and have specific nursing requirements for licensure and certification. Compliance with these laws is directly linked to the method of payment for the services. For example, a service must be licensed and certified to obtain payment for services through Medicare. Federal regulations implementing Medicare/Medicaid have an enormous effect on much of nursing practice, including how nurses record details of their visits, record time spent in care activities, and document client care and the client’s status and progress.
In addition, many states have passed laws requiring nurses to report elder abuse to the proper authorities, as is done with children and youth. Laws affecting home care and hospice ser- vices have focused on such issues as the right to death with dignity, rights of residents of long-term facilities and home health clients, definitions of death, and the use of living wills and advance directives. The legal and ethical dimensions of nursing practice are particularly important. Individual rights, such as the right to refuse treatment, and nursing responsibili- ties, such as the legal duty to render reasonable and prudent care, may appear to be in conflict in delivering home and hospice services. Much case discussion (sometimes including outside ethics consultation) may be needed to resolve such conflicts.
Correctional Health Correctional health nursing practice is significantly shaped by federal and state laws and regulations and by recent Supreme Court decisions. The laws and decisions primarily relate to the type and amount of services that must be provided for incarcer- ated individuals. For example, physical examinations are
180 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
individuals do the legwork, research, paperwork, and other activities that move policy ideas into bills and then into law. In addition to the individual legislator’s office, the congressional committee staffs are also important. They are usually experts in the content of the work of a committee, such as a health and welfare committee. Frequently, developing a working relation- ship with key legislative staffers can be as important to achiev- ing a policy objective as the relationship with the policy maker (i.e., the legislator).
The legislative process begins with ideas (policy options) that are developed into bills. After a bill is drafted, it is intro- duced to the legislature, given a number, read, and assigned to a committee. Hearings, testimony, lobbying, education, research, and informal discussions follow. If the bill is passed from the legislative committee, the entire House of Representatives hears the bill, amends it as necessary, and votes on it. A majority vote moves the bill to Senate where it is read and amended, and then a vote is taken. Figure 8-2 shows the necessary formal process of the legislative pathway.
Nurses can be involved in the legislative process at any point. Many professional nursing associations have legislative com- mittees made up of volunteers, governmental relations staff professionals, and sometimes political action committees (PACs), all engaged in efforts to monitor, analyze, and shape health policy.
Common methods of influencing health policy outcomes include face-to-face encounters, personal letters, mailgrams, electronic mail, telephone calls, testimony, petitions, reports, position papers, fact sheets, letters to the editor, news releases, speeches, coalition building, demonstrations, and lawsuits. Depending on the issue, any of these can be effective. Although most business, including politics and the policy agendas, are dependent upon the Internet today for instant communication and quick response, all of these methods continue to be of great importance in influencing policy agendas. For example, if a face-to-face encounter is used with a legislator or a staffer, these persons can put a “face on the policy” agenda, and the reality that the policy affects real persons is an important consider- ation when the legislator or staff pushes the policy agenda forward. Guidelines on communication are provided in the How To box. Tips on communication and visiting legislators and their staffs, as well as general tips on political action, are presented in Boxes 8-1, 8-2, and 8-3. Political activities in which nurses can and should be involved include a wide variety of activities such as being informed voters (a must!), participating in a political party, registering others to vote, getting out the vote, fundraising for candidates, building networks or commu- nication links for issues (e.g., a phone tree or Internet distribu- tion list), and participating in organizations to ensure their effective involvement in health policy and politics.
• Face-to-face visits are viewed as the most effective. • Call ahead and ask how much time the staff or legislator is able to give you. • When you arrive, ask if the appointment time is the same or if a scheduled vote
on the House/Senate floor is going to need the legislator’s attention. • Engage in small talk at the beginning of the conversation only if the staff or
legislator has time. • Structure time so that the issue can be briefly presented. The visit will prob-
ably be 15 minutes or less. • Allow an opportunity for the staff or Congress member to seek clarity or ask
questions. • Offer to provide additional information or find answers to questions asked.
• Do not assume that the legislator or the legislator’s staff is well informed on the issue.
• Leave a one- or two-page fact sheet on the issue. • Numbers count. If the views you express are shared by a local nurses’ orga-
nization or by nurses employed at a health care facility, let the legislator know.
• Invite Congress members and their staffs to conferences or meetings of nurses’ organizations, or to tour nursing facilities to meet others interested in the same policy issues.
• If appropriate, invite the media and let the legislator know. • Follow up with a letter of thanks to both the legislator and the staffer.
BOX 8-1 Tips for Visits with Legislators
Modified from Mason D et al: Policy and politics in government, ed 5,St Louis, 2007, Elsevier.
• Communicate in writing to express opinions. • Identify yourself as a nurse. • Acknowledge the Congress member’s work as positive or negative, but be
courteous. • Follow up on meetings or phone calls with a letter or e-mail. • Share knowledge about a particular problem. • Recommend policy solutions so the legislator or staff will know why you are
writing. • The letter should be typed, a maximum of two pages, and focused on one
or two issues at most. • The purpose of the letter should be stated at the beginning. • Present clear and compelling rationales for your concern or position on an
issue. • If the purpose of the letter is to express disappointment regarding a stance
on an issue or a vote that has been cast, the letter should be as positive as possible.
• Write letters thanking a Congress member for taking a particular position on an issue.
• A letter to the editor of the local newspaper or a nursing newsletter praising a legislator’s position (with a copy forwarded to the legislator) is welcome publicity, especially during an election year.
• If you visited with the legislator or a staffer, review the major points covered in person and answer any questions that were raised during conversation.
• Have personal business cards and include them with letters. • Address written correspondence as follows (the same general format applies
to state and local officials):
U.S. Senator U.S. Representative Honorable Jane Doe Honorable Jane Doe United States Senate House of Representatives Washington, DC 20510 Washington, DC 20515 Dear Senator Doe: Dear Representative Doe:
BOX 8-2 Tips for Written Communication with Legislators
Modified from Mason D et al: Policy and politics in government, ed 5,St Louis, 2007, Elsevier.
181CHAPTER 8 Public Health Policy
FIG 8-2 How a bill becomes a law. (From Mason DJ, Leavitt JK, Chaffee MW: Policy and politics in nursing and health care, ed 6, St Louis, 2011, Elsevier.)
Compromise version voted on
HR 1 Introduced in
House
S 2 Introduced in
Senate
Referred to subcommittee
Referred to subcommittee
Referred to House committee
Referred to Senate committee
Reported by full committee
Reported by full committee
Rules committee action
Compromise version voted on
Conference action
Presidential action
Issue Identified
The Federal Level
Nursing Involvement
Provide testimony
Send emails and make phone calls
Send letter to President
Continue lobbying efforts
Provide member of Congress with information to draft bill
Provide testimony and information to committee members
Lobby members in district and Washington, DC
Floor ActionFloor Action
1
2
3
VETOED SIGNED
House debate, vote on passage
Senate debate, vote on passage
4
1 A bill goes to full committee first, then to special subcommittees for hearings, debate, revisions, and approval. The same process occurs when it goes to full committee. It either dies in committee or proceeds to the next step. 2 Only the House has a Rules Committee to set the “rule” for floor action and conditions for debate and amendments. In the Senate, the leadership schedules action. 3 The bill is debated, amended, and passed or defeated. If passed, it goes to the other chamber and follows the same path. If each chamber passes a similar bill, both versions go to conference. 4 The President may sign the bill into law, allow it to become law without his signature, or veto it and return it to Congress. To override the veto, both houses must approve the bill by a two-thirds majority vote.
182 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
staff mix, and outcomes, and it requires the USDHHS to review and approve all health care acquisitions and mergers. All of these requirements are to determine any long-term effect on the health and safety of clients, communities, and staff.
On the state legislative level, all 50 states have passed title protection for APNs; this was achieved by individual nurses, state nurses associations, and various nursing specialty groups participating in the legislative process with the 50 state legisla- tors. Title protection means that only certain nurses who meet state criteria can call themselves advanced practice nurses.
Regulatory Action The regulatory process, although it may not be as visible a process as legislation, can also be used to shape laws and dra- matically affect health policy. This process should be on the radar screen of professional nurses who wish to successfully participate in policy activity.
At each level of government, the executive branch can and, in most cases, must prepare regulations for implementing policy for new laws and new programs. These regulations are detailed, and they establish, fix, and control standards and cri- teria for carrying out certain laws. Figure 8-3 shows the steps in the typical process of writing regulations. When the legislature passes a law and delegates its oversight to an agency, it gives that agency the power to make regulations. Because regulations flow from legislation, they have the force of law.
The Process of Regulation After a law is passed, the appropriate executive department begins the process of regulation by studying the topic or issue. Advisory groups or special task forces are sometimes formed to provide the content for the regulations. Nurses can influence these regulations by writing letters to the regulatory agency in charge or by speaking at open public hearings. Many letters are now accepted by Internet.
After rewriting, the proposed regulations are put into final draft form and printed in the legally required publication (e.g., at the federal level, the Federal Register). Similar registers exist in most states, where regulations from state executive
HOW TO Be an Effective Communicator • Use simple communications that will be readily understood. • Choose language that clearly conveys information to individuals
of diverse cultures, different ages, and different educational backgrounds.
• Target oral or written communication to the issue and omit jargon unique to medicine and nursing.
• State your expertise on the issue first. • Briefly describe your education and experience. • Identify the relevance of the issue beyond nursing. • Provide information regarding the impact of the issue on the
legislator’s constituents. • Present accurate, credible data. • Do not oversell or give inaccurate information about the problem. • Present information in an organized, thorough, concise form that
is based on factual data (when available). • Give examples.
The direct reimbursement of advanced practice nurses (APNs) in the Medicare program is one example of how nurses can use their influence. The inclusion of amendments to Medi- care that authorized APN reimbursement regardless of specialty or client location in the Balanced Budget Act of 1997 required the sustained efforts of the ANA and other national nursing organizations over a long period (Nursing World, 2000; USDHHS, CMS, 2011. During that time, individual nurses provided testimony to Congress and to MEDPAC (the physi- cians’ political action committee) on the importance of direct reimbursement to APNs. Many APNs worked closely and vigorously with their congressional representatives to lobby for this Medicare amendment. Even more wrote letters and pro- vided position papers and fact sheets to help legislators under- stand the value of APNs. Although the process took more than 10 years to achieve fully, APN reimbursement in Medicare became a reality. Both the nursing profession and Medicare beneficiaries will benefit from the enhanced access of Medicare clients to APNs.
The ANA was likewise a strong supporter for the Patient Safety Act of 1997 (ANA, 1997). This law requires health care agencies to make public some information on nurse staff levels,
• Become informed. • Become acquainted with elected officials. • Become involved in the state nurses’ association. • Build communication and leadership skills. • Increase your knowledge about a range of professional issues. • Expand and strengthen your professional network. • Build relationships within the profession and with representatives of public
and private sector organizations with an interest in health care. • Be aware of what is taking place in health care beyond the environment and
the practice in which you work. • Communicate with legislators regularly and share expertise and perspective
on issues related to health care and nursing. • Offer your expertise to assist in developing new legislation, modifying exist-
ing legislation or regulations.
• Identify yourself as a nurse with associated education and expertise. • Let people know that nurses are capable of functioning in many different
roles and making substantial contributions. • Be confident. • Do not burn bridges. • Be friendly. • Lend a hand to other nurses. It benefits all of us. • Find an experienced mentor to work with you if you are new to the policy
arena. • Volunteer, seek appointments, or participate in elections in campaigns. • Explore opportunities for involvement through internships, fellowships, and
volunteer work at all levels (local, state, and national).
BOX 8-3 Tips for Action
Modified from Mason D, Keavitt JK, Chaffee MW: Policy and politics ingovernment, ed 5, St Louis, 2007, Elsevier.
183CHAPTER 8 Public Health Policy
final regulations to recognize the state definitions for APN prac- tice autonomy.
Final regulations, published in a Code of Regulations (both federal and state), usually lead to changes in practice. For example, Medicare regulations setting standards for nursing homes and home health are incorporated into these agencies’ manuals. In the case of APN reimbursement, some Medicare fiscal interme- diaries have had difficulty in recognizing APNs as appropriate providers, but professional nursing organization advocates have forcefully addressed these implementation barriers.
Nursing Advocacy Advocacy begins with the art of influencing others (politics) to adopt a specific course of action (policy) to solve a societal problem. This is accomplished by building relationships with the appropriate policy makers—the individuals or groups that determine a specific course of action to be followed by a government or institution to achieve a desired end (policy outcome). Relationships for effective advocacy can be built in a number of ways.
In January 2006, Medicare Part D—the prescription drug benefits policy—became effective. Public health professionals need to continue to assist many vulnerable persons to under- stand the value of enrolling in Part D, to educate them on how to use the benefits, and to ensure that the populations who are
FIG 8-3 The process of writing regulations.
Changes in practice occur
Legislation passed
by Congress President signs bill into law
Executive department studies law
President assigns
law to Executive department
Time set for hearing and public comments
Final regulations published
Regulations drafted
and published
Final regulations
drafted
departments, including state health departments, are published. Public comment is called for in written form or oral presenta- tion within a given period.
Revisions made to proposed regulations are based on public comment and public hearing. Depending on the amount and content of the public reaction, final regulations are prepared or more study of the area and issues is conducted. Final published regulations carry the force of law. When regulations become effective, health care practice is changed to conform to the new regulations. Monitoring administrative regulations is essential for the professional nurse, who can influence regulations by attending the hearings, providing comments, testifying, and engaging in lobbying aimed at individuals involved in the writing of the regulations. Concrete written suggestions for revision submitted to these individuals are frequently persua- sive and must be acknowledged by government in publishing the final rules. An excellent example of how nurses must con- tinue to influence health policy outcomes, even after positive legislation has passed, occurred after the passage of the Bal- anced Budget Act of 1997 (PL 105-33, 1997). The HCFA began to implement the BBA ’97 through the publication of draft regulations seeking to define APN practice and Medicare reim- bursement. The nursing community responded vigorously with negative opinions about the initial restrictive definitions and requirement. Their reactions were effective and reshaped the
184 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
and the clients that nurses serve. Keeping up to date on issues within government, professional organizations, law, and public policy is vitally important. Informed activism directed toward a professional role, image, and value for professional nurses, and toward a health care system in the United States that provides high quality and affordable universal access to health care, should be a life-long commitment for all profes- sional nurses.
“dually” enrolled in both Medicare and Medicaid are registered. Coordinating efforts between civic, religious, and health care agencies to provide health education is a necessity.
A letter or visit to the district, state, or national office of a legislator to discuss a particular policy or health care issue can be interesting, educational, and effective. Contributions of money, labor, expertise, or influence may also be welcomed by the policy makers involved in setting a course of action to obtain a desired health outcome for an individual, a family, a group, a community, or society (health policy). In addition, one may develop a grassroots network of community and profes- sional friends with a mutual interest in health policy advocacy. The network may be able to promote health policy initiatives for the community. During the Obama presidential campaign, many advocacy networks were established via the Internet and monies were solicited using this process.
Many special-interest groups in health care have the poten- tial, desire, and resources to influence the health policy process. A tremendous advantage that nursing has in advocating for issues and in influencing policy makers is the force of its numbers, since nursing is the largest of the health professions. However, nursing must organize its numbers in such a way that each nurse joins with others to speak with one voice. The great- est effect will be had when all nurses make similar demands for policy outcomes.
During 2002, the nursing profession spoke clearly, distinctly, and together on a serious problem for the health arena and for the profession: the nursing shortage. Health care facilities and employers were having ever-increasing difficulty finding expe- rienced nurses to employ. In addition, the need for RNs was predicted to balloon in the next 20 years because of the aging of the U.S. population, technological advances, and economic factors. Demand for RNs was anticipated to increase by 22% by the year 2008. This increased demand for professional nurses, coupled with the expected retirement of a rapidly aging nursing workforce, placed a tremendous stress on the health care system.
The workforce shortage resulted from a complex set of factors such as fewer young people entering the profession, declining nursing school enrollment, the aging of the current nurse workforce, and uncomfortable working conditions in which nurses felt pressured to “do more with less.” On Decem- ber 4, 2009, the BLS (2009) reported that the health care sector of the economy was continuing to grow, despite significant job losses in nearly all major industries. During the same time period a shortage of registered nurses was projected to spread across the country between 2009 and 2030 (AJMQ, 2012).
The American Association of Colleges of Nursing (AACN) remained concerned about the shortage of RNs and worked with schools, policy makers, other organizations, and the media to bring attention to this health care crisis. AACN worked to enact legislation, identify strategies, and form collaborations to address the nursing shortage (AACN, 2010). However, in June 2011 it was reported that employers and staffing agencies posted more than 121,000 new job ads for Registered Nurses in May, up 46% from May 2010 (AACN, 2014).
Advocacy by expert and committed health professionals can bring about positive change for the profession, the community,
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES • Targeted competency: Quality improvement • Knowledge: Describe strategies for learning about the outcomes of care
in the public setting • Skills: Seek information about outcomes of care for populations served in
care settings • Attitudes: Appreciate that continuous quality improvement is an essential
part of the daily work of all professionals
QI Question The Quad Council competency of policy development and program planning skills indicates that the beginning PHN collects information that will inform policy decisions. Also the PHN describes the legislative policy development process and identifies outcomes of current health policy relevant to PHN prac- tice. The 2014 outbreak of the Ebola virus in the United States brought quick recognition that there was a need for improvement in policies related to infec- tious disease control. What were the indicators that the infection control poli- cies in place were not sufficient to prevent the spread of disease? Describe the CQI data collection processes that determined the need for policy change. What role did nurses and organized nursing play in improving the infection control policy and guidelines nationally? What has been the outcome of the new policy and how were populations affected both locally and nationally?
LINKING CONTENT TO PRACTICE
An example of how the policy process works follows, involving a nursing organization and individual members. Whether you are a member of a group as described below, or working on your own to influence health policy, the steps described here apply.
Over a 15-month time frame, the American Nurses Association was involved in advocating for health care reform. During the presidential campaign, can- didates were educated about the nursing profession and ANA’s Agenda for Health System Reform. ANA and its members participated in national media interviews and local media events. The message was that the association and its members believed that health care is a basic right. ANA collaborated with the nursing community to outline the profession’s priorities as proposals were developed in Congress. Testimony was given before three key congressional committees. ANA representatives met with White House and congressional health care reform staff, and took part in two presidential press conferences at the White House.
As reported by ANA, thousands of nurses joined ANA’s health care reform team, sending letters to representatives of Congress, sharing their stories, and meeting with members of Congress. They also participated in rallies and events.
For more information on ANA’s health care reform work, visit http:// www.rnaction.org/toolkit.
185CHAPTER 8 Public Health Policy
P R A C T I C E A P P L I C A T I O N Larry was in his final rotation in the Bachelor of Science in nursing program at State University. He was anxious to com- plete his final nursing course, because upon graduation he would begin a position as a staff nurse specializing in school health at the local health department. His wife was expecting their first child, and she had been receiving prenatal care at the health department.
Larry was aware that a few years ago the federal government had, by law, provided block grants to states for primary care, maternal–child health programs, and other health care needs of states. He had read the Federal Register and knew that the regu- lations for these grants had been written through USDHHS departments. He was aware that these regulations did not require states to fund specific programs.
Larry read in the local newspaper that the health department was closing its prenatal clinic at the end of the month. When
his state had received its block grant, it decided to spend the money for programs other than prenatal care. Larry found that a 3-year study in his own state showed improved pregnancy outcomes as a result of prenatal care. The results were further improved when the care was delivered by population-centered nurses. After Larry’s daughter was born, he read in the Federal Register that states could apply for federal stimulus funds and receive a grant for home visiting services to support mothers and new babies.
Larry was concerned that, as a student, he would have little influence on how such grant dollars would be spent. However, he decided to call his classmates together to plan a course of action.
What would such an action plan include? Answers can be found on the Evolve site.
K E Y P O I N T S • The legal basis for most congressional action in health care
can be found in Article I, Section 8, of the U.S. Constitution. • The five major health care functions of the federal govern-
ment are direct service, financing, information, policy setting, and public protection.
• The goal of the World Health Organization is the attainment by all people of the highest possible level of health.
• Many federal agencies are involved in government health care functions. The agency most directly involved with the health and welfare of Americans is the U.S. Department of Health and Human Services (USDHHS).
• Most state and local governments have activities that affect nursing practice.
• The variety and range of functions of governmental agencies have had a major impact on nursing. Funding, in particular, has shaped the role and tasks of nurses.
• The private sector (of which nurses are a part) can influence legislation in many ways, especially through the process of writing regulations.
• The number and types of laws influencing health care are increasing. Because of this, involvement in the political process is important to nurses.
• Professional negligence and the scope of practice are two legal aspects particularly relevant to nursing practice.
• Nurses must consider the legal implications of their own practice in each clinical encounter.
• The federal and most state governments are composed of three branches: the executive, the legislative, and the judicial.
• Each branch of government plays a significant role in health policy.
• The U.S. Public Health Service was created in 1798. • The first national health insurance legislation was challenged
in the Supreme Court in 1937. • Health: United States (NCHS, 2013) is an important source
of data about the nation’s health care problems. • In 1921 the Sheppard-Towner Act was passed, and it had an
important influence on child health programs and population-centered nursing practice.
• The Division of Nursing, the National Institute of Nursing Research, and the Agency for Healthcare Policy and Research are governmental agencies important to nursing.
• Nurses, through state and local health departments, function as consultants, policy advocates, population level and direct care providers, researchers, teachers, supervisors, and program managers.
• The state governments are responsible for regulating nursing practice within the state.
• Federal and state social welfare programs have been devel- oped to provide monetary benefits to the poor, older adults, the disabled, and the unemployed.
• Social welfare programs affect nursing practice. These pro- grams improve the quality of life for special populations, thus making the nurse’s job easier in assisting the client with health needs.
• The nurse’s scope of practice is defined by legislation and by standards of practice within a specialty.
186 PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing
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C L I N I C A L D E C I S I O N — M A K I N G A C T I V I T I E S 1. Conduct an interview with a local health officer. Ask for
information from a 10-year period. Try to see trends in pop- ulation size, health needs and corresponding roles, and activ- ities of government that were implemented to meet these changes. What were some of the problems you identified?
2. Examine a current health department budget and compare it with a budget from previous years. Has there been any impact on health care because of changes in government spending (especially before and after the passing of the Patient Protec- tion and Affordable Care Act)? Give an example.
3. Locate your state register or other documents, such as news- papers, that publish proposed regulations. Select one set of proposed regulations and critique them. Submit your opinion in writing as public comment, or attend the hearing and testify on the regulations. Be sure to submit something in writing. Evaluate your participation by stating what you learned and whether the proposed regulations were changed in your favor.
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7. Ask about the conflict between the state’s rights and indi- vidual rights and how such issues are resolved.
8. Ask about the standards of care that apply to this issue and how it is decided which services offered to clients should be mandatory and which should be voluntary.
9. Explore how the role of public health differs in these epidem- ics compared with the past epidemics of smallpox and tuber- culosis. Be specific.
187CHAPTER 8 Public Health Policy
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188
Conceptual and Scientific Frameworks Applied to Population-Centered Nursing Practice
In recent years many foundations, organizations and associations have developed important documents that discuss the importance of public health nursing and that define the essential competencies for public health nursing practice. Because of the emerging public health threats in the United States and many other countries it has been important to focus on the essential role of public health nursing in dealing effectively with these threats. Specifically, there has been a reemergence of communicable diseases, and other diseases previously limited in scope have now become more virulent. At the same time, there has been an increased incidence of drug-resistant organisms. Also, environmental hazards that affect the water, land, air, and food that animals and people eat and drink and the locations where people live have increased. As will be discussed in other sections of the book, chronic diseases consume an increasing portion of health care expenditures, and many of these diseases are associated with lifestyle choices.
Many factors influence behavior and subsequently health. Edberg (2015) says that “ecological models inte- grate the various influences on health behavior, including interpersonal, organizational, community and public policy factors, to name a few” (p.12). Public health nursing incorporates an ecological approach as it responds to the needs of families, communities, and populations. Public health nurses are in an ideal position to identify risk factors as well as protective factors for the populations they serve.
Documents that can guide and assist public health nurses in developing strategies to serve their populations include the “Scope and Standards of Public Health Nursing” revised in 2013 by the American Nurses Associa- tion. This document provides a framework for the practice of public health nursing that builds on the current information about the influences on practice and the issues facing public health nurses. Similarly, in 2013, the American Association of Colleges of Nursing developed a supplement to the “Essentials of Baccalaureate Education for Professional Nursing Practice” entitled “Public Health: Recommended Baccalaureate Competen- cies and Curricular Guidelines for Public Health Nursing.” Another useful document that is cited in many chapters in the text is “Core Competences for Public Health Professionals” which was developed by the Council on Linkages Between Academia and Public Health Practice and revised in 2014. In 2011 the Quad Council of Public Health Nursing developed a companion document for the Core Competences for Public Health Profes- sionals that aligns the work of the Council on Linkages directly with public health nursing. Also, the Institute
P A R T 3
Edberg M: Essentials of Health Behavior, ed 2, Burlington MA, Jones & Bartlett Learning, 2015.
189PART 3 Conceptual and Scientific Frameworks
of Medicine developed “For the Public’s Health: Investing in a Healthier Future” in 2012 which provides considerable infor- mation about population-based prevention efforts designed to improve the health of Americans.
The chapters in Part Three support the tenants of these docu- ments and provide information about how to use conceptual
models, epidemiology, genomics, environmental health, infec- tious and communicable diseases, principles of education, and how evidence helps to organize population-centered nursing practice to meet the core functions of public health. Each chapter provides readers with tools that can be used to influence pop- ulation-centered nursing practice.
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Population-Based Public Health Nursing Practice: The Intervention Wheel
9
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Identify the components of the Intervention Wheel. 2. Describe the assumptions underlying the Intervention
Wheel.
3. Define the wedges and interventions of the Intervention Wheel.
4. Differentiate among three levels of practice (community, systems, and individual/family).
5. Apply the nursing process at three levels of practice.
K E Y T E R M S advocacy, p. 206 case finding, p. 206 case management, p. 206 coalition building, p. 206 collaboration, p. 206 community, p. 194 community-level practice, p. 195 community organizing, p. 206 consultation, p. 206 counseling, p. 206 delegated functions, p. 206 determinants of health, p. 194 disease and other health event investigation, p. 200
health teaching, p. 206 individual-level practice, p. 195 intermediate goals, p. 211 interventions, p. 195 levels of practice, p. 192 outcome health status indicators, p. 211 outreach, p. 200 policy development, p. 206 policy enforcement, p. 206 population, p. 193 population of interest, p. 193 population at risk, p. 193 prevention, p. 194
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz
• Case Studies • Glossary • Answers to Practice Application
Linda Olson Keller, DNP, CPH, APHN-BC, RN, FAAN Linda Olson Keller is a Clinical Associate Professor at the University of Minnesota School of Nursing. Her research focuses on evidence-based public health nursing practice and the infrastructure of the public health nursing workforce. She spent 20 years of her career in the Office of Public Health Practice at the Minnesota Department of Health. Dr. Olson Keller is certified in Public Health, board certified as an Advanced Public Health Nurse, and is a Fellow of the American Academy of Nursing. She is a frequent national speaker and consultant on public health leadership and practice.
Sue Strohschein’s public health nursing career spans more than 40 years and includes practice in both local and state health departments in Min- nesota. She was a generalized public health nurse consultant for the Minnesota Department of Health for 25 years. Since 2008 she has been with
the University of Minnesota School of Nursing as a senior research fellow.
Sue Strohschein, MS, RN/PHN, APRN, BC
191CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
In these times of change, the public health system is constantly challenged to keep focused on the health of populations. The Intervention Wheel is a conceptual framework that has proved to be a useful model in defining population-based practice and explaining how it contributes to improving population health.
The Intervention Wheel provides a graphic illustration of population-based public health practice (Keller et al, 1998, 2004a,b). It was previously introduced as the Public Health Intervention Model and was known nationally as the “Minne- sota Model”; it is now often simply referred to as the “Wheel.” The Wheel depicts how public health improves population
health through interventions with communities, the individuals and families that comprise communities, and the systems that impact the health of communities (Figure 9-1). The Wheel was derived from the practice of public health nurses (PHNs) and intended to support their work. It gives PHNs a means to describe the full scope and breadth of their practice.
This chapter applies the Intervention Wheel framework to public health nursing practice. However, it is important to note that other public health members of the interprofessional team such as nutritionists, health educators, planners, physicians, and epidemiologists also use these interventions.
K E Y T E R M S — cont’d primary prevention, p. 194 public health nursing, p. 193 referral and follow-up, p. 206 screening, p. 200 secondary prevention, p. 195 social marketing, p. 206
surveillance, p. 200 systems-level practice, p. 195 tertiary prevention, p. 194 wedges, p. 195 —See Glossary for definitions
C H A P T E R O U T L I N E The Intervention Wheel Origins and Evolution Assumptions Underlying the Intervention Wheel
Assumption 1: Defining Public Health Nursing Practice Assumption 2: Public Health Nursing Practice Focuses on
Populations Assumption 3: Public Health Nursing Practice Considers
the Determinants of Health Assumption 4: Public Health Nursing Practice Is Guided
by Priorities Identified Through an Assessment of Community Health
Assumption 5: Public Health Nursing Practice Emphasizes Prevention
Assumption 6: Public Health Nurses Intervene at All Levels of Practice
Assumption 7: Public Health Nursing Practice Uses the Nursing Process at All Levels of Practice
Assumption 8: Public Health Nursing Practice Uses a Common Set of Interventions Regardless of Practice Setting
Assumption 9: Public Health Nursing Practice Contributes to the Achievement of the 10 Essential Services
Assumption 10: Public Health Nursing Practice Is Grounded in a Set of Values and Beliefs
Using the Intervention Wheel in Public Health Nursing Practice
Components of the Model Component 1: The Model Is Population Based Component 2: The Model Encompasses Three Levels of
Practice Component 3: The Model Identifies and Defines 17 Public
Health Interventions Adoption of the Intervention Wheel in Practice, Education,
and Management Healthy People 2020
Applying the Nursing Process in Public Health Nursing Practice
Applying the Process at the Individual/Family Level Community Assessment Public Health Nursing Process: Assessment of a Family Public Health Nursing Process: Diagnosis Public Health Nursing Process: Planning (Including
Selection of Interventions) Public Health Nursing Process: Implementation Public Health Nursing Process: Evaluation
Applying the Public Health Nursing Process at the Community Level of Practice Scenario
Community Assessment (Public Health Nursing Process: Assessment)
Community Diagnosis (Public Health Nursing Process: Diagnosis)
Community Action Plan (Public Health Nursing Process: Planning, Including Selection of Interventions)
Community Implementation Plan (Public Health Nursing Process: Implementation)
Community Evaluation (Public Health Nursing Process: Evaluation)
Applying the Public Health Nursing Process to a Systems Level of Practice Scenario
Public Health Nursing Process: Assessment Public Health Nursing Process: Diagnosis Public Health Nursing Process: Planning (Including
Selection of Interventions) Public Health Nursing Process: Implementation Public Health Nursing Process: Evaluation
192 PART 3 Conceptual and Scientific Frameworks
FIG 9-1 The Intervention Wheel components. (Used with per- mission from Keller LO, Strohschein S, Lia-Hoagberg B, et al: Population-based public health interventions: practice-based and evidence-supported, part I. Public Health Nurs 21:453–468, 2004.)
The Intervention Wheel is composed of three distinct elements of equal importance:
• First, the model is population based.
• Second, the model encompasses three levels of practice (community, systems, individual/family).
• Third, the model identifies and defines 17 public health interventions.
Each intervention and level of practice contributes to improving population health.
A dv
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THE INTERVENTION WHEEL ORIGINS AND EVOLUTION The original version of the Wheel resulted from a grounded theory process carried out by PHN consultants at the Minne- sota Department of Health in the mid-1990s. This was a period of relentless change and considerable uncertainty for Minne- sota’s public health nursing community. Debates about health care reform and its impact on the role of local public health departments created confusion about the contributions of public health nursing to population-level health improvement. In response to the uncertainty, the consultant group presented a series of workshops across the state highlighting the core func- tions of public health nursing practice (see Chapter 1 for a description of these core functions). A workshop activity required participants to describe the actions they undertook to
carry out their work. The consultant group analyzed 200 prac- tice scenarios developed at the workshops that ranged from home care and school health to home visiting and correctional health. In the final analysis, 17 actions common to the work of PHNs regardless of their practice setting were identified. The analysis also demonstrated that most of these interventions were implemented at three levels: (1) with individuals, either singly or in groups, and with families; (2) with communities as a whole; and (3) with systems that impact the health of communities. A wheel-shaped graphic was developed to illus- trate the set of interventions and the levels of practice (see Figure 9-1).
The interventions were subjected to an extensive review of supporting evidence in the literature through a grant from the federal Division of Nursing awarded to the Minnesota Depart- ment of Health in the 1990s. In 1999 the PHN consultant group at the Minnesota Department of Health designed and imple- mented a systematic process identifying more than 600 items from supporting evidence in the literature. These items were rated for their quality and relevancy by a group of graduate nursing students. The resulting subset of 221 items was further analyzed by two expert panels. One panel was composed of public health nursing educators and expert practitioners from five states (Iowa, Minnesota, North Dakota, South Dakota, and Wisconsin). The other panel was a similarly composed national panel. The result was a slightly modified set of 17 interventions. Figure 9-2 graphically illustrates the systematic critique. Each intervention was defined at multiple levels of practice; each was accompanied by a set of basic steps for applying the framework and recommendations for best practices.
Adoption of the model was rapid and worldwide. Since its first publication in 1998, the Intervention Wheel has been incorporated into the public/community health coursework of numerous undergraduate and graduate curricula. The Wheel serves as a model for practice in many state and local health departments and has been presented in Mexico, Norway, Poland, Hungary, Namibia, Kazakhstan, and Japan. It has served as an organizing framework for inquiry for topics ranging from honors theses examining residents’ perceptions regarding envi- ronmental hazards in their community (Kariuki, 2012) to nursing curriculum reviews (Schoneman et al, 2014) to build- ing breast cancer screening coalitions (Depke and Onitilo, 2011). The Wheel’s strength comes from the common language it affords PHNs to discuss their work (Keller et al, 1998).
ASSUMPTIONS UNDERLYING THE INTERVENTION WHEEL As with all conceptual frameworks and models, assumptions are made that help to explain the model or framework. The Inter- vention Wheel framework is based on 10 assumptions.
Assumption 1: Defining Public Health Nursing Practice Public health nursing is defined as “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (APHA, 2013, p. 2).
193CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
FIG 9-2 Development of a conceptual framework using an evidence-based process. (Used with permission from Keller LO, Strohschein S, Lia-Hoagberg B, et al: Population-based public health interventions: practice-based and evidence-supported, part I. Public Health Nurs 21:459, 2004.)
Systematic Critique • Validate Interventions Through Best Evidence • Identify Best Practices for Each Intervention
Comprehensive search of public health nursing, public health, nursing literature
Survey of 51 BSN programs in five states to identify most frequently used community health/public
health nursing textbooks and readings
Critiqued for rigor by five public health nursing graduate students using an instrument designed for the project
(Tools for Analyzing Evidence, 1999)
Each source independently rated
for application to practice by at least 2
members of a 42- member panel of PHN practitioners
and educators
665 articles, books, papers, dissertations, and conference proceedings
221 sources met the criteria for further consideration:
42-Member expert panel deliberated the evidence during 2-day meeting to develop consensus on interventions, definitions, basic steps, and best practices for each intervention
Two rounds of a modified Delphi process achieved clarification and agreement on the revised intervention set
Field-tested with 150 practicing PHNs
through regional trainings
Critiqued by a 20-member national panel of expert PHN practitioners and
educators
Public Health Interventions: Applications for Public
Health Nursing Practice
Advocacy—16 Case Management—13 Coalition Building—12 Collaboration—21 Community Organizing—12 Consultation—5 Counseling—7 Delegated Functions—1 Disease Investigation—1
Health Teaching—15 Outreach/Case-Finding—11 Policy Development—22 Provider Education—12 Referral/Follow-up—11 Screening—12 Social Marketing—18 Surveillance—13
The title “public health nurse” designates a registered nurse with educational preparation in both public health and nursing. The primary focus of public health nursing is to promote health and prevent disease for entire population groups. This is done by working with individuals, families, communities, and/or systems.
Assumption 2: Public Health Nursing Practice Focuses on Populations The focus on populations as opposed to individuals is a key characteristic that differentiates public health nursing from other areas of nursing practice. A population is a collection of individuals who have one or more personal or environmental characteristics in common (Williams and Highriter, 1978). Populations may be understood as two categories. A population at risk is a population with a common identified risk factor or risk exposure that poses a threat to health. For example, all
adults who are overweight and hypertensive constitute a popu- lation at risk for cardiovascular disease. All under-immunized or un-immunized children are a population at risk for contract- ing vaccine-preventable diseases. A population of interest is a population that is essentially healthy but that could improve factors that promote or protect health. For instance, healthy adolescents are a population of interest that could benefit from social competency training. All first-time parents of newborns are a population of interest that could benefit from a public health nursing home visit. Populations are not limited to only individuals who seek services or individuals who are poor or otherwise vulnerable.
Assumption 3: Public Health Nursing Practice Considers the Determinants of Health Health inequities are defined as health status inequalities that society deems to be avoidable or unnecessary (Bleich, Jarlenski,
194 PART 3 Conceptual and Scientific Frameworks
Bell, and LaVeist, 2012). Significant health disparities related to race, gender, age, and socioeconomic status exist within the United States. The CDC’s (2013) Health Disparities and Inequalities Report—United States, 2013 provides the following examples: • In 2008, the U.S. rate of infant deaths per 1000 live births
was 6.61 for all races; across races and ethnicities the rates varied. For infants born to white women the rate was 5.52; for black and African American women, 12.67; for Asian or Pacific Islander women, 4.51; for American Indian or Alaskan Native women, 8.42, for Hispanic women, 5.59 (Table 1, pp 172).
• Infant mortality rates also differed based on the geographic location of the mother. The rates were generally higher in the Southern and Midwestern regions. The infant mortality rates were highest in DC (11.97 per 1000 live birth) and Mississippi (10.16 per live birth) and lowest in Massachusetts and Utah (both at 4.94 per 1000 live births) (Table 2, pp 173).
• Disparities in life expectancy exist between gender and race. In 2008, the life expectancy at birth for men in the United States was 75.6 years; yet for U.S. women, the life expectancy at birth was 80.6 (Table 1, p. 89). Furthermore, the life expec- tancy at birth for black populations in the U.S. was 74.0 years, compared to 78.5 years for white populations (Table 1, p. 89). What are the factors driving these differences? Factors that
influence health status across the life cycle are known as the determinants of health. They include income, education, employment, social support, biology and genetics, physical environment, housing, transportation, and personal health practices.
Resolving health inequities and addressing the determinants of health are key distinguishing characteristics of public health nursing. For example, historically, Lillian Wald’s Henry Street Settlement House offered numerous social programs, including drama and theater productions, vocational training for boys and girls, three kindergartens, summer camps for children, two large scholarship funds, study rooms staffed with people to help children with their homework, playgrounds for children, a neighborhood library, and classes in carpentry, sewing, art, diction, music, and dance. The following photo shows the settlement house’s backyard playground.
In a recent interpretive qualitative study of PHNs’ practice in Nova Scotia, researchers found that PHNs routinely imple- mented “ecosocial surveillance functions” that focused on mon- itoring changes in social determinants of health. The researchers observed that PHNs “…monitored both bottom-up changes in individual, family, and community determinants of health, and top-down vertical changes or policy directives in the larger system” (Meagher-Stewart et al, 2009, p 557).
Assumption 4: Public Health Nursing Practice Is Guided by Priorities Identified Through an Assessment of Community Health In the context of the Intervention Wheel, a community is defined as “a group of people who share common culture, values and/or interests, based on social identity and/or territory,
and who have some means of recognizing, and (inter)acting upon, these commonalities” (Gregory et al, 2009, p. 103).
Assessing the health status of the populations that comprise the community requires ongoing collection and analysis of rel- evant quantitative and qualitative data. Community assessment includes a comprehensive assessment of the determinants of health. Data analysis identifies deviations from expected or acceptable rates of disease, injury, death, or disability as well as risk and protective factors. Community assessment generally results in a lengthy list of community problems and issues. However, communities rarely possess sufficient resources to address the entire list. This gap between needs and resources necessitates a systematic priority-setting process. Although data analysis provides direction for priority setting, the community’s beliefs, attitudes, and opinions as well as the community’s readi- ness for change must be assessed (Keller et al, 2002). PHNs, with their extensive knowledge about the communities in which they work, provide important information and insights during the priority-setting process.
Assumption 5: Public Health Nursing Practice Emphasizes Prevention Prevention is “anticipatory action taken to prevent the occur- rence of an event or to minimize its effect after it has occurred” (Turnock, 2011). Prevention is customarily described as a con- tinuum moving from primary to tertiary prevention (Leavell and Clark, 1965; Shi and Johnson, 2013; Turnock, 2011). The Levels of Prevention box provides definitions and examples of the levels of prevention.
A hallmark of public health nursing practice is a focus on health promotion and disease prevention, emphasizing primary prevention whenever possible. Although not every event is pre- ventable, every event has a preventable component.
Assumption 6: Public Health Nurses Intervene at All Levels of Practice To improve population health, the work of PHNs is often carried out sequentially and/or simultaneously at three levels of prevention (see Figure 9-2).
From Jewish Women’s Archive: This day in history, March 10, 1893, Resource information for backyard of a Henry Street branch. Available at http://www.jwa.org/archive/jsp/gresInfo.jsp ?resID=297. Accessed December 11, 2010.
195CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
Community-level practice changes community norms, community attitudes, community awareness, community prac- tices, and community behaviors. It is directed toward entire populations within the community or occasionally toward pop- ulations at risk or populations of interest. An example of community-level practice is a social marketing campaign to promote a community norm that serving alcohol to under-aged youth at high school graduation parties is unacceptable. This is a community-level primary prevention strategy.
Systems-level practice changes organizations, policies, laws, and power structures within communities. The focus is on the systems that impact health, not directly on individuals and communities. Conducting compliance checks to ensure that bars and liquor stores do not serve minors or sell to individuals who supply alcohol to minors is an example of a systems-level secondary prevention strategy practice.
Individual-level practice changes knowledge, attitudes, beliefs, practices, and behaviors of individuals. This practice level is directed at individuals, alone or as part of a family, class, or group. Even though families, classes, and groups are com- prised of more than one individual, the focus is still on
individual change. Teaching effective refusal skills to groups of adolescents is an example of individual secondary prevention strategy level of practice.
Assumption 7: Public Health Nursing Practice Uses the Nursing Process at All Levels of Practice Although the components of the nursing process (assessment, diagnosis, planning, implementation, and evaluation) are inte- gral to all nursing practice, PHNs must customize the process to the three levels of practice. Table 9-1 outlines the nursing process at the community, systems, and individual/family levels of practice.
Assumption 8: Public Health Nursing Practice Uses a Common Set of Interventions Regardless of Practice Setting Interventions are “actions taken on behalf of communities, systems, individuals, and families to improve or protect health status” (ANA, 2010). The Intervention Wheel encompasses 17 interventions: surveillance, disease and other health investi- gation, outreach, screening, case finding, referral and follow- up, case management, delegated functions, health teaching, consultation, counseling, collaboration, coalition building, community organizing, advocacy, social marketing, and policy development and enforcement.
The interventions are grouped with related interventions; these wedges are color coordinated to make them more recog- nizable (Figure 9-3, A). For instance, the five interventions in the red wedge are frequently implemented in conjunction with one another. Surveillance is often paired with disease and health event investigation, even though either can be implemented independently. Screening frequently follows either surveillance or disease and health event investigation and is often preceded by outreach activities in order to maximize the number of those at risk who actually get screened. Most often, screening leads to case finding, but this intervention can also be carried out independently.
The green wedge consists of referral and follow-up, case man- agement, and delegated functions—three interventions that, in practice, are often implemented together (Figure 9-3, B).
Similarly, health teaching, counseling, and consultation—the blue wedge—are more similar than they are different; health teach- ing and counseling are especially often paired (Figure 9-3, C).
The interventions in the orange wedge—collaboration, coalition building, and community organizing—although dis- tinct, are grouped together because they are all types of collec- tive action and are most often carried out at systems or community levels of practice (Figure 9-3, D).
Similarly, advocacy, social marketing, and policy develop- ment and enforcement—the yellow wedge—are often interre- lated when implemented (Figure 9-3, E). In fact, advocacy is often viewed as a precursor to policy development; social mar- keting is seen by some as a method of carrying out advocacy.
The interventions on the right side of the Wheel (i.e., the red, green, and blue wedges) are most commonly used by PHNs who focus their work more on individuals, families, classes, and
LEVELS OF PREVENTION
Primary Prevention Primary prevention promotes health and protects against threats to health. It keeps problems from occurring in the first place. It promotes resiliency and protective factors or reduces susceptibility and exposure to risk factors. Primary prevention is implemented before a problem develops. It targets essentially well populations. Immunizing against a vaccine-preventable disease is an example of reducing susceptibility; building developmental assets in young persons to promote health is an example of promoting resil- iency and protective factors.
Secondary Prevention Secondary prevention detects and treats problems in their early stages. It keeps problems from causing serious or long-term effects or from affecting others. It identifies risk or hazards and modifies, removes, or treats them before a problem becomes more serious. Secondary prevention is imple- mented after a problem has begun, but before signs and symptoms appear. It targets populations that have risk factors in common. Programs that screen populations for hypertension, obesity, hyperglycemia, hypercholesterolemia, and other chronic disease risk factors are examples of secondary prevention.
Tertiary Prevention Tertiary prevention limits further negative effects from a problem. It keeps existing problems from getting worse. It alleviates the effects of disease and injury and restores individuals to their optimal level of functioning. Tertiary prevention is implemented after a disease or injury has occurred. It targets populations who have experienced disease or injury. Provision of directly observed therapy (DOT) to clients with active tuberculosis to ensure compli- ance with a medication regimen is an example of tertiary prevention.
Examples of Interventions Applied to Definition of Prevention
Data from Keller LO, Strohschein S, Lia-Hoagberg B, et al: Population- based public health nursing interventions: a model from practice. Public Health Nurs 15(3):207-15, 1998.
196 PART 3 Conceptual and Scientific Frameworks
FIG 9-3 The Intervention Wheel components (A-E). (Used with permission from Keller LO, Strohschein S, Lia-Hoagberg B, et al: Population-based public health interventions: practice-based and evidence-supported, part I. Public Health Nurs 21:453–468, 2004.)
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197CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
Public Health Nursing Process Systems Level Community Level Individual/Family Level
Recruit additional partners.
Recruit additional partners (local, regional, state, national) from systems that are key to impacting and/or who have an interest in the health issue/problem.
Recruit community organizations, services, and citizens who are part of the community intervention that have an interest in this health issue/problem.
Identify population of interest.
Identify those systems for which change is desired.
Identify the population of interest at risk for the problem.
Identify new and current clients in caseload who are at risk for the priority problem.
Establish relationship.
Begin/continue establishing relationship with system partners.
Begin/continue establishing relationship with community partners and population of interest.
Begin/continue establishing relationship with the family.
Assess priority. Assess the impact and interrelationships of the various systems on the development and extent of the health issue/problem.
Assess the health issue/problem (demographics, health determinants, past and current efforts).
Identify the particular strengths, health risks, and health influences of the population of interest
Identify the particular strengths, health risks, social supports, and other factors influencing the health of the family and each family member.
Elicit perceptions. Develop a common consensus among system partners of the health issue/problem and the desired changes.
Elicit the population of interest’s perception of their strengths, problems, and health influences.
Elicit family’s perception of their strengths, problems, and other factors influencing their health.
Set goals. In conjunction with system partners, develop system goals to be achieved.
In conjunction with the population of interest, negotiate and come to agreement on community-focused goals.
In conjunction with the family, negotiate and come to agreement on meaningful, achievable, measurable goals.
Select health status indicators.
Based on systems goals, select meaningful, measurable health status indicators that will be used to measure success.
Based on the refined community goal/ problem, select meaningful, measurable health status indicators that will be used to measure success.
Select meaningful, measurable health status indicators that will be used to measure success.
Select interventions. Select system-level interventions considering evidence of effectiveness, political support, acceptability to community, cost- effectiveness, legality, ethics, greatest potential for successful outcome, nonduplicative, levels of prevention.
Select community-level interventions considering evidence of effectiveness, acceptability to community, cost- effectiveness, legality, ethics, nonduplicative, greatest potential for successful outcome.
Select interventions considering evidence of effectiveness, acceptability to family, cost-effectiveness, legality, ethics, greatest potential for successful outcome.
Select intermediate outcome indicators.
Determine measurable, meaningful intermediate outcome indicators.
Determine measurable and meaningful intermediate outcome indicators.
Determine measurable, meaningful intermediate outcome indicators.
Determine strategy frequency and intensity.
Using best practices, determine intensity, sequencing, frequency of interventions considering urgency, political will, resources.
Using best practices, determine intensity, sequencing, frequency of interventions.
Using best practices, determine intensity, sequencing, frequency of interventions.
Determine evaluation methods.
Determine evaluation methods for measuring process, intermediate, and outcome indicators.
Determine evaluation methods for measuring process, intermediate, and outcome indicators.
Determine evaluation methods for measuring process, intermediate, and outcome indicators.
Implement the interventions.
Implement the interventions. Implement the interventions. Implement the interventions.
Regularly reassess interventions.
Regularly reassess the system’s response to the interventions and modify plan as indicated.
Reassess the population of interest’s response to the interventions on an ongoing basis and modify plan as indicated.
Reassess and modify plan at each contact as necessary.
Adjust interventions. Adjust the frequency and intensity of the interventions according to the needs and resources of the community.
Adjust the frequency and intensity of the interventions accordingly.
Adjust the frequency and intensity of the interventions according to the needs and resources of the family.
Provide feedback. Provide feedback to system’s representatives.
Provide feedback to the population of interest and informal and formal organizational representatives.
Provide regular feedback to family on progress (or lack thereof) of client goals.
Collect evaluation. Regularly and systematically collect evaluation information.
Regularly and systematically collect evaluation information.
Regularly and systematically collect evaluation information.
Compare results to plan.
Compare actual results with planned indicators.
Compare actual results with planned indicators.
Compare actual results with planned indicators.
TABLE 9-1 Public Health Nursing Process
Continued
198 PART 3 Conceptual and Scientific Frameworks
Public Health Nursing Practice • Focuses on the health of entire populations • Reflects community priorities and needs • Establishes caring relationships with the communities, families, individu-
als, and systems that comprise the populations PHNs serve • Is grounded in social justice, compassion, sensitivity to diversity, and
respect for the worth of all people, especially the vulnerable • Encompasses the mental, physical, emotional, social, spiritual, and envi-
ronmental aspects of health • Promotes health through strategies driven by epidemiologic evidence • Collaborates with community resources to achieve those strategies, but
can and will work alone if necessary • Derives its authority for independent action from the Nurse Practice Act
Cornerstones from Public Health
Cornerstones from Nursing
Population-based/focused Grounded in social justice
Relationship-based Grounded in an ethic of caring
Focus on greater good Sensitivity to diversity Focus on health promotion and disease
prevention Holistic focus Respect for the worth of all
Does what others cannot or will not Independent practice Driven by the science of epidemiology Organizes community resources
Long-term commitment to the community
BOX 9-1 Cornerstones of Public Health Nursing
Public Health Nursing Process Systems Level Community Level Individual/Family Level
Identify differences. Identify and analyze differences in those systems that achieved outcomes compared with those that did not.
Identify and analyze differences in those in the population of interest who achieved outcomes compared with those who did not.
Identify and analyze differences in services received by families who achieved outcomes compared with those who did not.
Apply results to practice.
Apply results to identify needed systems changes.
Depending on readiness of the system to accept the results, present results to decision makers and the general population.
Apply results to modify community interventions.
Present results to community for policy considerations as appropriate.
Report results to supervisor and other service providers as appropriate.
Apply results to personal practice and agency for policy considerations as appropriate.
TABLE 9-1 Public Health Nursing Process—cont’d
groups and to a lesser extent on work with systems and com- munities. The orange and yellow wedges, on the other hand, are more commonly used by PHNs who focus their work on effect- ing systems and communities. However, a PHN may use any or all of the interventions. No single PHN is expected to perform every intervention at all three levels of practice. From a manage- ment perspective, however, it is useful to ensure that a public health workforce has the capacity to implement all 17 interven- tions at all three practice levels.
Assumption 9: Public Health Nursing Practice Contributes to the Achievement of the 10 Essential Services Implementing the interventions ultimately contributes to the achievement of the 10 essential public health services (see Chapter 1). The 10 essential public health services describe what the public health system does to protect and promote the health of the public. Interventions are the means through which public health practitioners implement the 10 essential services. Inter- ventions are the how of public health practice (Public Health Functions Steering Committee, 1995).
Assumption 10: Public Health Nursing Practice Is Grounded in a Set of Values and Beliefs The Cornerstones of Public Health Nursing (Box 9-1) were developed as a companion document to the Intervention Wheel. The Wheel defines the “what and how” of public health nursing practice; the Cornerstones define the “why.” The Cor- nerstones synthesize foundational values and beliefs from both public health and nursing. They inspire, guide, direct, and chal- lenge public health nursing practice (Keller, Strohschein, and Schaffer, 2010).
USING THE INTERVENTION WHEEL IN PUBLIC HEALTH NURSING PRACTICE The Wheel is a conceptual model. It was conceived as a common language or catalog of general actions used by PHNs across all practice settings. When those actions are placed within the context of a set of associated assumptions or relations among
concepts, the Intervention Wheel serves as a conceptual model for public health nursing practice (Fawcett and DeSanto- Madeya, 2013). It creates a structure for identifying and docu- menting interventions performed by PHNs and captures the nature of their work. The Intervention Wheel provides a frame- work, a way of thinking about public health nursing practice. The Public Health Nursing: Scope and Standards of Practice includes the Intervention Wheel as one of several public health nursing frameworks used in practice today (ANA, 2013).
COMPONENTS OF THE MODEL As depicted in Figure 9-1, the model has three components: a population basis, three levels of practice, and 17 interventions.
199CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
Component 1: The Model Is Population Based The upper portion of the Intervention Wheel clearly illustrates that all levels of practice (community, systems, and individual/ family) are population based. Public health nursing practice is population focused. It identifies populations of interest or pop- ulations at risk through an assessment of community health status and an assignment of priorities. Services to individuals and families are population based only if they meet the follow- ing criteria: (1) Individuals receive services because they are members of an identified population, and (2) services to indi- viduals clearly contribute to improving the overall health status of the identified population.
The population of Sherburne County (Minnesota) increased almost 175% in 25 years (Minnesota Departments of Educa- tion, Health, Human Services, and Public Safety, 2013). The numerous new housing developments characterized urban sprawl, which has been implicated in the current obesity epi- demic in both children and adults (Ferdinand et al, 2012; Renalds, Smith, and Hale, 2010). The local health department staff was concerned about the prevalence of obesity in its popu- lation. Data from the U.S. Department of Agriculture’s Food Environment Atlas website showed that 25.7% of the popula- tion’s adults were considered obese in 2012 (USDA, 2014).
A 2013 state student health survey documented that 16% of ninth-grade girls and 26% of ninth-grade boys in the county were overweight or obese. In this same age group, 26% of girls and 21% of boys reported they had been active less than 60 minutes daily for two days or less of the previous seven days. It was clear that Sherburne County had an obesity problem (Min- nesota Departments of Education, Health, Human Services, and Public Safety, 2013).
Reversing this trend required reducing barriers to exercise. Health department staff recognized the impact of urban sprawl on their built environment (Renalds, Smith, and Hale, 2010), or the “collective availability of sidewalks, parks, trails, recreational facilities, traffic safety, and other neighborhood characteristics that promote recreational physical activity as well as active trans- port to work, school, or errands” (Ferdinand et al, 2012).
One of the first factors they considered was the walkability of their communities, or the extent to which planned transpor- tation networks and public spaces accommodate walking and other forms of physical exercise. Walkability includes: (1) con- tinuous and well-maintained sidewalks, (2) easy access, path directness, and street network connectivity, (3) crossing safety, (4) absence of heavy and high-speed traffic, (5) pedestrian buff- ering from traffic, (6) land-use density and diversity, (7) street trees and landscaping, (8) visual interest and sense of place, and (9) security (Lo, 2009; Walkability Checklist).
With these data, the public health staff engaged community members to determine the next steps to improve their com- munity walkability. The department asked undergraduate nursing students who were in their public health nursing clini- cal program to design, implement, and evaluate a walkability project. The students walked over 100 miles and rated the walk- ability of three different Sherburne County communities. The students analyzed the results and presented recommendations
for improvements to the city councils of the three communities. The findings were used by two of the three communities to secure funding for improvements to their community’s walk- ability (Zoller, 2010).
Component 2: The Model Encompasses Three Levels of Practice Public health nursing practice intervenes with communities, the individuals and families that comprise communities, and the systems that impact the health of communities. Interventions at each level of practice contribute to the overall goal of improv- ing population health. The work of PHNs is accomplished at all levels. No one level of practice is more important than another; in fact, many public health priorities are addressed simultane- ously at all three levels.
One public health priority that almost every PHN will encounter is the potential for the occurrence of vaccine- preventable disease because of delayed or missing immuniza- tions. A recent task analysis of 60 PHNs from 29 states revealed that 93% of all PHNs participated in immunization activities (Keller, 2008). This held true regardless of the PHN’s work setting (e.g., home, clinic, school, correctional facility, childcare center) or the population focus (e.g., maternal–child health, elderly chronic disease management, refugee health, disease prevention and control).
Vaccine-preventable diseases, or diseases that may be pre- vented through recommended immunizations, include diph- theria, pertussis, tetanus, polio, mumps, measles, rubella, hepatitis A, hepatitis B, varicella, meningitis, Haemophilus influ- enzae type b (Hib), pneumococcal pneumonia, rotavirus, human papillomavirus (HPV), herpes zoster, and seasonal influenza (CDC, 2012).
This section illustrates strategies for reducing the occurrence of vaccine-preventable diseases at all three levels of practice. These are only selected examples of strategies to improve immunization rates; it is not an inclusive list.
Community Level of Practice The goal of community-level practice is to increase the knowl- edge and attitude of the entire community about the impor- tance of immunization and the consequences of not being immunized. These strategies will lead to an increase in the per- centage of people who obtain recommended immunizations for themselves and their children.
At the community level, PHNs work with health educators on public awareness campaigns. They perform outreach at schools, senior centers, county fairs, community festivals, and neighborhood laundromats.
PHNs conduct or coordinate audits of immunization records of all children in schools and childcare centers to identify chil- dren who are under-immunized. The PHNs refer them to their medical providers or administer the immunizations through health department clinics.
When a confirmed case of a vaccine-preventable disease occurs, PHNs work with epidemiologists to identify and locate everyone exposed to the index case. PHNs assess the immunization status of people who were exposed and ensure appropriate treatment.
200 PART 3 Conceptual and Scientific Frameworks
In the event of an outbreak in the community, all PHNs have a role and ethical responsibility to take part in mass dis- pensing clinics. Mass dispensing clinics disperse immuniza- tions or medications to specific populations at risk. For example, clinics may be held in response to an epidemic of mumps, a case of hepatitis A attributable to a foodborne exposure in a restaurant, or an influenza pandemic in the general population.
Systems Level of Practice The goal of systems-level practice is to change the laws, policies, and practices that influence immunization rates, such as pro- moting population-based immunization registries and improv- ing clinic and provider practices.
PHNs work with schools, clinics, health plans, and parents to develop population-based immunization registries. Regis- tries, known officially by the Centers for Disease Control and Prevention (CDC) as “Immunization Information Systems,” combine immunization information from different sources into a single electronic record. A registry provides official immunization records for schools, daycare centers, health departments, and clinics. Registries track immunizations and remind families when an immunization is due or has been missed.
PHNs conduct audits of records in clinics that participate in the federal vaccine program. PHNs ascertain if a clinic is fol- lowing recommended immunization standards for vaccine handling and storage, documentation, and adherence to best practices. PHNs also provide feedback and guidance to clini- cians and office staff for quality improvement.
PHNs also work with health care providers in the commu- nity to ensure that providers accurately report vaccine- preventable diseases as legally required by state statute.
Individual/Family Level of Practice The goal of individual/family-level strategies is to identify indi- viduals who are not appropriately immunized, identify the bar- riers to immunization, and ensure that the individual’s immunizations are brought up to date.
At the individual level of practice, PHNs conduct health department immunization clinics. Unlike mass dispensing clinics, immunization clinics are generally available to anyone who needs an immunization and do not target a specific popu- lation. These clinics often provide an important service to indi- viduals without access to affordable health care.
PHNs use the registry to identify children with delayed or missing immunizations. They contact families by phone or through a home visit. The PHNs assess for barriers and consult with the family to develop a plan to obtain immunizations either through a medical clinic or from a health department clinic. The PHN follows up at a later date to ensure that the child was actually immunized.
PHNs routinely assess the immunization status for clients in all public health programs, such as well-child clinics, family planning clinics, maternal–child health home visits, or case management of elderly and disabled populations, and they ensure that immunizations are up to date.
Component 3: The Model Identifies and Defines 17 Public Health Interventions The Intervention Wheel encompasses 17 interventions: surveil- lance, disease and other health investigation, outreach, screen- ing, case finding, referral and follow-up, case management, delegated functions, health teaching, consultation, counseling, collaboration, coalition building, community organizing, advocacy, social marketing, and policy development and enforcement.
All interventions, except case finding, coalition building, and community organizing, are applicable at all three levels of prac- tice. Community organizing and coalition building cannot occur at the individual level. Case finding is the individual level of surveillance, disease and other health event investigation, outreach, and screening. Altogether, a PHN selects from among 43 different intervention-level actions.
Table 9-2 provides examples of the intervention at the three levels of practice for each of the 17 interventions. • Surveillance describes and monitors health events through
ongoing and systematic collection, analysis, and interpre- tation of health data for the purpose of planning, imple- menting, and evaluating public health interventions, and disseminating this data to those who need to know to prevent and control outbreaks (adapted from Morbidity and Mortal- ity Weekly Review, 2012).
• Disease and other health event investigation systematically gathers and analyzes data regarding threats to the health of populations, ascertains the source of the threat, identifies cases and others at risk, and determines control measures.
• Outreach locates populations of interest or populations at risk and provides information about the nature of the concern, what can be done about it, and how services can be obtained.
• Screening identifies individuals with unrecognized health risk factors or asymptomatic disease conditions in popula- tions (Box 9-2).
A school nurse was approached by the school’s health and physical education staff who expressed interest in implementing a BMI screening program for children in 4th through 8th grades. Their plan was to do height, weight, and BMI measurements during gym class and requested that the school nurse do the follow-up with the parents of children found to be overweight or obese and encourage that these children be seen by their family health care provider. Although aware that prevalence of obesity in that age group was growing, she was also aware that most local health care providers believed that “chunkiness” in the middle years was a natural occurrence for children. She was also aware that a cardinal rule of screening is that it is unethical to screen if effective treatment and other resources for follow-up do not exist.
In 2008 the U.S. Task Force on Community Preventive Services found insuf- ficient evidence to recommend school-based programs to prevent or reduce obesity. In addition, the American Academy of Pediatrics expressed caution to schools when considering implementing such a program (AAP, 2010). Based on this knowledge, the school nurse suggested to the health and physical education staff that together they find other means of addressing the issue.
BOX 9-2 Screening
Text continued on p. 206
201CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
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rv e n
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m ar
ke t
bo ot
h. A
ll th
e in
te rv
ie w
s w
er e
co nd
uc te
d in
t he
H
m on
g la
ng ua
ge .
O ut
re ac
h at
t he
In di
vi du
al L
ev el
is C
A SE
F IN
D IN
G (s
ee C
as e
Fi nd
in g
in te
rv en
tio n)
.
T A
B L E 9
-2
E x a m
p le
s o
f 1 7 I
n te
rv e n
ti o
n s
a t
T h
re e L
e v e ls
o f
P ra
ct ic
e
C on
ti n
u ed
202 PART 3 Conceptual and Scientific Frameworks
In te
rv e n
ti o
n s
S y
st e m
s C
o m
m u
n it
y In
d iv
id u
a l
Sc re
en in
g Vi
si on
s cr
ee ni
ng is
a c
or e
PH N
a ct
iv ity
w ith
t he
s ch
oo l-a
ge d
po pu
la tio
n. P
H N
s w
or ke
d w
ith a
c om
m un
ity g
ro up
t o
de te
rm in
e w
hy s
ch oo
l c hi
ld re
n w
ho f
ai le
d vi
si on
s cr
ee ni
ng
an d
w er
e re
fe rr
ed d
id n
ot r
ec ei
ve t
he r
ec om
m en
de d
fo llo
w -u
p. Is
su es
in cl
ud ed
t he
e xp
en se
o f
ey e-
ca re
se
rv ic
es a
nd g
la ss
es , l
ac k
of c
on ve
ni en
t ap
po in
tm en
t tim
es w
ith e
ye -c
ar e
sp ec
ia lis
ts , a
nd w
he th
er p
ar en
ts
va lu
ed e
ye c
ar e.
T he
P H
N s
pa rt
ic ip
at ed
in a
t as
k fo
rc e
th at
f ac
ili ta
te d
an a
gr ee
m en
t am
on g
ey e-
ca re
p ro
vi de
rs t
o sc
he du
le e
ve ni
ng a
nd w
ee ke
nd a
pp oi
nt m
en ts
, a rr
an ge
d su
pp or
t fr
om t
he L
io ns
In te
rn at
io na
l S er
vi ce
C lu
b to
w ar
d th
e pu
rc ha
se o
f ey
ew ea
r, an
d co
m m
un ic
at ed
t he
n ee
d fo
r fo
llo w
-u p
to p
ar en
ts a
t pa
re nt
–t ea
ch er
c on
fe re
nc es
.
PH N
s co
lla bo
ra te
d w
ith a
h ig
h sc
ho ol
o n
a pr
ev en
tio n
pr og
ra m
to
a dd
re ss
p hy
si ca
l i na
ct iv
ity a
nd u
nh ea
lth y
di et
ar y
be ha
vi or
s.
Th e
PH N
s co
nd uc
te d
he al
th s
cr ee
ni ng
s th
at g
av e
ea ch
s tu
de nt
a
“s na
ps ho
t” o
f hi
s or
h er
h ea
lth (h
ei gh
t, w
ei gh
t, BM
I, bl
oo d
pr es
su re
, t ot
al c
ho le
st er
ol , H
D L)
. S tu
de nt
s re
ce iv
ed a
r ep
or t
of
th ei
r nu
tr iti
on al
a nd
p hy
si ca
l a ct
iv ity
le ve
ls w
ith in
fo rm
at io
n ab
ou t
ho w
t o
be gi
n bu
ild in
g lif
es ty
le c
ha ng
es . O
ne h
un dr
ed
ni ne
ty -t
w o
st ud
en ts
f ro
m fi
ve s
ch oo
ls w
er e
sc re
en ed
a nd
7 1
w er
e re
fe rr
ed (3
7% r
ef er
ra l r
at e)
. U po
n co
m pl
et io
n of
t he
ed
uc at
io na
l c om
po ne
nt s,
s tu
de nt
s w
ho w
er e
re sc
re en
ed h
ad
a to
ta l c
ho le
st er
ol d
ec re
as e
of 2
19 p
oi nt
s.
Sc re
en in
g at
t he
In di
vi du
al L
ev el
is C
A SE
F IN
D IN
G (s
ee C
as e
Fi nd
in g
In te
rv en
tio n)
.
Ca se
fi nd
in g
D oe
s no
t ap
pl y
at t
hi s
pr ac
tic e
le ve
l D
oe s
no t
ap pl
y at
t hi
s pr
ac tic
e le
ve l
A s
ta te
’s n
ew bo
rn b
lo od
s cr
ee ni
ng p
ro gr
am d
et ec
te d
an
in fa
nt w
ith a
p os
si bl
e ca
se o
f co
ng en
ita l h
yp ot
hy ro
id is
m .
Th e
in fo
rm at
io n
w as
s en
t to
t he
in fa
nt ’s
m ed
ic al
p ro
vi de
r, w
ho w
as e
xp ec
te d
to c
on ta
ct t
he f
am ily
. T he
m ot
he r
of
th e
in fa
nt w
as a
s in
gl e
H is
pa ni
c w
om an
w ho
d id
n ot
sp
ea k
En gl
is h
an d
di d
no t
re sp
on d
to t
he c
lin ic
’s n
um er
ou s
ca lls
. T he
p ro
vi de
r re
fe rr
ed t
he s
itu at
io n
to a
P H
N f
or
as si
st an
ce in
lo ca
tin g
th e
m ot
he r.
A ft
er t
al ki
ng w
ith
co nt
ac ts
in t
he H
is pa
ni c
co m
m un
ity , t
he P
H N
lo ca
te d
fr ie
nd s
of t
he y
ou ng
m ot
he r
w ho
c on
fir m
ed s
he h
ad
re tu
rn ed
t o
M ex
ic o
w ith
t he
in fa
nt . T
he y
di d
no t
kn ow
ho
w t
o co
nt ac
t he
r bu
t ag
re ed
t o
al er
t th
os e
w ith
in t
he
H is
pa ni
c co
m m
un ity
o f
th e
se rio
us ne
ss o
f th
e ba
by ’s
pr
ob le
m . A
bo ut
2 m
on th
s la
te r
th e
m ot
he r
di d
re tu
rn ,
so ug
ht t
he P
H N
’s a
ss is
ta nc
e, a
nd r
ec ei
ve d
ca re
f or
t he
ba
by .
Re fe
rr al
a nd
fo
llo w
-u p
PH N
s pr
ov id
in g
he al
th s
er vi
ce s
to in
m at
es in
a c
ou nt
y ja
il no
tic ed
t ha
t in
di vi
du al
s w
ith m
en ta
l h ea
lth is
su es
, c hr
on ic
he
al th
c on
ce rn
s, c
he m
ic al
d ep
en de
nc y
is su
es , o
r ho
m el
es sn
es s
fr eq
ue nt
ly r
et ur
ne d
to ja
il. F
ew o
f th
es e
is su
es w
er e
ty pi
ca lly
a dd
re ss
ed p
rio r
th e
in m
at es
’ r el
ea se
. Th
e PH
N s
in iti
at ed
R A
PP (R
el ea
se A
dv an
ce P
la nn
in g
Pr og
ra m
), a
vo lu
nt ar
y “d
is ch
ar ge
p la
nn in
g” p
ro ce
ss
th ro
ug h
w hi
ch r
ef er
ra ls
a nd
o th
er a
rr an
ge m
en ts
w ith
co
m m
un ity
r es
ou rc
es c
ou ld
b e
m ad
e pr
io r
to t
he in
m at
es
re tu
rn in
g to
t he
c om
m un
ity . R
ec id
iv is
m r
at es
d ec
re as
ed b
y 57
% b
y th
e th
ird y
ea r
of t
he p
ro gr
am ’s
o pe
ra tio
n.
PH N
s of
te n
se rv
e as
c om
m un
ity r
es ou
rc e
di re
ct or
ie s.
P H
N s
ar e
kn ow
n by
c om
m un
ity m
em be
rs f
or t
he ir
ex te
ns iv
e kn
ow le
dg e
of w
ho m
o r
w he
re t
o ca
ll fo
r a
va rie
ty o
f pr
ob le
m s
or is
su es
. Fo
r ex
am pl
e, P
H N
s in
a r
ur al
h ea
lth d
ep ar
tm en
t re
sp on
de d
to
ca lls
r an
gi ng
f ro
m r
at s
to c
oc kr
oa ch
es t
o be
db ug
s, f
ro m
s ep
tic
ta nk
f ai
lu re
s to
p ee
lin g
pa in
t, an
d fr
om a
ir qu
al ity
t o
bl ue
-g re
en a
lg ae
. T he
P H
N s
of te
n fo
llo w
ed u
p w
ith
co m
m un
ity m
em be
rs t
o en
su re
t ha
t th
ei r
is su
es w
er e
re so
lv ed
.
A P
H N
r ec
ei ve
d a
re fe
rr al
o n
a m
en ta
lly il
l y ou
ng m
an f
ro m
a
sm al
l t ow
n. H
e ne
ed ed
r eg
ul ar
in je
ct io
ns t
o pr
ev en
t re
ho sp
ita liz
at io
n. W
he n
th e
PH N
w as
u na
bl e
to lo
ca te
t hi
s cl
ie nt
a t
ho m
e, s
he f
ou nd
h im
a t
hi s
re gu
la r
“h an
go ut
”— th
e lo
ca l b
ar —
w he
re h
e dr
an k
on ly
s od
a po
p. W
hi le
cr
ea tiv
el y
m ai
nt ai
ni ng
c on
fid en
tia lit
y, t
he P
H N
w or
ke d
w ith
t he
b ar
te nd
er in
t hi
s es
ta bl
is hm
en t
to s
et u
p re
gu la
r ap
po in
tm en
t tim
es f
or t
he c
lie nt
.
Ca se
m an
ag em
en t
Pu bl
ic h
ea lth
n ur
se s
re pr
es en
tin g
10 c
ou nt
y he
al th
de
pa rt
m en
ts , m
ed ic
al c
lin ic
s, a
la rg
e he
al th
p la
n co
m pa
ny ,
an d
th e
st at
e he
al th
d ep
ar tm
en t
w or
ke d
to ge
th er
t o
pr ov
id e
co or
di na
te d
pr en
at al
c ar
e to
im pr
ov e
bi rt
h ou
tc om
es . T
he g
ro up
c re
at ed
a n
in te
gr at
ed p
re na
ta l c
ar e
sy st
em t
ha t
pr om
ot ed
e ar
ly p
re na
ta l c
ar e,
im pr
ov ed
nu
tr iti
on , a
nd li
nk ed
w om
en t
o se
rv ic
es in
t he
co
m m
un iti
es .
PH N
s pr
ov id
ed c
as e
m an
ag em
en t
fo r
al l f
ra il
el de
rly a
nd
di sa
bl ed
p er
so ns
a t
ris k
fo r
in st
itu tio
na liz
at io
n bu
t de
em ed
el
ig ib
le f
or c
om m
un ity
p la
ce m
en t.
Ca se
m an
ag em
en t
m ai
nt ai
ne d
th is
v ul
ne ra
bl e
po pu
la tio
n in
t he
ir ho
m es
o r
co m
m un
ity a
nd e
ns ur
ed t
ha t
th ei
r ne
ed s
w er
e m
et w
ith in
t he
al
lo tt
ed a
m ou
nt o
f m
on ey
t ha
t w
ou ld
o th
er w
is e
be s
pe nt
o n
ho sp
ita liz
at io
n or
n ur
si ng
h om
e ca
re .
A lo
ca l p
hy si
ci an
r ep
or te
d a
hi gh
ly c
on ta
gi ou
s ac
tiv e
in fe
ct io
us t
ub er
cu lo
si s
(T B)
c as
e th
at w
as d
et er
m in
ed t
o be
m ul
tid ru
g re
si st
an t.
Th e
cl ie
nt d
id n
ot s
pe ak
E ng
lis h.
Th
e PH
N c
oo rd
in at
ed h
is c
ar e
w ith
t he
p hy
si ci
an , t
he s
ta te
he
al th
d ep
ar tm
en t’s
T B
un it,
t he
C D
C, a
nd a
h om
e he
al th
ag
en cy
. N ei
th er
t he
h os
pi ta
l o ut
pa tie
nt d
ep ar
tm en
t no
r an
y ho
m e
he al
th a
ge nc
y w
ou ld
a gr
ee t
o tr
ea t
th is
c lie
nt in
th
ei r
fa ci
lit y
or m
ak e
ho m
e vi
si ts
. ( Co
nt in
ue d
un de
r de
le ga
te d
fu nc
tio ns
b el
ow .)
D el
eg at
ed
fu nc
tio ns
In a
c ou
nt y
of 1
20 ,0
00 r
es id
en ts
, P H
N s
fr om
t he
lo ca
l h ea
lth
de pa
rt m
en t
le d
a co
al iti
on o
f ho
sp ita
ls , c
lin ic
s, s
ch oo
ls ,
an d
em er
ge nc
y m
an ag
er s
in d
es ig
ni ng
a nd
im pl
em en
tin g
a co
m m
un ity
-w id
e m
as s
im m
un iz
at io
n pl
an t
o ad
m in
is te
r in
flu en
za v
ac ci
ne . T
he d
es ig
n in
cl ud
ed t
he e
st ab
lis hm
en t
of a
dm in
is tr
at io
n pr
ot oc
ol s
ap pr
ov ed
b y
th e
he al
th
de pa
rt m
en t’s
m ed
ic al
a dv
is or
. T he
h ea
lth d
ep ar
tm en
t al
so
se rv
ed a
s th
e ce
nt ra
l d is
tr ib
ut io
n po
in t
fo r
al l v
ac ci
ne s
av ai
la bl
e w
ith in
t he
c ou
nt y.
PH N
s ad
m in
is te
re d
im m
un iz
at io
ns a
t “d
riv e-
th ru
” flu
c lin
ic s
he
ld in
a c
ou nt
y hi
gh w
ay g
ar ag
e. R
es id
en ts
r ec
ei ve
d th
ei r
as se
ss m
en t
an d
flu s
ho ts
in t
he ir
ve hi
cl es
. T hi
s un
iq ue
a cc
es s
in cr
ea se
d th
e nu
m be
rs o
f im
m un
iz at
io ns
r ec
ei ve
d by
e ld
er ly
an
d di
sa bl
ed r
es id
en ts
, p ar
tic ul
ar ly
t ho
se w
ith li
m ite
d m
ob ili
ty . T
he d
riv e-
th ru
c lin
ic a
ls o
re du
ce d
th e
ex po
su re
po
te nt
ia l t
o in
fe ct
io us
d is
ea se
s th
at w
as in
he re
nt in
r eg
ul ar
cl
in ic
w ai
tin g
ro om
s.
(S ee
a bo
ve c
as e
m an
ag em
en t.)
In a
dd iti
on t
o do
in g
da ily
di
re ct
o bs
er ve
d th
er ap
y (D
O T)
, t he
P H
N w
as t
he o
nl y
he al
th c
ar e
pr ov
id er
w ho
w ou
ld d
o w
ee kl
y la
b dr
aw s,
d ai
ly
IV t
he ra
py , a
nd b
iw ee
kl y
dr es
si ng
c ha
ng es
f or
t he
fi rs
t 7
m on
th s
of t
re at
m en
t. W
ith ou
t PH
N in
vo lv
em en
t, th
is c
lie nt
w
ou ld
h av
e lik
el y
su cc
um be
d to
T B.
T he
c lie
nt c
om pl
et ed
a
fu ll
18 m
on th
s of
t he
ra py
a nd
r ec
ov er
ed .
H ea
lth t
ea ch
in g
PH N
s w
or ke
d w
ith t
he e
pi de
m io
lo gi
st in
t he
ir he
al th
de
pa rt
m en
t to
d ev
el op
“ be
st p
ra ct
ic e”
g ui
de lin
es f
or
pe di
cu lo
si s
(li ce
) t re
at m
en t
fr om
t he
p er
sp ec
tiv es
o f
th e
sc ie
nt ifi
c lit
er at
ur e
an d
th e
pr ac
tic e
co m
m un
ity .
Re co
m m
en da
tio ns
in cl
ud ed
b ot
h su
ff oc
at in
g an
d ch
em ic
al
ag en
ts . C
lin ic
s, s
ch oo
ls , a
nd p
ha rm
ac is
ts u
se d
th e
ne w
gu
id el
in es
. T he
p ub
lic h
ea lth
d ep
ar tm
en t
cr ea
te d
an
in te
rn al
s ta
nd ar
di ze
d pe
di cu
lo si
s re
sp on
se p
ro ce
du re
, a nd
th
e co
un ty
’s s
oc ia
l s er
vi ce
s de
pa rt
m en
t de
ve lo
pe d
a ne
w
po lic
y fo
r sc
ho ol
t ru
an cy
is su
es r
el at
ed t
o pe
di cu
lo si
s.
Se ve
ra l r
ur al
c ou
nt ie
s la
un ch
ed a
p ro
gr am
t o
he lp
y ou
th
in co
rp or
at e
a he
al th
y di
et a
nd e
xe rc
is e
in to
t he
ir liv
es . A
he
al th
f ai
r w
as h
el d
in c
on ju
nc tio
n w
ith p
ar en
t– te
ac he
r co
nf er
en ce
s. C
om m
itt ee
s co
m po
se d
of y
ou th
a nd
a du
lts
pl an
ne d
ac tiv
iti es
s uc
h as
“ D
an ce
‘n ’ D
ip s,
” a
da nc
e fo
llo w
ed
by a
d ip
a t
th e
ci ty
p oo
l. M
em be
rs o
f a
ch ur
ch b
eg an
o ff
er in
g ev
en in
g ex
er ci
se c
la ss
es . A
s m
al l t
ow n
sp on
so re
d th
e “R
un ,
W al
k ’n
R ol
l” t
ha t
w as
o pe
n to
r un
ne rs
, w al
ke rs
, s tr
ol le
rs , a
nd
w he
el ch
ai rs
. T he
“ To
ile t
Pa pe
r” d
oc um
en t,
a m
on th
ly n
ut rit
io n
an d
he al
th t
ip s
he et
d es
ig ne
d to
r es
em bl
e to
ile t
pa pe
r, w
as
di sp
la ye
d in
1 52
b at
hr oo
m s,
n ex
t to
t he
t oi
le t
pa pe
r di
sp en
se rs
. T he
t ip
s w
er e
po pu
la r;
PH N
s re
po rt
ed t
ha t
pe op
le
ca m
e up
t o
th em
o n
th e
st re
et t
o di
sc us
s th
e tip
s. P
H N
s re
po rt
ed s
ee in
g ch
an ge
s in
c om
m un
ity a
tt itu
de s.
A P
H N
w or
ks w
ith p
re gn
an t
an d
pa re
nt in
g te
en s
at a
n al
te rn
at iv
e hi
gh s
ch oo
l p ro
gr am
t ha
t pr
ov id
es e
du ca
tio na
l op
tio ns
f or
t ee
ns w
ho se
li ve
s di
d no
t fit
t he
t ra
di tio
na l
sc ho
ol d
ay . T
he p
ro gr
am in
cl ud
ed t
ee ns
f ro
m a
v ar
ie ty
o f
cu ltu
re s
an d
ba ck
gr ou
nd s.
T he
p ro
gr am
h ad
a n
on si
te
ch ild
ca re
c en
te r;
st ud
en ts
w er
e ab
le t
o vi
si t
th ei
r ch
ild
du rin
g th
e sc
ho ol
d ay
. T he
P H
N s
ta ug
ht w
ee kl
y pr
en at
al
cl as
se s
in c
on ju
nc tio
n w
ith li
fe s
ki lls
a nd
c hi
ld
de ve
lo pm
en t
cl as
se s.
P H
N s
al so
w or
ke d
w ith
e ac
h st
ud en
t to
lo ok
a t
fa m
ily p
la nn
in g
op tio
ns . T
he ir
“P re
gn an
cy F
re e
Cl ub
” pr
ov id
ed e
ac h
st ud
en t
pr iv
at e
tim e
w ith
a P
H N
t o
lo ok
a t
ba rr
ie rs
t ha
t pr
ev en
te d
th e
st ud
en t
fr om
e ff
ec tiv
el y
us in
g bi
rt h
co nt
ro l.
Th e
pr og
ra m
h ad
a r
ep ea
t ad
ol es
ce nt
pr
eg na
nc y
ra te
s ig
ni fic
an tly
lo w
er t
ha n
th e
na tio
na l
av er
ag e,
d ec
lin in
g fr
om a
b as
el in
e of
2 5%
t o
a m
ea n
of
4. 7%
o ve
r 9
ye ar
s of
t he
p ro
gr am
. Co
un se
lin g
PH N
s pa
rt ne
re d
w ith
a c
om m
un ity
f am
ily c
en te
r to
p ro
m ot
e pr
en at
al a
tt ac
hm en
t fo
r fa
m ili
es w
ho w
er e
is ol
at ed
, w ho
ha
d ex
pe rie
nc ed
p re
vi ou
s pr
eg na
nc y
lo ss
, o r
w ho
h ad
ot
he r
at ta
ch m
en t
is su
es . T
he p
ro je
ct p
ro m
ot ed
a tt
ac hm
en t
to t
he b
ab y
th ro
ug h
th e
us e
of d
ou la
s, g
ui de
d vi
de ot
ap in
g,
nu tr
iti on
c ou
ns el
in g,
a nd
r el
ax at
io n
th ro
ug h
m us
ic a
nd
im ag
er y.
In r
es po
ns e
to m
ul tip
le d
ea th
s w
ith in
a n
A m
er ic
an In
di an
co
m m
un ity
, P H
N s
in a
t rib
al h
ea lth
d ep
ar tm
en t
w or
ke d
w ith
th
e co
m m
un ity
t o
de si
gn a
nd im
pl em
en t
a cu
ltu ra
lly
ap pr
op ria
te g
rie f
an d
lo ss
p ro
gr am
. I nt
er ve
nt io
ns in
cl ud
ed
dr um
m in
g ac
tiv iti
es f
or y
ou th
, t ra
di tio
na l h
ea le
rs , a
nd p
ee r
co un
se lo
rs .
A P
H N
le d
m on
th ly
s up
po rt
g ro
up s
fo r
fa m
ily m
em be
rs a
nd
vo lu
nt ee
rs p
ro vi
di ng
in -h
om e
ca re
t o
in di
vi du
al s
w ith
A
lz he
im er
’s d
is ea
se . T
he P
H N
p ro
vi de
d on
e- to
-o ne
ca
re gi
ve r
co ac
hi ng
t o
th os
e ne
ed in
g ad
di tio
na l s
up po
rt .
T A
B L E 9
-2
E x a m
p le
s o
f 1 7 I
n te
rv e n
ti o
n s
a t
T h
re e L
e v e ls
o f
P ra
ct ic
e —
co n
t’ d
203CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
C on
ti n
u ed
In te
rv e n
ti o
n s
S y st
e m
s C
o m
m u
n it
y In
d iv
id u
a l
Sc re
en in
g Vi
si on
s cr
ee ni
ng is
a c
or e
PH N
a ct
iv ity
w ith
t he
s ch
oo l-a
ge d
po pu
la tio
n. P
H N
s w
or ke
d w
ith a
c om
m un
ity g
ro up
t o
de te
rm in
e w
hy s
ch oo
l c hi
ld re
n w
ho f
ai le
d vi
si on
s cr
ee ni
ng
an d
w er
e re
fe rr
ed d
id n
ot r
ec ei
ve t
he r
ec om
m en
de d
fo llo
w -u
p. Is
su es
in cl
ud ed
t he
e xp
en se
o f
ey e-
ca re
se
rv ic
es a
nd g
la ss
es , l
ac k
of c
on ve
ni en
t ap
po in
tm en
t tim
es w
ith e
ye -c
ar e
sp ec
ia lis
ts , a
nd w
he th
er p
ar en
ts
va lu
ed e
ye c
ar e.
T he
P H
N s
pa rt
ic ip
at ed
in a
t as
k fo
rc e
th at
f ac
ili ta
te d
an a
gr ee
m en
t am
on g
ey e-
ca re
p ro
vi de
rs t
o sc
he du
le e
ve ni
ng a
nd w
ee ke
nd a
pp oi
nt m
en ts
, a rr
an ge
d su
pp or
t fr
om t
he L
io ns
In te
rn at
io na
l S er
vi ce
C lu
b to
w ar
d th
e pu
rc ha
se o
f ey
ew ea
r, an
d co
m m
un ic
at ed
t he
n ee
d fo
r fo
llo w
-u p
to p
ar en
ts a
t pa
re nt
–t ea
ch er
c on
fe re
nc es
.
PH N
s co
lla bo
ra te
d w
ith a
h ig
h sc
ho ol
o n
a pr
ev en
tio n
pr og
ra m
to
a dd
re ss
p hy
si ca
l i na
ct iv
ity a
nd u
nh ea
lth y
di et
ar y
be ha
vi or
s.
Th e
PH N
s co
nd uc
te d
he al
th s
cr ee
ni ng
s th
at g
av e
ea ch
s tu
de nt
a
“s na
ps ho
t” o
f hi
s or
h er
h ea
lth (h
ei gh
t, w
ei gh
t, BM
I, bl
oo d
pr es
su re
, t ot
al c
ho le
st er
ol , H
D L)
. S tu
de nt
s re
ce iv
ed a
r ep
or t
of
th ei
r nu
tr iti
on al
a nd
p hy
si ca
l a ct
iv ity
le ve
ls w
ith in
fo rm
at io
n ab
ou t
ho w
t o
be gi
n bu
ild in
g lif
es ty
le c
ha ng
es . O
ne h
un dr
ed
ni ne
ty -t
w o
st ud
en ts
f ro
m fi
ve s
ch oo
ls w
er e
sc re
en ed
a nd
7 1
w er
e re
fe rr
ed (3
7% r
ef er
ra l r
at e)
. U po
n co
m pl
et io
n of
t he
ed
uc at
io na
l c om
po ne
nt s,
s tu
de nt
s w
ho w
er e
re sc
re en
ed h
ad
a to
ta l c
ho le
st er
ol d
ec re
as e
of 2
19 p
oi nt
s.
Sc re
en in
g at
t he
In di
vi du
al L
ev el
is C
A SE
F IN
D IN
G (s
ee C
as e
Fi nd
in g
In te
rv en
tio n)
.
Ca se
fi nd
in g
D oe
s no
t ap
pl y
at t
hi s
pr ac
tic e
le ve
l D
oe s
no t
ap pl
y at
t hi
s pr
ac tic
e le
ve l
A s
ta te
’s n
ew bo
rn b
lo od
s cr
ee ni
ng p
ro gr
am d
et ec
te d
an
in fa
nt w
ith a
p os
si bl
e ca
se o
f co
ng en
ita l h
yp ot
hy ro
id is
m .
Th e
in fo
rm at
io n
w as
s en
t to
t he
in fa
nt ’s
m ed
ic al
p ro
vi de
r, w
ho w
as e
xp ec
te d
to c
on ta
ct t
he f
am ily
. T he
m ot
he r
of
th e
in fa
nt w
as a
s in
gl e
H is
pa ni
c w
om an
w ho
d id
n ot
sp
ea k
En gl
is h
an d
di d
no t
re sp
on d
to t
he c
lin ic
’s n
um er
ou s
ca lls
. T he
p ro
vi de
r re
fe rr
ed t
he s
itu at
io n
to a
P H
N f
or
as si
st an
ce in
lo ca
tin g
th e
m ot
he r.
A ft
er t
al ki
ng w
ith
co nt
ac ts
in t
he H
is pa
ni c
co m
m un
ity , t
he P
H N
lo ca
te d
fr ie
nd s
of t
he y
ou ng
m ot
he r
w ho
c on
fir m
ed s
he h
ad
re tu
rn ed
t o
M ex
ic o
w ith
t he
in fa
nt . T
he y
di d
no t
kn ow
ho
w t
o co
nt ac
t he
r bu
t ag
re ed
t o
al er
t th
os e
w ith
in t
he
H is
pa ni
c co
m m
un ity
o f
th e
se rio
us ne
ss o
f th
e ba
by ’s
pr
ob le
m . A
bo ut
2 m
on th
s la
te r
th e
m ot
he r
di d
re tu
rn ,
so ug
ht t
he P
H N
’s a
ss is
ta nc
e, a
nd r
ec ei
ve d
ca re
f or
t he
ba
by .
Re fe
rr al
a nd
fo
llo w
-u p
PH N
s pr
ov id
in g
he al
th s
er vi
ce s
to in
m at
es in
a c
ou nt
y ja
il no
tic ed
t ha
t in
di vi
du al
s w
ith m
en ta
l h ea
lth is
su es
, c hr
on ic
he
al th
c on
ce rn
s, c
he m
ic al
d ep
en de
nc y
is su
es , o
r ho
m el
es sn
es s
fr eq
ue nt
ly r
et ur
ne d
to ja
il. F
ew o
f th
es e
is su
es w
er e
ty pi
ca lly
a dd
re ss
ed p
rio r
th e
in m
at es
’ r el
ea se
. Th
e PH
N s
in iti
at ed
R A
PP (R
el ea
se A
dv an
ce P
la nn
in g
Pr og
ra m
), a
vo lu
nt ar
y “d
is ch
ar ge
p la
nn in
g” p
ro ce
ss
th ro
ug h
w hi
ch r
ef er
ra ls
a nd
o th
er a
rr an
ge m
en ts
w ith
co
m m
un ity
r es
ou rc
es c
ou ld
b e
m ad
e pr
io r
to t
he in
m at
es
re tu
rn in
g to
t he
c om
m un
ity . R
ec id
iv is
m r
at es
d ec
re as
ed b
y 57
% b
y th
e th
ird y
ea r
of t
he p
ro gr
am ’s
o pe
ra tio
n.
PH N
s of
te n
se rv
e as
c om
m un
ity r
es ou
rc e
di re
ct or
ie s.
P H
N s
ar e
kn ow
n by
c om
m un
ity m
em be
rs f
or t
he ir
ex te
ns iv
e kn
ow le
dg e
of w
ho m
o r
w he
re t
o ca
ll fo
r a
va rie
ty o
f pr
ob le
m s
or is
su es
. Fo
r ex
am pl
e, P
H N
s in
a r
ur al
h ea
lth d
ep ar
tm en
t re
sp on
de d
to
ca lls
r an
gi ng
f ro
m r
at s
to c
oc kr
oa ch
es t
o be
db ug
s, f
ro m
s ep
tic
ta nk
f ai
lu re
s to
p ee
lin g
pa in
t, an
d fr
om a
ir qu
al ity
t o
bl ue
-g re
en a
lg ae
. T he
P H
N s
of te
n fo
llo w
ed u
p w
ith
co m
m un
ity m
em be
rs t
o en
su re
t ha
t th
ei r
is su
es w
er e
re so
lv ed
.
A P
H N
r ec
ei ve
d a
re fe
rr al
o n
a m
en ta
lly il
l y ou
ng m
an f
ro m
a
sm al
l t ow
n. H
e ne
ed ed
r eg
ul ar
in je
ct io
ns t
o pr
ev en
t re
ho sp
ita liz
at io
n. W
he n
th e
PH N
w as
u na
bl e
to lo
ca te
t hi
s cl
ie nt
a t
ho m
e, s
he f
ou nd
h im
a t
hi s
re gu
la r
“h an
go ut
”— th
e lo
ca l b
ar —
w he
re h
e dr
an k
on ly
s od
a po
p. W
hi le
cr
ea tiv
el y
m ai
nt ai
ni ng
c on
fid en
tia lit
y, t
he P
H N
w or
ke d
w ith
t he
b ar
te nd
er in
t hi
s es
ta bl
is hm
en t
to s
et u
p re
gu la
r ap
po in
tm en
t tim
es f
or t
he c
lie nt
.
Ca se
m an
ag em
en t
Pu bl
ic h
ea lth
n ur
se s
re pr
es en
tin g
10 c
ou nt
y he
al th
de
pa rt
m en
ts , m
ed ic
al c
lin ic
s, a
la rg
e he
al th
p la
n co
m pa
ny ,
an d
th e
st at
e he
al th
d ep
ar tm
en t
w or
ke d
to ge
th er
t o
pr ov
id e
co or
di na
te d
pr en
at al
c ar
e to
im pr
ov e
bi rt
h ou
tc om
es . T
he g
ro up
c re
at ed
a n
in te
gr at
ed p
re na
ta l c
ar e
sy st
em t
ha t
pr om
ot ed
e ar
ly p
re na
ta l c
ar e,
im pr
ov ed
nu
tr iti
on , a
nd li
nk ed
w om
en t
o se
rv ic
es in
t he
co
m m
un iti
es .
PH N
s pr
ov id
ed c
as e
m an
ag em
en t
fo r
al l f
ra il
el de
rly a
nd
di sa
bl ed
p er
so ns
a t
ris k
fo r
in st
itu tio
na liz
at io
n bu
t de
em ed
el
ig ib
le f
or c
om m
un ity
p la
ce m
en t.
Ca se
m an
ag em
en t
m ai
nt ai
ne d
th is
v ul
ne ra
bl e
po pu
la tio
n in
t he
ir ho
m es
o r
co m
m un
ity a
nd e
ns ur
ed t
ha t
th ei
r ne
ed s
w er
e m
et w
ith in
t he
al
lo tt
ed a
m ou
nt o
f m
on ey
t ha
t w
ou ld
o th
er w
is e
be s
pe nt
o n
ho sp
ita liz
at io
n or
n ur
si ng
h om
e ca
re .
A lo
ca l p
hy si
ci an
r ep
or te
d a
hi gh
ly c
on ta
gi ou
s ac
tiv e
in fe
ct io
us t
ub er
cu lo
si s
(T B)
c as
e th
at w
as d
et er
m in
ed t
o be
m ul
tid ru
g re
si st
an t.
Th e
cl ie
nt d
id n
ot s
pe ak
E ng
lis h.
Th
e PH
N c
oo rd
in at
ed h
is c
ar e
w ith
t he
p hy
si ci
an , t
he s
ta te
he
al th
d ep
ar tm
en t’s
T B
un it,
t he
C D
C, a
nd a
h om
e he
al th
ag
en cy
. N ei
th er
t he
h os
pi ta
l o ut
pa tie
nt d
ep ar
tm en
t no
r an
y ho
m e
he al
th a
ge nc
y w
ou ld
a gr
ee t
o tr
ea t
th is
c lie
nt in
th
ei r
fa ci
lit y
or m
ak e
ho m
e vi
si ts
. ( Co
nt in
ue d
un de
r de
le ga
te d
fu nc
tio ns
b el
ow .)
D el
eg at
ed
fu nc
tio ns
In a
c ou
nt y
of 1
20 ,0
00 r
es id
en ts
, P H
N s
fr om
t he
lo ca
l h ea
lth
de pa
rt m
en t
le d
a co
al iti
on o
f ho
sp ita
ls , c
lin ic
s, s
ch oo
ls ,
an d
em er
ge nc
y m
an ag
er s
in d
es ig
ni ng
a nd
im pl
em en
tin g
a co
m m
un ity
-w id
e m
as s
im m
un iz
at io
n pl
an t
o ad
m in
is te
r in
flu en
za v
ac ci
ne . T
he d
es ig
n in
cl ud
ed t
he e
st ab
lis hm
en t
of a
dm in
is tr
at io
n pr
ot oc
ol s
ap pr
ov ed
b y
th e
he al
th
de pa
rt m
en t’s
m ed
ic al
a dv
is or
. T he
h ea
lth d
ep ar
tm en
t al
so
se rv
ed a
s th
e ce
nt ra
l d is
tr ib
ut io
n po
in t
fo r
al l v
ac ci
ne s
av ai
la bl
e w
ith in
t he
c ou
nt y.
PH N
s ad
m in
is te
re d
im m
un iz
at io
ns a
t “d
riv e-
th ru
” flu
c lin
ic s
he
ld in
a c
ou nt
y hi
gh w
ay g
ar ag
e. R
es id
en ts
r ec
ei ve
d th
ei r
as se
ss m
en t
an d
flu s
ho ts
in t
he ir
ve hi
cl es
. T hi
s un
iq ue
a cc
es s
in cr
ea se
d th
e nu
m be
rs o
f im
m un
iz at
io ns
r ec
ei ve
d by
e ld
er ly
an
d di
sa bl
ed r
es id
en ts
, p ar
tic ul
ar ly
t ho
se w
ith li
m ite
d m
ob ili
ty . T
he d
riv e-
th ru
c lin
ic a
ls o
re du
ce d
th e
ex po
su re
po
te nt
ia l t
o in
fe ct
io us
d is
ea se
s th
at w
as in
he re
nt in
r eg
ul ar
cl
in ic
w ai
tin g
ro om
s.
(S ee
a bo
ve c
as e
m an
ag em
en t.)
In a
dd iti
on t
o do
in g
da ily
di
re ct
o bs
er ve
d th
er ap
y (D
O T)
, t he
P H
N w
as t
he o
nl y
he al
th c
ar e
pr ov
id er
w ho
w ou
ld d
o w
ee kl
y la
b dr
aw s,
d ai
ly
IV t
he ra
py , a
nd b
iw ee
kl y
dr es
si ng
c ha
ng es
f or
t he
fi rs
t 7
m on
th s
of t
re at
m en
t. W
ith ou
t PH
N in
vo lv
em en
t, th
is c
lie nt
w
ou ld
h av
e lik
el y
su cc
um be
d to
T B.
T he
c lie
nt c
om pl
et ed
a
fu ll
18 m
on th
s of
t he
ra py
a nd
r ec
ov er
ed .
H ea
lth t
ea ch
in g
PH N
s w
or ke
d w
ith t
he e
pi de
m io
lo gi
st in
t he
ir he
al th
de
pa rt
m en
t to
d ev
el op
“ be
st p
ra ct
ic e”
g ui
de lin
es f
or
pe di
cu lo
si s
(li ce
) t re
at m
en t
fr om
t he
p er
sp ec
tiv es
o f
th e
sc ie
nt ifi
c lit
er at
ur e
an d
th e
pr ac
tic e
co m
m un
ity .
Re co
m m
en da
tio ns
in cl
ud ed
b ot
h su
ff oc
at in
g an
d ch
em ic
al
ag en
ts . C
lin ic
s, s
ch oo
ls , a
nd p
ha rm
ac is
ts u
se d
th e
ne w
gu
id el
in es
. T he
p ub
lic h
ea lth
d ep
ar tm
en t
cr ea
te d
an
in te
rn al
s ta
nd ar
di ze
d pe
di cu
lo si
s re
sp on
se p
ro ce
du re
, a nd
th
e co
un ty
’s s
oc ia
l s er
vi ce
s de
pa rt
m en
t de
ve lo
pe d
a ne
w
po lic
y fo
r sc
ho ol
t ru
an cy
is su
es r
el at
ed t
o pe
di cu
lo si
s.
Se ve
ra l r
ur al
c ou
nt ie
s la
un ch
ed a
p ro
gr am
t o
he lp
y ou
th
in co
rp or
at e
a he
al th
y di
et a
nd e
xe rc
is e
in to
t he
ir liv
es . A
he
al th
f ai
r w
as h
el d
in c
on ju
nc tio
n w
ith p
ar en
t– te
ac he
r co
nf er
en ce
s. C
om m
itt ee
s co
m po
se d
of y
ou th
a nd
a du
lts
pl an
ne d
ac tiv
iti es
s uc
h as
“ D
an ce
‘n ’ D
ip s,
” a
da nc
e fo
llo w
ed
by a
d ip
a t
th e
ci ty
p oo
l. M
em be
rs o
f a
ch ur
ch b
eg an
o ff
er in
g ev
en in
g ex
er ci
se c
la ss
es . A
s m
al l t
ow n
sp on
so re
d th
e “R
un ,
W al
k ’n
R ol
l” t
ha t
w as
o pe
n to
r un
ne rs
, w al
ke rs
, s tr
ol le
rs , a
nd
w he
el ch
ai rs
. T he
“ To
ile t
Pa pe
r” d
oc um
en t,
a m
on th
ly n
ut rit
io n
an d
he al
th t
ip s
he et
d es
ig ne
d to
r es
em bl
e to
ile t
pa pe
r, w
as
di sp
la ye
d in
1 52
b at
hr oo
m s,
n ex
t to
t he
t oi
le t
pa pe
r di
sp en
se rs
. T he
t ip
s w
er e
po pu
la r;
PH N
s re
po rt
ed t
ha t
pe op
le
ca m
e up
t o
th em
o n
th e
st re
et t
o di
sc us
s th
e tip
s. P
H N
s re
po rt
ed s
ee in
g ch
an ge
s in
c om
m un
ity a
tt itu
de s.
A P
H N
w or
ks w
ith p
re gn
an t
an d
pa re
nt in
g te
en s
at a
n al
te rn
at iv
e hi
gh s
ch oo
l p ro
gr am
t ha
t pr
ov id
es e
du ca
tio na
l op
tio ns
f or
t ee
ns w
ho se
li ve
s di
d no
t fit
t he
t ra
di tio
na l
sc ho
ol d
ay . T
he p
ro gr
am in
cl ud
ed t
ee ns
f ro
m a
v ar
ie ty
o f
cu ltu
re s
an d
ba ck
gr ou
nd s.
T he
p ro
gr am
h ad
a n
on si
te
ch ild
ca re
c en
te r;
st ud
en ts
w er
e ab
le t
o vi
si t
th ei
r ch
ild
du rin
g th
e sc
ho ol
d ay
. T he
P H
N s
ta ug
ht w
ee kl
y pr
en at
al
cl as
se s
in c
on ju
nc tio
n w
ith li
fe s
ki lls
a nd
c hi
ld
de ve
lo pm
en t
cl as
se s.
P H
N s
al so
w or
ke d
w ith
e ac
h st
ud en
t to
lo ok
a t
fa m
ily p
la nn
in g
op tio
ns . T
he ir
“P re
gn an
cy F
re e
Cl ub
” pr
ov id
ed e
ac h
st ud
en t
pr iv
at e
tim e
w ith
a P
H N
t o
lo ok
a t
ba rr
ie rs
t ha
t pr
ev en
te d
th e
st ud
en t
fr om
e ff
ec tiv
el y
us in
g bi
rt h
co nt
ro l.
Th e
pr og
ra m
h ad
a r
ep ea
t ad
ol es
ce nt
pr
eg na
nc y
ra te
s ig
ni fic
an tly
lo w
er t
ha n
th e
na tio
na l
av er
ag e,
d ec
lin in
g fr
om a
b as
el in
e of
2 5%
t o
a m
ea n
of
4. 7%
o ve
r 9
ye ar
s of
t he
p ro
gr am
. Co
un se
lin g
PH N
s pa
rt ne
re d
w ith
a c
om m
un ity
f am
ily c
en te
r to
p ro
m ot
e pr
en at
al a
tt ac
hm en
t fo
r fa
m ili
es w
ho w
er e
is ol
at ed
, w ho
ha
d ex
pe rie
nc ed
p re
vi ou
s pr
eg na
nc y
lo ss
, o r
w ho
h ad
ot
he r
at ta
ch m
en t
is su
es . T
he p
ro je
ct p
ro m
ot ed
a tt
ac hm
en t
to t
he b
ab y
th ro
ug h
th e
us e
of d
ou la
s, g
ui de
d vi
de ot
ap in
g,
nu tr
iti on
c ou
ns el
in g,
a nd
r el
ax at
io n
th ro
ug h
m us
ic a
nd
im ag
er y.
In r
es po
ns e
to m
ul tip
le d
ea th
s w
ith in
a n
A m
er ic
an In
di an
co
m m
un ity
, P H
N s
in a
t rib
al h
ea lth
d ep
ar tm
en t
w or
ke d
w ith
th
e co
m m
un ity
t o
de si
gn a
nd im
pl em
en t
a cu
ltu ra
lly
ap pr
op ria
te g
rie f
an d
lo ss
p ro
gr am
. I nt
er ve
nt io
ns in
cl ud
ed
dr um
m in
g ac
tiv iti
es f
or y
ou th
, t ra
di tio
na l h
ea le
rs , a
nd p
ee r
co un
se lo
rs .
A P
H N
le d
m on
th ly
s up
po rt
g ro
up s
fo r
fa m
ily m
em be
rs a
nd
vo lu
nt ee
rs p
ro vi
di ng
in -h
om e
ca re
t o
in di
vi du
al s
w ith
A
lz he
im er
’s d
is ea
se . T
he P
H N
p ro
vi de
d on
e- to
-o ne
ca
re gi
ve r
co ac
hi ng
t o
th os
e ne
ed in
g ad
di tio
na l s
up po
rt .
204 PART 3 Conceptual and Scientific Frameworks
In te
rv e n
ti o
n s
S y
st e m
s C
o m
m u
n it
y In
d iv
id u
a l
Co ns
ul ta
tio n
A ft
er h
ea rin
g ab
ou t
th e
ris k
fo r
se rio
us in
fe ct
io us
d is
ea se
fo
r ch
ild re
n in
d ay
ca re
, P H
N d
ay ca
re c
on su
lta nt
s fr
om
ei gh
t lo
ca l h
ea lth
d ep
ar tm
en ts
d ev
el op
ed a
c ur
ric ul
um o
n ha
nd w
as hi
ng f
or c
hi ld
re n.
T he
y ob
ta in
ed a
g ra
nt t
o de
ve lo
p a
vi de
o in
s ev
er al
la ng
ua ge
s an
d w
id el
y di
st rib
ut ed
t he
h an
dw as
hi ng
m at
er ia
ls .
PH N
s pr
ov id
in g
po st
pa rt
um h
om e
vi si
ts t
o ne
w m
ot he
rs n
ot ed
th
at w
om en
e m
pl oy
ed b
y a
ce rt
ai n
la rg
e co
m pa
ny o
ft en
g av
e up
b re
as tf
ee di
ng u
po n
re tu
rn in
g to
w or
k. R
ea so
ns in
cl ud
ed
la ck
o f
pr iv
at e
sp ac
e to
e xp
re ss
m ilk
a nd
n on
su pp
or tiv
e su
pe rv
is or
s. T
he P
H N
s ap
pr oa
ch ed
t he
c om
pa ny
’s h
um an
re
so ur
ce s
di re
ct or
a nd
p re
se nt
ed a
b us
in es
s ca
se f
or
br ea
st fe
ed in
g. A
ft er
s ev
er al
m ee
tin gs
t he
c om
pa ny
a gr
ee d
to
re va
m p
its p
ol ic
ie s
on b
re as
tf ee
di ng
in t
he w
or kp
la ce
a nd
re
qu es
te d
PH N
s’ a
ss is
ta nc
e in
p ro
vi di
ng t
ra in
in g.
Th e
ol de
r si
st er
o f
an e
ld er
ly b
ac he
lo r
fa rm
er d
ie d.
T he
si
st er
h ad
k ep
t ho
us e
an d
co ok
ed f
or h
er b
ro th
er f
or t
he ir
en tir
e ad
ul t
liv es
. U po
n he
r de
at h,
h e
w as
u na
bl e
to li
ve
in de
pe nd
en tly
. N ei
gh bo
rs c
on ce
rn ed
f or
h is
w el
l-b ei
ng
co nv
in ce
d hi
m t
o ta
lk w
ith a
P H
N /s
oc ia
l w or
ke r
te am
t o
ex pl
or e
hi s
pr ef
er en
ce s
an d
de te
rm in
e th
e be
st o
pt io
ns
fo r
a liv
in g
si tu
at io
n th
at r
es pe
ct ed
h is
n ee
d fo
r se
lf- de
te rm
in at
io n.
H e
ev en
tu al
ly m
ov ed
in to
a n
as si
st ed
liv
in g
fa ci
lit y
th at
m et
h is
n ee
ds .
Co lla
bo ra
tio n
PH N
s ch
an ge
d th
e w
ay t
he y
ha d
tr ad
iti on
al ly
r el
at ed
t o
th e
26 m
ed ic
al c
lin ic
s in
t he
ir co
m m
un ity
. T he
y vi
si te
d ea
ch
cl in
ic q
ua rt
er ly
t o
pr ov
id e
in fo
rm at
io n
ab ou
t ch
an ge
in
va cc
in e
po lic
y an
d im
pr ov
in g
th e
re po
rt in
g of
n ot
ifi ab
le
di se
as es
a s
re qu
ire d
by la
w . T
he y
al so
a ns
w er
ed
qu es
tio ns
, p ro
m ot
ed d
is ea
se p
re ve
nt io
n pr
og ra
m s,
a nd
re
so lv
ed p
ro bl
em s
to ge
th er
, s uc
h as
v ac
ci ne
s ho
rt ag
es .
Th is
r el
at io
ns hi
p be
ne fit
ed t
he p
ub lic
h ea
lth d
ep ar
tm en
t an
d th
e m
ed ic
al c
lin ic
s.
Ev er
yo ne
is a
b ul
ly , i
s be
in g
bu lli
ed , o
r is
a b
ys ta
nd er
. S ch
oo l
nu rs
es w
or ke
d w
ith a
c om
m un
ity a
ct io
n te
am t
o de
ve lo
p co
m m
un ity
a ss
et s—
ca rin
g, e
nc ou
ra gi
ng e
nv iro
nm en
t fo
r yo
ut h
an d
va lu
in g
of y
ou th
b y
ad ul
ts . T
hr ou
gh s
tr at
eg ie
s su
ch
as a
m en
to rin
g pr
og ra
m f
or a
t- ris
k el
em en
ta ry
s ch
oo l s
tu de
nt s
an d
a re
vi ta
liz ed
o rie
nt at
io n
pr og
ra m
f or
n in
th g
ra de
rs
en te
rin g
hi gh
s ch
oo l,
th e
in ci
de nc
e of
b ul
ly in
g be
ha vi
or w
as
re du
ce d.
O ve
r a
pe rio
d of
y ea
rs , a
P H
N w
as a
bl e
to e
st ab
lis h
a tr
us tin
g re
la tio
ns hi
p w
ith a
H ai
tia n
cl ie
nt w
ith H
IV .
Th ro
ug h
he r
tr an
sa ct
io ns
w ith
t hi
s cl
ie nt
, t he
P H
N c
am e
to
un de
rs ta
nd h
er o
w n
va lu
es d
iff er
en tly
a nd
h on
or ed
t he
cl
ie nt
’s s
pi rit
ua l v
al ue
s an
d pr
ac tic
es .
Co al
iti on
b ui
ld in
g PH
N s
w er
e pa
rt o
f a
co al
iti on
t ha
t fo
rm ed
t o
ad dr
es s
th e
ex pl
od in
g be
db ug
is su
e in
t he
c om
m un
ity . T
he c
oa lit
io n
w as
a r
es po
ns e
to r
eq ue
st s
fr om
lo ca
l h ou
si ng
p ro
vi de
rs
fo r
as si
st an
ce . C
oa lit
io n
m em
be rs
in cl
ud ed
P H
N s
al on
g w
ith p
ro pe
rt y
ow ne
rs a
nd m
an ag
er s,
c om
m er
ci al
p es
t m
an ag
em en
t op
er at
or s,
u ni
ve rs
ity e
nt om
ol og
is ts
, a nd
t he
lo
ca l h
ou si
ng a
ut ho
rit y.
T he
y pr
ov id
ed e
du ca
tio n
ab ou
t th
e er
ad ic
at io
n an
d pr
ev en
tio n
of b
ed bu
g in
fe st
at io
ns , c
os t
im pl
ic at
io ns
, a nd
p ot
en tia
l l iti
ga tio
n is
su es
t o
lo ca
l ap
ar tm
en t
m an
ag er
s, f
ra te
rn ity
h ou
se o
pe ra
to rs
, a nd
ho
us in
g of
fic ia
ls .
A s
tu de
nt h
ea lth
s ur
ve y
re ve
al ed
a g
re at
er t
ha n
ex pe
ct ed
nu
m be
r of
o ve
rw ei
gh t
or o
be se
c hi
ld re
n in
a s
ch oo
l d is
tr ic
t. A
co
al iti
on o
f sc
ho ol
n ur
se s,
e du
ca to
rs , a
nd h
ea lth
c ar
e pr
ov id
er s
co nc
er ne
d ab
ou t
ch ild
ho od
o be
si ty
d ev
el op
ed a
sc
ho ol
-b as
ed p
ro gr
am f
or e
le m
en ta
ry s
tu de
nt s.
A s
a re
su lt
of
th e
w or
k of
t hi
s co
al iti
on , p
ar en
ts r
ec ei
ve d
a re
po rt
c ar
d ab
ou t
th ei
r ch
ild ’s
B M
I. Pa
re nt
s al
so r
ec ei
ve d
ed uc
at io
na l
m at
er ia
ls t
ha t
of fe
re d
tip s
fo r
he al
th y
liv in
g an
d a
di re
ct or
y of
ph
ys ic
al a
ct iv
ity o
pt io
ns . A
f ol
lo w
-u p
ev al
ua tio
n re
ve al
ed t
ha t
pa re
nt s
w ho
r ec
ei ve
d a
re po
rt c
ar d
w er
e m
or e
lik el
y to
h av
e in
iti at
ed d
ie ta
ry c
ha ng
es o
r a
ph ys
ic al
a ct
iv ity
p la
n th
an
pa re
nt s
w ho
h ad
n ot
.
Co al
iti on
b ui
ld in
g is
n ot
im pl
em en
te d
at t
he in
di vi
du al
le ve
l of
p ra
ct ic
e.
Co m
m un
ity
or ga
ni zi
ng A
lo ca
l n ew
sp ap
er r
ep or
te d
th at
a s
ta te
w id
e st
ud en
t he
al th
su
rv ey
r ev
ea le
d th
ei r
sc ho
ol d
is tr
ic t
ha d
on e
of t
he h
ig he
st
te en
a lc
oh ol
-u se
r at
es in
t he
s ta
te . N
um er
ou s
le tt
er s
to
th e
ed ito
rs q
ue st
io ne
d w
hy t
he c
om m
un ity
w as
n ot
d oi
ng
an yt
hi ng
a bo
ut t
he p
ro bl
em a
nd d
em an
de d
co m
m un
ity
ac tio
n. In
r es
po ns
e, a
P H
N f
ro m
t he
p ub
lic h
ea lth
de
pa rt
m en
t pa
rt ne
re d
w ith
o th
er c
om m
un ity
g ro
up s
an d
or ga
ni za
tio ns
t o
de ve
lo p
a pl
an t
o ad
dr es
s al
co ho
l u se
in
th e
co m
m un
ity . T
he p
la n
in cl
ud ed
e nf
or ci
ng e
xi st
in g
la w
s,
su ch
a s
en fo
rc in
g “n
ot a
d ro
p” la
w s
w ith
m in
or s
an d
de ve
lo pi
ng s
oc ia
l m ed
ia m
es sa
ge s
fo r
ad ol
es ce
nt s
th at
em
ph as
iz ed
“ N
ot e
ve ry
on e
dr in
ks …
”
In r
es po
ns e
to a
p ub
lic s
af et
y m
ee tin
g w
he re
7 50
a ng
ry
re si
de nt
s sh
ow ed
u p
to c
om pl
ai n
ab ou
t w
ha t
th ey
s aw
a s
th e
de te
rio ra
tio n
of t
he ir
co m
m un
ity , a
c ity
h ea
lth d
ep ar
tm en
t di
sp er
se d
a te
am o
f PH
N s
to d
ev el
op “
so ci
al c
ap ita
l.” T
he
PH N
s fa
ci lit
at ed
t he
d ev
el op
m en
t of
s oc
ia l c
on ne
ct io
ns ,
re la
tio ns
hi ps
, a nd
t ru
st in
a c
om m
un ity
t ha
t ha
d ex
pe rie
nc ed
an
in flu
x of
m ai
nl y
po or
, m in
or ity
r en
te rs
. T he
ir go
al w
as t
o en
su re
t ha
t ne
ig hb
or s
kn ow
a nd
c ar
e ab
ou t
ea ch
o th
er
en ou
gh t
o ru
n ne
xt d
oo r
to b
or ro
w a
c up
o f
su ga
r or
o ff
er t
o he
lp t
he e
ld er
ly w
om an
d ow
n th
e bl
oc k.
P H
N s
he lp
ed
or ga
ni ze
e xe
rc is
e cl
as se
s, a
f ar
m er
’s m
ar ke
t, co
m m
un ity
ga
rd en
s, a
nd n
ei gh
bo rh
oo d
di nn
er s,
w hi
ch w
er e
fr ee
w ith
t he
on
ly r
eq ui
re m
en t
th at
d in
er s
ea t
ne xt
t o
so m
eb od
y th
ey d
id
no t
kn ow
.
Co m
m un
ity o
rg an
iz in
g is
n ot
im pl
em en
te d
at t
he in
di vi
du al
le
ve l o
f pr
ac tic
e.
A dv
oc ac
y A
w or
ke r
at a
la rg
e m
ea t
pa ck
in g
pl an
t th
at e
m pl
oy ed
o ve
r 10
00 p
eo pl
e sp
ea ki
ng 1
2 la
ng ua
ge s
w as
d ia
gn os
ed w
ith
ac tiv
e in
fe ct
io us
t ub
er cu
lo si
s (T
B) . I
ni tia
lly t
he p
la nt
m
an ag
er s
w er
e m
or e
co nc
er ne
d ab
ou t
lo si
ng p
ro du
ct io
n th
an b
ei ng
e xp
os ed
. T he
P H
N s
w or
ke d
w ith
t he
m an
ag er
s to
c on
vi nc
e th
em t
ha t
ex po
su re
t o
TB w
as a
s er
io us
pr
ob le
m a
nd t
ha t
th ey
c ou
ld c
oo pe
ra te
w ith
p ub
lic h
ea lth
w
ith ou
t de
cr ea
si ng
p ro
du ct
io n.
A lth
ou gh
t he
m an
ag er
s w
ou ld
n ot
m an
da te
t es
tin g,
t he
y di
d al
lo w
P H
N s
to o
ff er
fr
ee M
an to
ux t
es ts
d ur
in g
w or
k tim
e on
a ll
th re
e sh
ift s
to
an y
em pl
oy ee
w ho
w an
te d
to b
e te
st ed
. O ve
r 70
0 em
pl oy
ee s
w er
e te
st ed
, w ith
o ve
r 70
p os
iti ve
s. M
an y
of
th e
em pl
oy ee
s w
ith p
os iti
ve M
an to
ux t
es ts
la ck
ed a
cc es
s to
h ea
lth c
ar e.
T he
P H
N s
ne go
tia te
d re
du ce
d cl
in ic
f ee
s an
d se
cu re
d co
m m
un ity
g ra
nt f
un ds
t o
pa y
fo r
x- ra
ys a
nd
pr es
cr ib
ed t
re at
m en
t fo
r in
fe ct
ed p
er so
ns w
ho w
er e
un in
su re
d an
d w
ith ou
t re
so ur
ce s.
(S ee
in di
vi du
al a
dv oc
ac y
ex am
pl e.
)
A v
is iti
ng n
ur se
a ge
nc y
(V N
A ) s
er ve
d m
an y
fa m
ili es
w ith
s m
al l
ch ild
re n
liv in
g at
o r
be lo
w p
ov er
ty le
ve l.
M an
y w
er e
ho m
el es
s, e
xp er
ie nc
in g
m en
ta l h
ea lth
is su
es , a
lc oh
ol o
r dr
ug
ab us
e, o
r do
m es
tic v
io le
nc e.
C lu
b 10
0 w
as a
v ol
un ta
ry
or ga
ni za
tio n
of c
om m
un ity
w om
en a
nd m
en a
ss oc
ia te
d w
ith
th e
VN A
. I t
is a
p ro
gr am
t ha
t re
ac he
s ou
t in
to t
he c
om m
un ity
to
a sk
p eo
pl e
of m
ea ns
t o
he lp
c ar
e fo
r pe
op le
w ho
h av
e ve
ry
lit tle
. I t
pa ire
d m
en a
nd w
om en
w ith
V N
A n
ur se
s an
d th
ei r
at -r
is k
fa m
ily c
lie nt
el e.
T he
v ol
un te
er s
of C
lu b
10 0
w er
e di
vi de
d in
to t
ea m
s th
at w
or ke
d w
ith a
P H
N . T
he P
H N
s el
ec te
d cl
ie nt
s w
ho w
ou ld
b en
efi t
fr om
t he
p ro
gr am
a nd
p re
se nt
ed
th e
cl ie
nt ’s
c as
e to
t he
t ea
m o
n a
qu ar
te rly
b as
is . T
he c
lu b
pr ov
id ed
“ gi
ft s”
s uc
h as
h ig
h ch
ai rs
, s tr
ol le
rs , d
ia pe
rs , b
oo ks
, to
ys , a
nd t
oo ls
t o
su pp
or t
fa m
ily s
el f-
su ffi
ci en
cy a
nd im
pr ov
ed
th e
liv es
o f
th es
e m
en , w
om en
a nd
c hi
ld re
n.
A P
H N
r ec
ei ve
d a
re fe
rr al
o n
a 9-
m on
th -o
ld b
oy w
ith a
re
ce nt
d ia
gn os
is o
f m
en in
gi tis
r es
ul tin
g fr
om a
ct iv
e TB
. Th
e ch
ild ’s
p ar
en ts
w er
e a
yo un
g H
is pa
ni c
co up
le w
ho d
id
no t
sp ea
k En
gl is
h. T
he c
hi ld
’s m
ot he
r w
as p
re gn
an t
an d
st ay
ed a
t ho
m e
w ith
h er
t w
o sm
al l c
hi ld
re n.
T he
f am
ily
ha d
no t
el ep
ho ne
a nd
n ei
th er
p ar
en t
ha d
a dr
iv er
’s li
ce ns
e.
Th e
en tir
e fa
m ily
r ea
ct ed
p os
iti ve
ly t
o th
e M
an to
ux t
es ts
th
at t
he P
H N
a dm
in is
te re
d. A
t th
is p
oi nt
, t he
P H
N
ar ra
ng ed
a n
ap po
in tm
en t
at t
he lo
ca l c
lin ic
f or
t he
e nt
ire
fa m
ily , c
om pl
et e
w ith
t ra
ns po
rt at
io n
an d
in te
rp re
te rs
. T he
fa
th er
w as
f ou
nd t
o ha
ve a
ct iv
e in
fe ct
io us
T B.
H e
w as
or
de re
d no
t to
r et
ur n
to h
is jo
b at
t he
m ea
t pa
ck in
g pl
an t
an d
co ns
eq ue
nt ly
lo st
h is
h ea
lth in
su ra
nc e.
T he
P H
N
as si
st ed
t he
f am
ily in
a pp
ly in
g fo
r m
ed ic
al a
ss is
ta nc
e an
d ot
he r
se rv
ic es
f or
w hi
ch t
he y
w er
e el
ig ib
le . (
Th e
fa ct
t ha
t a
m ea
t pa
ck in
g pl
an t
em pl
oy ee
h ad
in fe
ct io
us T
B re
qu ire
d th
is P
H N
t o
in te
rv en
e at
t he
s ys
te m
s le
ve l—
— se
e sy
st em
s ad
vo ca
cy e
xa m
pl e.
) So
ci al
m ar
ke tin
g A
p ar
tn er
sh ip
o f
he al
th d
ep ar
tm en
ts , m
an ag
ed c
ar e
or ga
ni za
tio ns
, p ha
rm ac
eu tic
al c
om pa
ni es
, h ea
lth c
ar e
in su
re rs
, a nd
o th
er s
so ug
ht t
o de
cr ea
se u
nn ec
es sa
ry
an tim
ic ro
bi al
u se
a nd
r ed
uc e
th e
sp re
ad o
f an
tim ic
ro bi
al
re si
st an
ce . “
M ox
ie C
ill in
” an
d “A
nn ie
B io
tic ”
w er
e m
as co
ts t
ha t
ap pe
ar ed
o n
pa m
ph le
ts , p
os te
rs , s
tic ke
rs ,
an d
in p
er so
n. T
he y
ur ge
d di
sc on
tin ua
tio n
of in
ap pr
op ria
te
re qu
es tin
g of
a nt
ib io
tic s
by p
ar en
ts a
nd u
nn ec
es sa
ry
pr es
cr ib
in g
of a
nt ib
io tic
s by
h ea
lth c
ar e
pr ov
id er
s.
A P
H N
w or
ki ng
in a
s m
al l r
ur al
c ou
nt y
w as
a ss
ig ne
d to
w or
k on
a
Fe ta
l A lc
oh ol
S yn
dr om
e pr
ev en
tio n
gr an
t in
p ar
tn er
sh ip
w ith
th
e lo
ca l h
os pi
ta l.
Th e
PH N
c oo
rd in
at ed
t he
g ra
nt a
ct iv
iti es
, w
hi ch
in cl
ud ed
m as
s m
ed ia
e ff
or ts
s uc
h as
b ill
bo ar
ds , r
ad io
sp
ot s
re ad
b y
lo ca
l c el
eb rit
ie s,
a nd
n ew
sp ap
er a
rt ic
le s.
M
ul tip
le p
os te
rs w
er e
pl ac
ed in
e ve
ry b
ar in
t he
c om
m un
ity ,
an d
lo ca
l b ar
te nd
er s
w er
e en
ga ge
d as
p ar
tn er
s in
t he
e ff
or t
to
re du
ce a
lc oh
ol u
se a
m on
g pr
eg na
nt w
om en
. A ft
er 2
y ea
rs , t
he
pr oj
ec t
do cu
m en
te d
an in
cr ea
se in
c om
m un
ity a
w ar
en es
s,
w hi
ch is
t he
fi rs
t st
ep in
c ha
ng in
g th
e co
m m
un ity
n or
m
re ga
rd in
g al
co ho
l u se
a m
on g
pr eg
na nt
w om
en .
PH N
s ro
ut in
el y
co nd
uc te
d ho
m e
sa fe
ty c
he ck
s w
ith p
re gn
an t
an d
pa re
nt in
g fa
m ili
es t
o pr
ev en
t ch
ild ho
od in
ju rie
s. A
s in
ce nt
iv es
, t he
y di
st rib
ut ed
s af
et y
ki ts
t ha
t in
cl ud
ed it
em s
to c
hi ld
-p ro
of a
h om
e, s
uc h
as c
up bo
ar d
sa fe
ty lo
ck s,
ou
tle t
co ve
rs , d
oo r
kn ob
s af
et y
co ve
rs , a
nd d
ra w
er la
tc he
s.
W hi
le h
av in
g a
PH N
c he
ck in
g co
nt en
ts in
c up
bo ar
ds a
nd
w at
er t
em pe
ra tu
re s
m ay
h av
e fe
lt in
tr us
iv e
to s
om e
fa m
ili es
, t he
k its
in cr
ea se
d th
e nu
m be
r of
f am
ili es
w ho
w
er e
re ce
pt iv
e to
h om
e sa
fe ty
c he
ck s.
Po lic
y de
ve lo
pm en
t an
d en
fo rc
em en
t Lo
ca l h
ea lth
d ep
ar tm
en t
PH N
s an
d he
al th
e du
ca to
rs
pa rt
ne re
d w
ith la
w e
nf or
ce m
en t
to e
st ab
lis h
or di
na nc
es
pr oh
ib iti
ng t
he s
al e
of t
ob ac
co t
o un
de r-
ag e
yo ut
h. P
ar t
of
th e
in iti
at iv
e in
cl ud
ed r
ec ru
iti ng
a nd
t ra
in in
g yo
ut h
to
co nd
uc t
co m
pl ia
nc e
ch ec
ks , i
n w
hi ch
u nd
er -a
ge y
ou th
at
te m
pt ed
t o
pu rc
ha se
c ig
ar et
te s
in r
et ai
l s to
re s.
P H
N s
al so
c re
at ed
a n
el ec
tr on
ic c
om pl
ia nc
e tr
ac ki
ng s
ys te
m t
ha t
w as
e ve
nt ua
lly u
se d
by t
he e
nt ire
s ta
te .
A P
H N
in ve
st ig
at ed
a p
ub lic
h ea
lth c
om pl
ai nt
a bo
ut a
fl y
pr ob
le m
o rig
in at
in g
fr om
t he
m an
ur e
pi t
of a
f ar
m t
ha t
ho us
ed
m ill
io ns
o f
ch ic
ke ns
. G ar
be d
in p
ro te
ct iv
e eq
ui pm
en t,
th e
in tr
ep id
P H
N c
ra w
le d
un de
r th
e ch
ic ke
n ca
ge s
th at
d um
pe d
in to
t he
m an
ur e
pi ts
a nd
f ou
nd m
as se
s of
m ag
go ts
. A ft
er
de te
rm in
in g
th at
t he
s itu
at io
n co
ns tit
ut ed
a p
ub lic
h ea
lth
nu is
an ce
, t he
P H
N s
uc ce
ss fu
lly w
or ke
d w
ith t
he b
us in
es s
ow ne
rs t
o fin
d a
so lu
tio n
th at
in vo
lv ed
t he
d ry
in g
of m
an ur
e to
p re
ve nt
t he
m ag
go ts
f ro
m s
ur vi
vi ng
.
A P
H N
r ec
ei ve
d a
re fe
rr al
r eg
ar di
ng t
he s
af et
y of
a n
80 -y
ea r-
ol d
w om
an li
vi ng
a lo
ne o
n a
lit te
re d
fa rm
s ite
. T he
w
om an
li ve
d w
ith 1
8 ca
ts in
a h
ou se
w ith
ou t
he at
t ha
t w
as a
nk le
-d ee
p w
ith c
an s,
c lo
th es
, a nd
c at
f ec
es . T
he
PH N
in iti
at ed
a v
ul ne
ra bl
e ad
ul t
ev al
ua tio
n th
at r
es ul
te d
in
a “n
ot s
uf fic
ie nt
ly v
ul ne
ra bl
e” fi
nd in
g un
de r
st at
e st
at ut
e.
Th ro
ug h
re pe
at ed
c on
ta ct
s, t
he P
H N
w as
a bl
e to
e st
ab lis
h a
tr us
tin g
re la
tio ns
hi p;
t he
w om
en a
cc ep
te d
a re
fe rr
al f
or
ca re
t o
a ph
ys ic
ia n.
H ow
ev er
, s he
w as
n ot
s uc
ce ss
fu l i
n ch
an gi
ng t
he w
om an
’s li
vi ng
s itu
at io
n.
T A
B L E 9
-2
E x a m
p le
s o
f 1 7 I
n te
rv e n
ti o
n s
a t
T h
re e L
e v e ls
o f
P ra
ct ic
e —
co n
t’ d
205CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
In te
rv e n
ti o
n s
S y st
e m
s C
o m
m u
n it
y In
d iv
id u
a l
Co ns
ul ta
tio n
A ft
er h
ea rin
g ab
ou t
th e
ris k
fo r
se rio
us in
fe ct
io us
d is
ea se
fo
r ch
ild re
n in
d ay
ca re
, P H
N d
ay ca
re c
on su
lta nt
s fr
om
ei gh
t lo
ca l h
ea lth
d ep
ar tm
en ts
d ev
el op
ed a
c ur
ric ul
um o
n ha
nd w
as hi
ng f
or c
hi ld
re n.
T he
y ob
ta in
ed a
g ra
nt t
o de
ve lo
p a
vi de
o in
s ev
er al
la ng
ua ge
s an
d w
id el
y di
st rib
ut ed
t he
h an
dw as
hi ng
m at
er ia
ls .
PH N
s pr
ov id
in g
po st
pa rt
um h
om e
vi si
ts t
o ne
w m
ot he
rs n
ot ed
th
at w
om en
e m
pl oy
ed b
y a
ce rt
ai n
la rg
e co
m pa
ny o
ft en
g av
e up
b re
as tf
ee di
ng u
po n
re tu
rn in
g to
w or
k. R
ea so
ns in
cl ud
ed
la ck
o f
pr iv
at e
sp ac
e to
e xp
re ss
m ilk
a nd
n on
su pp
or tiv
e su
pe rv
is or
s. T
he P
H N
s ap
pr oa
ch ed
t he
c om
pa ny
’s h
um an
re
so ur
ce s
di re
ct or
a nd
p re
se nt
ed a
b us
in es
s ca
se f
or
br ea
st fe
ed in
g. A
ft er
s ev
er al
m ee
tin gs
t he
c om
pa ny
a gr
ee d
to
re va
m p
its p
ol ic
ie s
on b
re as
tf ee
di ng
in t
he w
or kp
la ce
a nd
re
qu es
te d
PH N
s’ a
ss is
ta nc
e in
p ro
vi di
ng t
ra in
in g.
Th e
ol de
r si
st er
o f
an e
ld er
ly b
ac he
lo r
fa rm
er d
ie d.
T he
si
st er
h ad
k ep
t ho
us e
an d
co ok
ed f
or h
er b
ro th
er f
or t
he ir
en tir
e ad
ul t
liv es
. U po
n he
r de
at h,
h e
w as
u na
bl e
to li
ve
in de
pe nd
en tly
. N ei
gh bo
rs c
on ce
rn ed
f or
h is
w el
l-b ei
ng
co nv
in ce
d hi
m t
o ta
lk w
ith a
P H
N /s
oc ia
l w or
ke r
te am
t o
ex pl
or e
hi s
pr ef
er en
ce s
an d
de te
rm in
e th
e be
st o
pt io
ns
fo r
a liv
in g
si tu
at io
n th
at r
es pe
ct ed
h is
n ee
d fo
r se
lf- de
te rm
in at
io n.
H e
ev en
tu al
ly m
ov ed
in to
a n
as si
st ed
liv
in g
fa ci
lit y
th at
m et
h is
n ee
ds .
Co lla
bo ra
tio n
PH N
s ch
an ge
d th
e w
ay t
he y
ha d
tr ad
iti on
al ly
r el
at ed
t o
th e
26 m
ed ic
al c
lin ic
s in
t he
ir co
m m
un ity
. T he
y vi
si te
d ea
ch
cl in
ic q
ua rt
er ly
t o
pr ov
id e
in fo
rm at
io n
ab ou
t ch
an ge
in
va cc
in e
po lic
y an
d im
pr ov
in g
th e
re po
rt in
g of
n ot
ifi ab
le
di se
as es
a s
re qu
ire d
by la
w . T
he y
al so
a ns
w er
ed
qu es
tio ns
, p ro
m ot
ed d
is ea
se p
re ve
nt io
n pr
og ra
m s,
a nd
re
so lv
ed p
ro bl
em s
to ge
th er
, s uc
h as
v ac
ci ne
s ho
rt ag
es .
Th is
r el
at io
ns hi
p be
ne fit
ed t
he p
ub lic
h ea
lth d
ep ar
tm en
t an
d th
e m
ed ic
al c
lin ic
s.
Ev er
yo ne
is a
b ul
ly , i
s be
in g
bu lli
ed , o
r is
a b
ys ta
nd er
. S ch
oo l
nu rs
es w
or ke
d w
ith a
c om
m un
ity a
ct io
n te
am t
o de
ve lo
p co
m m
un ity
a ss
et s—
ca rin
g, e
nc ou
ra gi
ng e
nv iro
nm en
t fo
r yo
ut h
an d
va lu
in g
of y
ou th
b y
ad ul
ts . T
hr ou
gh s
tr at
eg ie
s su
ch
as a
m en
to rin
g pr
og ra
m f
or a
t- ris
k el
em en
ta ry
s ch
oo l s
tu de
nt s
an d
a re
vi ta
liz ed
o rie
nt at
io n
pr og
ra m
f or
n in
th g
ra de
rs
en te
rin g
hi gh
s ch
oo l,
th e
in ci
de nc
e of
b ul
ly in
g be
ha vi
or w
as
re du
ce d.
O ve
r a
pe rio
d of
y ea
rs , a
P H
N w
as a
bl e
to e
st ab
lis h
a tr
us tin
g re
la tio
ns hi
p w
ith a
H ai
tia n
cl ie
nt w
ith H
IV .
Th ro
ug h
he r
tr an
sa ct
io ns
w ith
t hi
s cl
ie nt
, t he
P H
N c
am e
to
un de
rs ta
nd h
er o
w n
va lu
es d
iff er
en tly
a nd
h on
or ed
t he
cl
ie nt
’s s
pi rit
ua l v
al ue
s an
d pr
ac tic
es .
Co al
iti on
b ui
ld in
g PH
N s
w er
e pa
rt o
f a
co al
iti on
t ha
t fo
rm ed
t o
ad dr
es s
th e
ex pl
od in
g be
db ug
is su
e in
t he
c om
m un
ity . T
he c
oa lit
io n
w as
a r
es po
ns e
to r
eq ue
st s
fr om
lo ca
l h ou
si ng
p ro
vi de
rs
fo r
as si
st an
ce . C
oa lit
io n
m em
be rs
in cl
ud ed
P H
N s
al on
g w
ith p
ro pe
rt y
ow ne
rs a
nd m
an ag
er s,
c om
m er
ci al
p es
t m
an ag
em en
t op
er at
or s,
u ni
ve rs
ity e
nt om
ol og
is ts
, a nd
t he
lo
ca l h
ou si
ng a
ut ho
rit y.
T he
y pr
ov id
ed e
du ca
tio n
ab ou
t th
e er
ad ic
at io
n an
d pr
ev en
tio n
of b
ed bu
g in
fe st
at io
ns , c
os t
im pl
ic at
io ns
, a nd
p ot
en tia
l l iti
ga tio
n is
su es
t o
lo ca
l ap
ar tm
en t
m an
ag er
s, f
ra te
rn ity
h ou
se o
pe ra
to rs
, a nd
ho
us in
g of
fic ia
ls .
A s
tu de
nt h
ea lth
s ur
ve y
re ve
al ed
a g
re at
er t
ha n
ex pe
ct ed
nu
m be
r of
o ve
rw ei
gh t
or o
be se
c hi
ld re
n in
a s
ch oo
l d is
tr ic
t. A
co
al iti
on o
f sc
ho ol
n ur
se s,
e du
ca to
rs , a
nd h
ea lth
c ar
e pr
ov id
er s
co nc
er ne
d ab
ou t
ch ild
ho od
o be
si ty
d ev
el op
ed a
sc
ho ol
-b as
ed p
ro gr
am f
or e
le m
en ta
ry s
tu de
nt s.
A s
a re
su lt
of
th e
w or
k of
t hi
s co
al iti
on , p
ar en
ts r
ec ei
ve d
a re
po rt
c ar
d ab
ou t
th ei
r ch
ild ’s
B M
I. Pa
re nt
s al
so r
ec ei
ve d
ed uc
at io
na l
m at
er ia
ls t
ha t
of fe
re d
tip s
fo r
he al
th y
liv in
g an
d a
di re
ct or
y of
ph
ys ic
al a
ct iv
ity o
pt io
ns . A
f ol
lo w
-u p
ev al
ua tio
n re
ve al
ed t
ha t
pa re
nt s
w ho
r ec
ei ve
d a
re po
rt c
ar d
w er
e m
or e
lik el
y to
h av
e in
iti at
ed d
ie ta
ry c
ha ng
es o
r a
ph ys
ic al
a ct
iv ity
p la
n th
an
pa re
nt s
w ho
h ad
n ot
.
Co al
iti on
b ui
ld in
g is
n ot
im pl
em en
te d
at t
he in
di vi
du al
le ve
l of
p ra
ct ic
e.
Co m
m un
ity
or ga
ni zi
ng A
lo ca
l n ew
sp ap
er r
ep or
te d
th at
a s
ta te
w id
e st
ud en
t he
al th
su
rv ey
r ev
ea le
d th
ei r
sc ho
ol d
is tr
ic t
ha d
on e
of t
he h
ig he
st
te en
a lc
oh ol
-u se
r at
es in
t he
s ta
te . N
um er
ou s
le tt
er s
to
th e
ed ito
rs q
ue st
io ne
d w
hy t
he c
om m
un ity
w as
n ot
d oi
ng
an yt
hi ng
a bo
ut t
he p
ro bl
em a
nd d
em an
de d
co m
m un
ity
ac tio
n. In
r es
po ns
e, a
P H
N f
ro m
t he
p ub
lic h
ea lth
de
pa rt
m en
t pa
rt ne
re d
w ith
o th
er c
om m
un ity
g ro
up s
an d
or ga
ni za
tio ns
t o
de ve
lo p
a pl
an t
o ad
dr es
s al
co ho
l u se
in
th e
co m
m un
ity . T
he p
la n
in cl
ud ed
e nf
or ci
ng e
xi st
in g
la w
s,
su ch
a s
en fo
rc in
g “n
ot a
d ro
p” la
w s
w ith
m in
or s
an d
de ve
lo pi
ng s
oc ia
l m ed
ia m
es sa
ge s
fo r
ad ol
es ce
nt s
th at
em
ph as
iz ed
“ N
ot e
ve ry
on e
dr in
ks …
”
In r
es po
ns e
to a
p ub
lic s
af et
y m
ee tin
g w
he re
7 50
a ng
ry
re si
de nt
s sh
ow ed
u p
to c
om pl
ai n
ab ou
t w
ha t
th ey
s aw
a s
th e
de te
rio ra
tio n
of t
he ir
co m
m un
ity , a
c ity
h ea
lth d
ep ar
tm en
t di
sp er
se d
a te
am o
f PH
N s
to d
ev el
op “
so ci
al c
ap ita
l.” T
he
PH N
s fa
ci lit
at ed
t he
d ev
el op
m en
t of
s oc
ia l c
on ne
ct io
ns ,
re la
tio ns
hi ps
, a nd
t ru
st in
a c
om m
un ity
t ha
t ha
d ex
pe rie
nc ed
an
in flu
x of
m ai
nl y
po or
, m in
or ity
r en
te rs
. T he
ir go
al w
as t
o en
su re
t ha
t ne
ig hb
or s
kn ow
a nd
c ar
e ab
ou t
ea ch
o th
er
en ou
gh t
o ru
n ne
xt d
oo r
to b
or ro
w a
c up
o f
su ga
r or
o ff
er t
o he
lp t
he e
ld er
ly w
om an
d ow
n th
e bl
oc k.
P H
N s
he lp
ed
or ga
ni ze
e xe
rc is
e cl
as se
s, a
f ar
m er
’s m
ar ke
t, co
m m
un ity
ga
rd en
s, a
nd n
ei gh
bo rh
oo d
di nn
er s,
w hi
ch w
er e
fr ee
w ith
t he
on
ly r
eq ui
re m
en t
th at
d in
er s
ea t
ne xt
t o
so m
eb od
y th
ey d
id
no t
kn ow
.
Co m
m un
ity o
rg an
iz in
g is
n ot
im pl
em en
te d
at t
he in
di vi
du al
le
ve l o
f pr
ac tic
e.
A dv
oc ac
y A
w or
ke r
at a
la rg
e m
ea t
pa ck
in g
pl an
t th
at e
m pl
oy ed
o ve
r 10
00 p
eo pl
e sp
ea ki
ng 1
2 la
ng ua
ge s
w as
d ia
gn os
ed w
ith
ac tiv
e in
fe ct
io us
t ub
er cu
lo si
s (T
B) . I
ni tia
lly t
he p
la nt
m
an ag
er s
w er
e m
or e
co nc
er ne
d ab
ou t
lo si
ng p
ro du
ct io
n th
an b
ei ng
e xp
os ed
. T he
P H
N s
w or
ke d
w ith
t he
m an
ag er
s to
c on
vi nc
e th
em t
ha t
ex po
su re
t o
TB w
as a
s er
io us
pr
ob le
m a
nd t
ha t
th ey
c ou
ld c
oo pe
ra te
w ith
p ub
lic h
ea lth
w
ith ou
t de
cr ea
si ng
p ro
du ct
io n.
A lth
ou gh
t he
m an
ag er
s w
ou ld
n ot
m an
da te
t es
tin g,
t he
y di
d al
lo w
P H
N s
to o
ff er
fr
ee M
an to
ux t
es ts
d ur
in g
w or
k tim
e on
a ll
th re
e sh
ift s
to
an y
em pl
oy ee
w ho
w an
te d
to b
e te
st ed
. O ve
r 70
0 em
pl oy
ee s
w er
e te
st ed
, w ith
o ve
r 70
p os
iti ve
s. M
an y
of
th e
em pl
oy ee
s w
ith p
os iti
ve M
an to
ux t
es ts
la ck
ed a
cc es
s to
h ea
lth c
ar e.
T he
P H
N s
ne go
tia te
d re
du ce
d cl
in ic
f ee
s an
d se
cu re
d co
m m
un ity
g ra
nt f
un ds
t o
pa y
fo r
x- ra
ys a
nd
pr es
cr ib
ed t
re at
m en
t fo
r in
fe ct
ed p
er so
ns w
ho w
er e
un in
su re
d an
d w
ith ou
t re
so ur
ce s.
(S ee
in di
vi du
al a
dv oc
ac y
ex am
pl e.
)
A v
is iti
ng n
ur se
a ge
nc y
(V N
A ) s
er ve
d m
an y
fa m
ili es
w ith
s m
al l
ch ild
re n
liv in
g at
o r
be lo
w p
ov er
ty le
ve l.
M an
y w
er e
ho m
el es
s, e
xp er
ie nc
in g
m en
ta l h
ea lth
is su
es , a
lc oh
ol o
r dr
ug
ab us
e, o
r do
m es
tic v
io le
nc e.
C lu
b 10
0 w
as a
v ol
un ta
ry
or ga
ni za
tio n
of c
om m
un ity
w om
en a
nd m
en a
ss oc
ia te
d w
ith
th e
VN A
. I t
is a
p ro
gr am
t ha
t re
ac he
s ou
t in
to t
he c
om m
un ity
to
a sk
p eo
pl e
of m
ea ns
t o
he lp
c ar
e fo
r pe
op le
w ho
h av
e ve
ry
lit tle
. I t
pa ire
d m
en a
nd w
om en
w ith
V N
A n
ur se
s an
d th
ei r
at -r
is k
fa m
ily c
lie nt
el e.
T he
v ol
un te
er s
of C
lu b
10 0
w er
e di
vi de
d in
to t
ea m
s th
at w
or ke
d w
ith a
P H
N . T
he P
H N
s el
ec te
d cl
ie nt
s w
ho w
ou ld
b en
efi t
fr om
t he
p ro
gr am
a nd
p re
se nt
ed
th e
cl ie
nt ’s
c as
e to
t he
t ea
m o
n a
qu ar
te rly
b as
is . T
he c
lu b
pr ov
id ed
“ gi
ft s”
s uc
h as
h ig
h ch
ai rs
, s tr
ol le
rs , d
ia pe
rs , b
oo ks
, to
ys , a
nd t
oo ls
t o
su pp
or t
fa m
ily s
el f-
su ffi
ci en
cy a
nd im
pr ov
ed
th e
liv es
o f
th es
e m
en , w
om en
a nd
c hi
ld re
n.
A P
H N
r ec
ei ve
d a
re fe
rr al
o n
a 9-
m on
th -o
ld b
oy w
ith a
re
ce nt
d ia
gn os
is o
f m
en in
gi tis
r es
ul tin
g fr
om a
ct iv
e TB
. Th
e ch
ild ’s
p ar
en ts
w er
e a
yo un
g H
is pa
ni c
co up
le w
ho d
id
no t
sp ea
k En
gl is
h. T
he c
hi ld
’s m
ot he
r w
as p
re gn
an t
an d
st ay
ed a
t ho
m e
w ith
h er
t w
o sm
al l c
hi ld
re n.
T he
f am
ily
ha d
no t
el ep
ho ne
a nd
n ei
th er
p ar
en t
ha d
a dr
iv er
’s li
ce ns
e.
Th e
en tir
e fa
m ily
r ea
ct ed
p os
iti ve
ly t
o th
e M
an to
ux t
es ts
th
at t
he P
H N
a dm
in is
te re
d. A
t th
is p
oi nt
, t he
P H
N
ar ra
ng ed
a n
ap po
in tm
en t
at t
he lo
ca l c
lin ic
f or
t he
e nt
ire
fa m
ily , c
om pl
et e
w ith
t ra
ns po
rt at
io n
an d
in te
rp re
te rs
. T he
fa
th er
w as
f ou
nd t
o ha
ve a
ct iv
e in
fe ct
io us
T B.
H e
w as
or
de re
d no
t to
r et
ur n
to h
is jo
b at
t he
m ea
t pa
ck in
g pl
an t
an d
co ns
eq ue
nt ly
lo st
h is
h ea
lth in
su ra
nc e.
T he
P H
N
as si
st ed
t he
f am
ily in
a pp
ly in
g fo
r m
ed ic
al a
ss is
ta nc
e an
d ot
he r
se rv
ic es
f or
w hi
ch t
he y
w er
e el
ig ib
le . (
Th e
fa ct
t ha
t a
m ea
t pa
ck in
g pl
an t
em pl
oy ee
h ad
in fe
ct io
us T
B re
qu ire
d th
is P
H N
t o
in te
rv en
e at
t he
s ys
te m
s le
ve l—
— se
e sy
st em
s ad
vo ca
cy e
xa m
pl e.
) So
ci al
m ar
ke tin
g A
p ar
tn er
sh ip
o f
he al
th d
ep ar
tm en
ts , m
an ag
ed c
ar e
or ga
ni za
tio ns
, p ha
rm ac
eu tic
al c
om pa
ni es
, h ea
lth c
ar e
in su
re rs
, a nd
o th
er s
so ug
ht t
o de
cr ea
se u
nn ec
es sa
ry
an tim
ic ro
bi al
u se
a nd
r ed
uc e
th e
sp re
ad o
f an
tim ic
ro bi
al
re si
st an
ce . “
M ox
ie C
ill in
” an
d “A
nn ie
B io
tic ”
w er
e m
as co
ts t
ha t
ap pe
ar ed
o n
pa m
ph le
ts , p
os te
rs , s
tic ke
rs ,
an d
in p
er so
n. T
he y
ur ge
d di
sc on
tin ua
tio n
of in
ap pr
op ria
te
re qu
es tin
g of
a nt
ib io
tic s
by p
ar en
ts a
nd u
nn ec
es sa
ry
pr es
cr ib
in g
of a
nt ib
io tic
s by
h ea
lth c
ar e
pr ov
id er
s.
A P
H N
w or
ki ng
in a
s m
al l r
ur al
c ou
nt y
w as
a ss
ig ne
d to
w or
k on
a
Fe ta
l A lc
oh ol
S yn
dr om
e pr
ev en
tio n
gr an
t in
p ar
tn er
sh ip
w ith
th
e lo
ca l h
os pi
ta l.
Th e
PH N
c oo
rd in
at ed
t he
g ra
nt a
ct iv
iti es
, w
hi ch
in cl
ud ed
m as
s m
ed ia
e ff
or ts
s uc
h as
b ill
bo ar
ds , r
ad io
sp
ot s
re ad
b y
lo ca
l c el
eb rit
ie s,
a nd
n ew
sp ap
er a
rt ic
le s.
M
ul tip
le p
os te
rs w
er e
pl ac
ed in
e ve
ry b
ar in
t he
c om
m un
ity ,
an d
lo ca
l b ar
te nd
er s
w er
e en
ga ge
d as
p ar
tn er
s in
t he
e ff
or t
to
re du
ce a
lc oh
ol u
se a
m on
g pr
eg na
nt w
om en
. A ft
er 2
y ea
rs , t
he
pr oj
ec t
do cu
m en
te d
an in
cr ea
se in
c om
m un
ity a
w ar
en es
s,
w hi
ch is
t he
fi rs
t st
ep in
c ha
ng in
g th
e co
m m
un ity
n or
m
re ga
rd in
g al
co ho
l u se
a m
on g
pr eg
na nt
w om
en .
PH N
s ro
ut in
el y
co nd
uc te
d ho
m e
sa fe
ty c
he ck
s w
ith p
re gn
an t
an d
pa re
nt in
g fa
m ili
es t
o pr
ev en
t ch
ild ho
od in
ju rie
s. A
s in
ce nt
iv es
, t he
y di
st rib
ut ed
s af
et y
ki ts
t ha
t in
cl ud
ed it
em s
to c
hi ld
-p ro
of a
h om
e, s
uc h
as c
up bo
ar d
sa fe
ty lo
ck s,
ou
tle t
co ve
rs , d
oo r
kn ob
s af
et y
co ve
rs , a
nd d
ra w
er la
tc he
s.
W hi
le h
av in
g a
PH N
c he
ck in
g co
nt en
ts in
c up
bo ar
ds a
nd
w at
er t
em pe
ra tu
re s
m ay
h av
e fe
lt in
tr us
iv e
to s
om e
fa m
ili es
, t he
k its
in cr
ea se
d th
e nu
m be
r of
f am
ili es
w ho
w
er e
re ce
pt iv
e to
h om
e sa
fe ty
c he
ck s.
Po lic
y de
ve lo
pm en
t an
d en
fo rc
em en
t Lo
ca l h
ea lth
d ep
ar tm
en t
PH N
s an
d he
al th
e du
ca to
rs
pa rt
ne re
d w
ith la
w e
nf or
ce m
en t
to e
st ab
lis h
or di
na nc
es
pr oh
ib iti
ng t
he s
al e
of t
ob ac
co t
o un
de r-
ag e
yo ut
h. P
ar t
of
th e
in iti
at iv
e in
cl ud
ed r
ec ru
iti ng
a nd
t ra
in in
g yo
ut h
to
co nd
uc t
co m
pl ia
nc e
ch ec
ks , i
n w
hi ch
u nd
er -a
ge y
ou th
at
te m
pt ed
t o
pu rc
ha se
c ig
ar et
te s
in r
et ai
l s to
re s.
P H
N s
al so
c re
at ed
a n
el ec
tr on
ic c
om pl
ia nc
e tr
ac ki
ng s
ys te
m t
ha t
w as
e ve
nt ua
lly u
se d
by t
he e
nt ire
s ta
te .
A P
H N
in ve
st ig
at ed
a p
ub lic
h ea
lth c
om pl
ai nt
a bo
ut a
fl y
pr ob
le m
o rig
in at
in g
fr om
t he
m an
ur e
pi t
of a
f ar
m t
ha t
ho us
ed
m ill
io ns
o f
ch ic
ke ns
. G ar
be d
in p
ro te
ct iv
e eq
ui pm
en t,
th e
in tr
ep id
P H
N c
ra w
le d
un de
r th
e ch
ic ke
n ca
ge s
th at
d um
pe d
in to
t he
m an
ur e
pi ts
a nd
f ou
nd m
as se
s of
m ag
go ts
. A ft
er
de te
rm in
in g
th at
t he
s itu
at io
n co
ns tit
ut ed
a p
ub lic
h ea
lth
nu is
an ce
, t he
P H
N s
uc ce
ss fu
lly w
or ke
d w
ith t
he b
us in
es s
ow ne
rs t
o fin
d a
so lu
tio n
th at
in vo
lv ed
t he
d ry
in g
of m
an ur
e to
p re
ve nt
t he
m ag
go ts
f ro
m s
ur vi
vi ng
.
A P
H N
r ec
ei ve
d a
re fe
rr al
r eg
ar di
ng t
he s
af et
y of
a n
80 -y
ea r-
ol d
w om
an li
vi ng
a lo
ne o
n a
lit te
re d
fa rm
s ite
. T he
w
om an
li ve
d w
ith 1
8 ca
ts in
a h
ou se
w ith
ou t
he at
t ha
t w
as a
nk le
-d ee
p w
ith c
an s,
c lo
th es
, a nd
c at
f ec
es . T
he
PH N
in iti
at ed
a v
ul ne
ra bl
e ad
ul t
ev al
ua tio
n th
at r
es ul
te d
in
a “n
ot s
uf fic
ie nt
ly v
ul ne
ra bl
e” fi
nd in
g un
de r
st at
e st
at ut
e.
Th ro
ug h
re pe
at ed
c on
ta ct
s, t
he P
H N
w as
a bl
e to
e st
ab lis
h a
tr us
tin g
re la
tio ns
hi p;
t he
w om
en a
cc ep
te d
a re
fe rr
al f
or
ca re
t o
a ph
ys ic
ia n.
H ow
ev er
, s he
w as
n ot
s uc
ce ss
fu l i
n ch
an gi
ng t
he w
om an
’s li
vi ng
s itu
at io
n.
206 PART 3 Conceptual and Scientific Frameworks
• Case finding locates individuals and families with identified risk factors and connects them with resources.
• Referral and follow-up assists individuals, families, groups, organizations, and/or communities to identify and access necessary resources in order to prevent or resolve problems or concerns.
• Case management optimizes self-care capabilities of indi- viduals and families and the capacity of systems and com- munities to coordinate and provide services.
• Delegated functions are direct care tasks a registered profes- sional nurse carries out under the authority of a health care practitioner as allowed by law. Delegated functions also include any direct care tasks a registered professional nurse entrusts to other appropriate personnel to perform.
• Health teaching communicates facts, ideas, and skills that change knowledge, attitudes, values, beliefs, behaviors, and practices of individuals, families, systems, and/or communi- ties (Box 9-3).
• Counseling establishes an interpersonal relationship with a community, system, family, or individual intended to increase or enhance their capacity for self-care and coping. Counsel- ing engages the community, system, family, or individual at an emotional level.
• Consultation seeks information and generates optional solutions to perceived problems or issues through interactive problem solving with a community, system, family, or indi- vidual. The community, system, family, or individual selects and acts on the option best meeting the circumstances.
• Collaboration commits two or more persons or organiza- tions to achieve a common goal through enhancing the capacity of one or more of the members to promote and protect health (Freshman et al, 2010; Henneman et al, 1995).
• Coalition building promotes and develops alliances among organizations or constituencies for a common purpose. It builds linkages, solves problems, and/or enhances local leadership to address health concerns.
• Health teaching communicates facts, ideas, and skills that change knowl- edge, attitudes, values, beliefs, behaviors, practices, and skills of individu- als, families, systems, and/or communities.
• Knowledge is familiarity, awareness, or understanding gained through experience or study.
• Attitude is a relatively constant feeling, predisposition, or set of beliefs directed toward an object, person, or situation, usually in judgment of something as good or bad, positive or negative.
• Value is a core guide to action. • Belief is a statement or sense, declared or implied, intellectually and/or
emotionally accepted as true by a person or group. • Behavior is an action that has a specific frequency, duration, and purpose,
whether conscious or unconscious. • Practice is the act or process of doing something or the habitual or custom-
ary performance of an action. • Skill is proficiency, facility, or dexterity that is acquired or developed
through training or experience.
BOX 9-3 Health Teaching FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES Targeted competency: Client-centered care Knowledge: Integrate understanding of multiple dimensions of client-
centered care including communication, information, and education. Skills: Communicate values, preferences, and expressed needs to all
members of the team Attitudes: Values seeing health care situation through the client’s health Question: The Quad Council competency, community dimensions of practice,
supports the application of the Intervention Wheel’s PHN intervention of community organizing. The Quad Council suggests beginning PHN’s partici- pate effectively in activities that facilitate community involvement.
A statewide behavioral risk survey was conducted by the state health department. The survey shows that in your community there is still a high rate of smoking among the population. What types of activities could be planned to identify common goals among the population and the health care system? How could you participate? What might your role be in resource mobilization and development of strategies to be implemented for reaching goals?
• Community organizing helps community groups to iden- tify common problems or goals, mobilize resources, and develop and implement strategies for reaching the goals they collectively have set (Bezboruah, 2013; Minkler, 2012).
• Advocacy pleads someone’s cause or acts on someone’s behalf, with a focus on developing the capacity of the com- munity, system, individual, or family to plead their own cause or act on their own behalf.
• Social marketing uses commercial marketing principles and technologies for programs designed to influence the knowl- edge, attitudes, values, beliefs, behaviors, and practices of the population of interest.
• Policy development places health issues on decision makers’ agendas, acquires a plan of resolution, and determines needed resources. Policy development results in laws, rules, regulations, ordinances, and policies.
• Policy enforcement compels others to comply with the laws, rules, regulations, ordinances, and policies created in con- junction with policy development.
In addition to the definition and examples, each intervention has basic steps for implementation at each of the three levels (i.e., community, systems, and individual/family) as well as a listing of best practices for each intervention. The basic steps are intended as a guide for the novice public health nurse or the experienced public health nurse wishing to review his/her effec- tiveness. Box 9-4 describes the basic steps of the counseling intervention.
The best practices are provided as a resource for PHNs seeking excellence in implementing the interventions. They were constructed by a panel of expert public health nursing educators and practitioners after a thorough analysis of the literature. Many practices of public health nursing are either not researched or, if they are researched, not published. The process used to develop this model considered this limitation and met the challenge with the use of expert practitioners
207CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
McGuire S, Eigsti Gerber D, Clemen-Stone S: Meeting the diverse needs of clients in the community: effective use of the referral process. Nursing Outlook 44(5):218–222, 1996; Stanhope M, Lancaster J: Com- munity health nursing: process and practice for promoting health. St Louis, 1984, Mosby, p 357; Will M: Referral: a process, not a form. Nursing 77:44–55, 1977; Wolff I: Referral—a process and a skill. Nurs Outlook 10(4):253–262, 1962.
Best Practice Successful implementation is increased when the: • PHN respects the client’s right to refuse a referral. • PHN develops referrals that are timely, merited, practical, tailored to the
client, client controlled, and coordinated. • Client is an active participant in the process and the PHN involves family
members as appropriate. • PHN establishes a relationship based on trust, respect, caring, and
listening. • PHN allows for client dependency in the client–PHN relationship until the
client’s self-care capacity sufficiently develops. • PHN develops comprehensive, seamless, client-sensitive resources that
routinely monitor their own systems for barriers.
Evidence McGuire, Eigsti Gerber, Clemen-Stone, 1996 (expert opinion) Stanhope and Lancaster, 1984 (text) Will, 1977 (expert opinion) Wolff, 1962 (expert opinion)
Expert Panel Recommendation McGuire, Eigsti Gerber, Clemen-Stone, 1996 (expert opinion) Stanhope and Lancaster, 1984 (text) Will, 1977 (expert opinion) Wolff, 1962 (expert opinion)
BOX 9-5 Best Practices for the Intervention of Referral and Follow-up
Health Nursing Scope and Standards of Practice (ANA, 2007, 2012).
• The Los Angeles County Department of Health Services used the Intervention Wheel in their initiative to reinvigorate public health nursing practice—orientation, practice stan- dards, documentation, recruitment, and retention—for their 500 public health nurse generalists and specialists (LACDHS, 2002; Avilla and Smith, 2003; Smith and Bazini- Barakat, 2003).
• The Massachusetts Association of Public Health Nurses used the Intervention Wheel as the framework for their state “Leadership Guide and Resource Manual” (Massachusetts Association of Public Health Nurses, 2009).
• PHNs in the Shiprock Service Unit of the Indian Health Service use the Wheel in their practice and adapted it to reflect the Navajo culture. The Navajo Intervention Wheel (Figure 9-4) is presented as a Navajo basket and uses the traditional colors of the Navajo nation.
• From 2001 to 2005, the Intervention Wheel served as the frame- work for a Division of Nursing grant that successfully brought together education and practice communities to collaboratively redesign the public health nursing student’s clinical experience. Several of these collaboratives remain viable and active.
Working alone or with others, PHNs: 1. Meet the “client”—the individual, family, system, or community. 2. Establish rapport by listening and attending to what the client is saying
and how it is said.†
3. Explore the issues. 4. Gain the client’s perception of the nature and cause of the identified
problem or issue and what needs to change.‡
5. Identify priorities. 6. Gain the client’s perspective on the urgency or importance of the issues;
negotiate the order in which they will be addressed. 7. Establish the emotional context. 8. Explore, with the client, emotional responses to the problem or issue. 9. Identify alternative solutions.
10. Establish, with the client, different ways to achieve the desired outcomes and anticipate what would have to change in order for this to happen.
11. Agree on a contract. 12. Negotiate, with the client, a plan for the nature, frequency, timing, and
end point of the interactions. 13. Support the individual, family, system, or community through the change. 14. Provide reinforcement and continuing motivation to complete the change
process. 15. Bring closure when the PHN and client mutually agree that the desired
outcomes are achieved.
BOX 9-4 Basic Steps for the Intervention of Counseling*
*Complete version available at http://www.health.state.mn.us/divs/cfh/ ophp/resources/docs/phinterventionsmanual2001.pdf. †Modifi ed from Burnard P: Counseling: a guide to practice in nursing , Oxford, England, 1992, Butterworth-Heineman. ‡Understanding the client’s cultural or ethnic context is important to perception. For further information, please see Sue DW: Counseling the Culturally Diverse: Theory and Practice, ed. 6, New Jersey, 2013, Wiley.
and educators. The best practices are a combination of research and other evidence from the literature and/or the collective wisdom of experts. Box 9-5 outlines an example of a set of best practices for the intervention of referral and follow-up, some supported by evidence and others supported by practice expertise.
ADOPTION OF THE INTERVENTION WHEEL IN PRACTICE, EDUCATION, AND MANAGEMENT The speed at which the Intervention Wheel was adopted may be attributed to the balance between its practice base and its evidence-based support. The Intervention Wheel has led to numerous innovations in practice and education since it was first published in 1998 (Keller et al, 2004a). Further dissemina- tion of the model has occurred through the hundreds of gradu- ate and undergraduate schools of nursing that use the Intervention Wheel as a framework for teaching public health nursing.
The Intervention Wheel has been widely adopted as a frame- work for public health nursing practice: • In 2007, the American Nurses Association officially recog-
nized the Intervention Wheel as a framework in the Public
208 PART 3 Conceptual and Scientific Frameworks
FIG 9-4 Navajo Wheel. (Courtesy Shiprock Service Unit, Shiprock, NM, Indian Health Service.)
Community-Focuse d
Systems-Focused
Individual-Focused
Po pu
lati on-B
ased
Po pu
lati on-B
ased
Po pu
lati on-B
ased
The Navajo basket represents mother earth (the tan area), the black design represents the four sacred mountains that surround the Navajo Nation, and the red area represents the rainbow, which symbolizes harmony. In Navajo philosophy, one should not enclose oneself without an opening. Therefore, the basket has an opening, or doorway, to receive all that is good/positive, and allow all the bad/negative to exit.
Neva Kayaani
C ase finding
Disease and
health event
investigation
Surveillance
O utreach
S cre
e n
in g
R eferral and
follow -up
Case
m anagem
ent
Delegated
functions
Health teachingC
oun seli
ng
Co ns
ul ta
tio n
C ol
la bo
ra tio
n C
o a lit
io n
b u ild
in g
C om
m un
ity or
ga ni
zi ng
Ad vo
ca cy
Soc ial
mar ketin
g
Policy development and
intercement
• PHN consultants at the Wisconsin Department of Health used the Intervention Wheel to differentiate levels of nursing practice in local health departments related to educational preparation and to outline the role of the associate degree and diploma nurse in public health. (Although the baccalaureate degree is the accepted stan- dard for entry to public health nursing practice, shortages of baccalaureate prepared nurses sometimes result in
health departments employing associate degree and diploma nurses.)
• PHNs at the St. Paul-Ramsey County (MN) Department of Health used the Intervention Wheel to illustrate the activities of their refugee health program. Their display (Figure 9-5) identified the most common interventions implemented with the refugee population and illustrated each interven- tion with a photograph.
209CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
FIG 9-5 St. Paul-Ramsey County Public Health Family Health International Team. (Courtesy Sophia Emang, Public Health Nurse, St. Paul-Ramsey.)
Baisch MJ: A systematic method to document population-level nursing interventions in an electronic health system. Public Health Nursing 29(4):352–360, 2012.
Nursing informatics is relatively new for many public health departments in the United States. Community health nurses typically use the Omaha System to document their practice; however, this system is used by various disciplines working in public health. The Omaha System taxonomy is the conceptual framework for the Automated Community Health Information System (ACHIS), which is the longstanding electronic data system used to document nursing practice in community nursing centers. However, researchers identified a gap in the Omaha System and ACHIS in that both were better at capturing individual-level interventions than community- and system-level interventions. Therefore, researchers in this study incorporated interventions from the Inter- vention Wheel into the existing electronic record system in hopes that com- munity- and system-level activities could be documented better. Nine Wheel interventions were added to the ACHIS: “Policy Development,” “Social Mar- keting,” “Advocacy,” “Community Organizing,” “Coalition Building,” “Collabo- ration,” “Consultation,” “Screening,” and “Outreach.” The newly expanded system was piloted by two community/public health nurses and the data indicated the system was successful in capturing a broad scope of the nurses’ practice. The researchers documented their methodology so that other admin- istrators in public health may replicate the adaptation of the electronic health record for community nursing practice.
Nurse Use By having a systematic data collection method, better evaluation of processes and outcomes of public health nursing and other public health professionals would be possible. Such data would also aid in providing evidence-based decision support for public health practice that could be used for quality improvement, funding proposals, and policy decisions.
EVIDENCE-BASED PRACTICE BOX
The Wheel provides a meaningful frame of reference and common language for staff to communicate about the nature of their work and is used in orientation programs in several states. • The Alaskan Public Health Nurse Leadership Academy uses
the Intervention Wheel to familiarize new staff with population-based practice (http://www.hss.state.ak.us/dph/ nursing/PFDs/Troshynski-Academy.pdf ).
• Several universities have developed online applications of the Intervention Wheel, including the Virginia Common- wealth University (http://www.people.vcu.edu/~elmiles/ interventions/) and the University of Minnesota School of Public Health (http://www.sph.umn.edu/ce/tools/wheel.asp).
The concepts of the model have also been used internation- ally. The Intervention Wheel was used in public health nursing projects in New Zealand and Ireland. The Institute of Primary Health & Ambulatory Care in the Townsville Health Service District, Queensland Health in Australia used the Intervention Wheel to develop a set of competencies (http:// www.health.qld.gov.au/townsville/Clinicians/default.asp).
The significance of the contributions of the Intervention Wheel has been recognized by the nursing community. The authors of the Intervention Wheel received Sigma Theta Tau International and National Pinnacle Awards for Research Dis- semination and a Creative Achievement Award from the Ameri- can Public Health Association, Section of Public Health Nursing.
HEALTHY PEOPLE 2020 The objectives chosen to be highlighted in this chapter show how many of the interventions from the Wheel are applied in the Healthy People 2020 document. It further indicates how appropriate these interventions are to improving the health of individuals, populations, and communities, thus improving the health of the nation.
APPLYING THE NURSING PROCESS IN PUBLIC HEALTH NURSING PRACTICE PHNs use the nursing process at all levels of practice. PHNs must customize the components of the nursing process (assess- ment, diagnosis, planning, implementation, evaluation) to the three levels of practice. See Table 9-2 for an outline of the nursing process at the community, systems, and individual/ family levels of practice.
APPLYING THE PROCESS AT THE INDIVIDUAL/FAMILY LEVEL Community Assessment During a health department’s community assessment process, information on the health status of children was obtained from the following: • Staff public health nurses who worked with families in
clinics, schools, and homes • Community partners who worked with families, including
health care providers, mental health workers, social workers, and school personnel
210 PART 3 Conceptual and Scientific Frameworks
• Preschool screening program data on the number of young children with developmental delays and problems for the past 5 years
• Data from the county social services department on the number of substantiated child maltreatment and neglect cases for the past 5 years
PHNs participated in the community meeting that prioritized the long list of issues identified in the community assessment. One of the top community priorities that emerged was the fol- lowing: Decreasing numbers of children at risk for delayed devel- opment, injury, and disease because of inadequate parenting by parents experiencing mental health problems.
The community health plan developed a goal to decrease the number of children with delayed development, injury, and disease attributable to inadequate parenting. The local health department, with the support of community partners, decided they would address this priority through a home visiting strat- egy. Home visiting enhances a child’s environment and increases the capacity of parents to behave appropriately. Although parental mental health problems are a major source of stress for children, this vulnerability can be tempered through support from others and a caring environment.
Home visiting to families is an example of practice at the individual level because the interventions are delivered to fami- lies with the goal of changing parental knowledge, attitudes, practices, and behaviors.
Public Health Nursing Process: Assessment of a Family A PHN received a referral on Tyler, age 3. He was the only child of Ashley, a 19-year-old single mother with severe depression. Ashley lived in an old rented house in the small town where she grew up. She had a boyfriend who was not Tyler’s biological father. Ashley survived on limited public assistance and occa- sional help from her mom.
The PHN assessed the resilience, assets, and protective factors as well as the problems, deficits, and health risks of this family. The PHN also tried to elicit Ashley’s perception of her situation, which was difficult because of her depressed state. This step is important because often a client’s perception of their problems or strengths may not align with the PHN’s professional assessment.
All public health nursing practice is relationship based, regardless of level of practice. An established trust relationship increases the likelihood of a successful outcome. One of the PHN’s main priorities was to establish a trusting relationship with Ashley. This was difficult because Ashley was seldom out of bed when the PHN arrived, but the PHN persisted and even- tually developed the relationship.
Public Health Nursing Process: Diagnosis • Diagnosis: Increased risk for delayed development, injury,
and disease because of inadequate parenting by a primary parent experiencing depression
HEALTHY PEOPLE 2020
Healthy People 2020 identifies action steps for 38 health priorities that the United States must take to achieve better population health by the year 2020. The 500 recommended objectives offer numerous opportunities for public health nurses to contribute through implementing interventions at any or all of the levels. Here are a few examples: • AH-8: Adolescent Health Objective: Increase the proportion of adolescents
who have had a wellness check-up in the past 12 months. PHNs who provide well-child screening services in school settings or local health departments will need well-designed outreach interventions to convince teens that even healthy kids can benefit from check-ups. This will require consulting with parents and groups of teens themselves to identify what “benefits” would attract them and incorporating them into the outreach design. PHNs will also need to collaborate with other health care providers in the community to ensure that diagnostic and treatment services are available for teens who require additional services.
• DH-7: Disability and Secondary Conditions Objective: Reduce the proportion of older adults with disabilities who use inappropriate medications. The case management that PHNs provide to elderly or disabled populations in their communities includes an assessment of clients’ medications to ensure com- pliance with the regimen prescribed by health care providers under delegated functions.
• ECBP-10: Education and Community-Based Programs Objective: Increase the number of community-based organizations providing population-based primary prevention services in the following areas: injury, violence, mental illness, tobacco use, substance abuse, unintended pregnancy, chronic disease programs, nutrition, and physical activity. PHNs may convene coalitions to
address an issue or serve as facilitators or participants of coalitions already organized. For instance, PHNs with expertise in substance use prevention might offer health teaching and consultation to a coalition organized to find ways to reduce substance use during pregnancy. It could also mean the establishment of a new screening and referral system among providers to identify early pregnant women and their partners struggling with drug or alcohol use and link with resources for treatment.
• EH-8.1: Environmental Health Objective: Eliminate elevated blood lead levels in children. PHNs providing services to families with young children assess (surveillance) the living conditions for lead. Housing constructed prior to 1978, the year lead-based paint for residential use was banned, is particularly suspect. Depending on the community’s housing and lead-abatement codes, PHNs may provide health teaching and counseling to the families regarding the dangers of lead exposure to small children or provide advocacy on their behalf with housing authorities.
• MICH-18: Maternal Infant and Child Health Objective: Decrease postpartum relapse of smoking among women who quit smoking during pregnancy. A recent systematic review of the literature on effective strategies to prevent postpartum smoking relapse concluded that PHNs would more likely be effec- tive in assisting new mothers to resist returning to smoking and exposing their child to second-hand smoke if they: (1) consistently used the U.S. Pre- ventive Services Task Forces “5 A’s” when counseling with smokers, (2) tailored health teaching regarding the dangers of second-hand smoke to the client’s specific situation, (3) empowered the mother and family members to adopt a smoke-free home smoking policy, and (4) advocated for the impor- tance of partners also quitting (Ashford et al, 2009).
From Ashford K, Hahn E, Hall L, et al: Postpartum smoking relapse and secondhand smoke, Public Health Rep 124:515-526, 2009.
211CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
• Population at risk: Young children who are being parented by a primary parent who is experiencing mental health problems
• Prevention level: Secondary prevention, because the families have an identified risk
Public Health Nursing Process: Planning (Including Selection of Interventions) Based on the assessment of this family, the PHN negotiated with Ashley to establish meaningful, measurable, achievable inter- mediate goals. In families experiencing mental illness (actually, in most families), behavior change occurs in very small steps. For this family, client goals included the following outcomes: • Ashley will get out of bed at least 3 days in the week. • Tyler will be dressed when the PHN arrives. • Tyler will get to the bus on time 3 days in a row. • The clutter will be cleaned off the steps. • Ashley will call to make a doctor’s appointment for Tyler’s
well-child check. • Ashley will use “time outs” instead of spanking. • Ashley will read a story to Tyler twice a week. (Intermediate
indicators at the individual level of practice are changes in an individual’s knowledge, attitudes, motivation, beliefs, values, skills, practices, and behavior that lead to desired changes in health status.) The PHN also selected meaningful, measurable outcome
health status indicators to measure the impact of the interven- tions on population health. Examples include no signs or reports of child maltreatment; child regularly attends preschool; child receives well-child examinations according to recom- mended schedule; child’s immunizations are up to date; the family seeks medical care for acute illness as needed and does not seek medical care inappropriately; and child falls within normal limits on developmental tests.
The PHN selected the interventions, which included collabora- tion, case management, health teaching, delegated functions, and referral and follow-up. In selecting these interventions, the PHN considered evidence of effectiveness, political support, acceptability to the family, cost-effectiveness, legality, ethics, greatest potential for successful outcome, and level of prevention.
Public Health Nursing Process: Implementation The PHN determined the sequence and frequency of her home visits based on her assessment of each family. Some families received home visits once a week, some twice a week, and others twice a month. The PHN visited this family weekly in the begin- ning and then spaced the home visits farther apart. She used the following interventions.
Collaboration The PHN identified and involved as many alternative caregivers in Tyler’s care as possible, including Tyler’s biological father, aunt and uncle, and grandparents as well as Ashley’s boyfriend.
Case Management The PHN arranged childcare services and coordinated trans- portation for Tyler to spend significant portions of his day outside of the home.
Health Teaching The PHN provided information on child growth and develop- ment, nutrition, immunizations, safety, medical and dental care, and discipline to Ashley and the alternative caregivers.
Delegated Functions (Public Health Nurse to Paraprofessional) The PHN placed a family health aide in the home to provide role modeling for Ashley. As part of this intervention, the PHN monitored and supervised the aide.
Referral and Follow-up Based on the assessment, the PHN referred Ashley to commu- nity resources and services that included early childhood ser- vices, legal aid, food stamps, mental health counselors, and transportation.
Public Health Nursing Process: Evaluation The PHN reassessed and modified her plan at each home visit. She provided regular feedback to Ashley and the other caregivers on their progress. The PHN documented her results and com- pared them with the selected indicators. After 6 months of home visits, Ashley got out of bed most days of the week but rarely got dressed. Ashley was more successful in getting Tyler to the bus and to preschool. The family health aide helped Ashley clean the clutter off the steps. Ashley scheduled a doctor’s appointment for Tyler’s well-child visit but failed to get him to the appoint- ment. Ashley was successful in learning to substitute “time outs” for spanking, with the help of the family aide. Tyler exhibited no signs of child maltreatment. He attended preschool regularly. Tyler was still behind on his immunizations because of the missed appointment. All of Tyler’s developmental tests were within normal limits.
The PHN reported her results to her supervisor during their regular supervisory meetings. The PHN also talked with other PHNs who worked with similar families about common issues and best practices, and applied what she had learned to her practice.
APPLYING THE PUBLIC HEALTH NURSING PROCESS AT THE COMMUNITY LEVEL OF PRACTICE SCENARIO Note: At the community level of practice, the community assess- ment, program planning, and evaluation process is the public health nursing process.
Community Assessment (Public Health Nursing Process: Assessment) Childhood obesity is a rapidly growing community problem. An increasing number of children ages 2 to 11 are considered overweight, as defined by a body mass index (BMI) at or above the 95th percentile (based on CDC Growth Charts; Ogden et al, 2010). The 2011-2012 National Health and Nutrition Examination Survey data estimated that 9.5% of boys and 7.2% of girls aged 2 to 5 were obese in the United
212 PART 3 Conceptual and Scientific Frameworks
FIG 9-6 LANA the Iguana. (Used with permission from Min- nesota Department of Health, Center for Health Promotion.)
States. Among children aged 6 to 11 years, the percentages were 16.4% for boys and 19.1% for girls (CDC, 2014). Childhood obesity and hyper plasia of adipose cells are linked to obesity later in life.
A health department recognized the well-established asso- ciation between overweight and obesity in childhood and the development of both continuing overweight/obesity as adults and a host of chronic diseases (CDC, 2010). In response, the public health nursing director of a health department con- vened a childhood obesity prevention summit. Over 80 partici- pants representing area health care providers, schools, child care, and governmental and community-based health organiza- tions met for an entire day to discuss the problem and frame solutions.
Community Diagnosis (Public Health Nursing Process: Diagnosis) The percentage of children aged 2 to 11 who are overweight or obese is unacceptable and threatens the future health status of the community. • Population of interest: Children aged 2 to 11 • Level of prevention: Primary prevention
Community Action Plan (Public Health Nursing Process: Planning, Including Selection of Interventions) At the conclusion of the summit, each organization repre- sented committed to promoting healthy eating and physical activity habits for all residents, with an emphasis on parents of young children. The health department recognized that a substantial portion of a child’s caloric intake occurs at child care.
Based on its assessment of the community, the health depart- ment initiated a 24-week evidence-based program that pro- motes the consumption of fruits and vegetables by young children through intervention with licensed home childcare providers. “LANA the Iguana” (Learning About Nutrition Through Activities) encourages eating eight targeted fruits and vegetables: broccoli, sweet red pepper, cherry tomatoes, apri- cots, sugar snap peas, kiwi, sweet potatoes, and strawberries (Figure 9-6). These fruits and vegetables were featured in activi- ties throughout the program related to menu changes, class- room activities, and family involvement.
Menu Changes Home childcare providers increased opportunities for children to eat more fruits and vegetables by serving the targeted fruits and vegetables on the menu, alternating four for one week and four the next. Fruits and vegetables were served as the morning and afternoon snack every day.
Classroom Activities Home childcare providers increased children’s preference for and knowledge of fruits and vegetables by featuring one of the targeted fruits and vegetables each week throughout the program. During that week, the featured fruit or vegetable was
the focus of tasting and cooking activities as well as the topic of stories and games.
Family Involvement Home childcare providers gave families information about the program and activities to do at home. These included quick and easy kid-tested recipes and take-home fruit/vegetable tasting kits.
The PHNs selected their interventions, which included con- sultation, health teaching, social marketing, collaboration, and surveillance. In selecting these interventions, the PHNs consid- ered evidence of effectiveness, acceptability to community, cost- effectiveness, legality, ethics, and greatest potential for successful outcome.
Community Implementation Plan (Public Health Nursing Process: Implementation) 1. Social marketing: LANA the Iguana was a social marketing
program. It incorporated a range of age-appropriate social marketing techniques including iguana puppets and story- books, recipe cards, and activities. The PHNs promoted retention by providing home childcare providers with incen- tives, including two grocery store gift cards and plastic fruit/ vegetable toys for the children. They worked with librarians to place LANA the Iguana kits (comprised of iguana puppets, activities, and storybooks) in the local library for parents to check out. PHNs also donned the LANA the Iguana costume to implement the curriculum directly to children as well as train the home childcare providers and parents.
2. Health teaching: The PHNs trained the home childcare pro- viders on the LANA curriculum to ensure fidelity to the program.
3. Consultation: The public health nurses consulted with home childcare providers about the program on a regular and ongoing basis.
4. Collaboration: PHNs collaborated with health educators to develop and distribute LANA materials, including a curricu-
213CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
lum guide, recipe books, storybooks, parent newsletters, and LANA the Iguana puppets. They also collaborated with public health nursing students to collect program eval- uation data.
5. Surveillance: The PHNs collected data on the consumption of fruits and vegetables in the home childcare setting.
Community Evaluation (Public Health Nursing Process: Evaluation) Follow-up surveys with the county’s 75 licensed home childcare providers, who served about 500 children, found that 67% of children were more or much more likely to eat fruits and 78% were more likely to eat vegetables; 92% of children were more likely to try new foods; and 76% of providers offered fruits and vegetables more often at snack time (Dakota County, 2010). Establishing healthy eating habits among young children will lead to reduced levels of obesity.
APPLYING THE PUBLIC HEALTH NURSING PROCESS TO A SYSTEMS LEVEL OF PRACTICE SCENARIO Health departments conduct assessments of community health status, a core function of public health, on an ongoing basis. The identification of some community problems emerges out of practice, rather than through a formal community assess- ment. This scenario is such an example.
Public Health Nursing Process: Assessment For several years, PHNs had been very concerned about the poor living conditions in an apartment complex in which many of their clients lived. The walls were moldy, the carpet was unclean and deteriorated, and closet doors had fallen off their runners and struck children living in the apartment. The PHNs were suspect of the required cash payments that the manager required for repairs, extra security deposits, and increased rent after the birth of a baby.
Many of the tenants were undocumented Latinos and tried not to create problems. Most could not speak or read English well, and often signed lease agreements without taking note of damage or existing problems in the apartment and were there- fore blamed for them. In addition, the manager blamed the tenants for the mold on the walls, implying that their cooking created too much humidity. Citing these “problems,” the manager often gave bad references for the tenants, which made it difficult for them to move.
Over the years, the PHNs had diligently worked with their clients to correct these problems, but with little success. When the PHNs met with the manager to discuss the issues, he became angry. As a result, the manager had the PHNs’ cars towed when- ever he saw them in the parking lot. The PHNs also had sought help from city officials, but the officials had no legal recourse to remedy the situation.
Finally, several events occurred that spurred the PHNs to action. One of the PHNs found a nonfunctioning smoke detec- tor in an apartment during a home safety check. The family
reported that the apartment manager had dismantled the smoke detector and left it that way. At the same time, another PHN was working with a family that was trying to move to a new, safer, cleaner apartment. The family had found a new apart- ment but could not move because the manager gave them a bad (although false) reference. The family no longer had a lease, but the manager said they could not move. The PHNs realized that there were many complex legal issues related to the living condi- tions of their clients.
Public Health Nursing Process: Diagnosis • Diagnosis: Families at risk of illness and injury because of
hazardous housing and abuse of legal rights • Population at risk: Families living in hazardous housing in
an apartment complex • Prevention level: Secondary, because families are at risk for
injury and illness
Public Health Nursing Process: Planning (Including Selection of Interventions) At the systems level of practice, the goal is to change policies, laws, and structures. The PHNs’ goals were to enforce the tenants’ legal rights and improve the living conditions in the apartment complex. Their plan was to seek advice from a housing advocate service and connect their clients with legal counsel. Before they could pursue this plan, the PHNs consulted with their supervisor. Their supervisor supported their decision but also had to clear the plan with the health department director and the city manager.
The PHNs selected their interventions, which included con- sultation, referral and follow-up, advocacy, policy development, and surveillance. In selecting these interventions, the PHNs considered evidence of effectiveness, political support, accept- ability to the family, cost-effectiveness, legality, ethics, greatest potential for a successful outcome, non-duplication, and level of prevention.
Public Health Nursing Process: Implementation The PHNs worked with the tenants and the housing advocacy service to implement the following interventions.
Consultation The PHNs consulted with attorneys at a housing advocate service.
Referral and Follow-up The attorneys informed the PHNs that they needed to hear directly from the tenants in order to proceed. The PHNs set up a meeting time between the tenants and the attorneys from the housing advocate service.
Advocacy The PHNs arranged for their public health interpreter to go door to door with an advocate from the housing service to invite tenants to the meeting. They also arranged for the interpreter to attend the meeting to interpret each family’s concerns. The PHNs strongly encouraged all of the tenants to attend.
214 PART 3 Conceptual and Scientific Frameworks
LINKING CONTENT TO PRACTICE
The discussions of the application of the nursing process to a variety of clients beginning on page 209 and Tables 9-1 and 9-2 provide numerous examples of how the content in this chapter is applied in practice. Please review these for examples of how you may apply this model in your practice.
Policy Development The public health nurses worked with the attorneys from the housing advocate service to develop the meeting agenda.
Surveillance The PHNs continued to conduct ongoing monitoring of living conditions in the apartment complex.
Public Health Nursing Process: Evaluation Many of the tenants attended the meeting. As a result of the meeting, the attorney chose to have the rent paid to the court and put in escrow until a legal determination could be
P R A C T I C E A P P L I C A T I O N Outreach locates populations of interest or populations at risk and provides information about the nature of the concern, what can be done about it, and how services can be obtained. Out- reach activities may be directed at whole communities, at tar- geted populations within those communities, and/or at systems that impact the community’s health. Outreach success is deter- mined by the proportion of those considered at risk that receive the information and act on it.
The chance of a 20-year-old woman developing breast cancer within the next 10 years is 1 in 1681. At age 30, a woman’s chance of developing breast cancer within the next 10 years is 1 in 232; at age 40, it is 1 in 69; at age 50, it is 1 in 42; at age 60, it is 1 in 29; and at age 70, it is 1 in 27 (Susan G. Komen Foundation, 2013).
A health system decided to offer free mammograms in rec- ognition of National Breast Cancer Month. They sponsored a
mobile mammography van at a large shopping mall every Sat- urday in October. The van offered mammograms to everyone, regardless of age. The health system advertised the service by placing windshield flyers on all the cars in the shopping mall parking lot. The van provided 180 mammograms, mostly to women in their 30s who had health insurance that covered preventive services. 1. What is the population most at risk of breast cancer? 2. Did the mammograms in the parking lot reach this
population? 3. What types of outreach would public health nurses conduct
to reach the population at risk? Answers can be found on the Evolve site.
K E Y P O I N T S • In these times of change, the public health system is con-
stantly challenged to keep focused on the health of populations.
• The Intervention Wheel is a conceptual framework that has proved to be a useful model in defining population-based practice and explaining how it contributes to improving population health.
• The Wheel depicts how public health improves population health through interventions with communities, the indi- viduals and families that comprise communities, and the systems that impact the health of communities.
• The Wheel serves as a model for practice in many state and local health departments.
• The Wheel is based on 10 assumptions. • The Intervention Wheel encompasses 17 interventions. • Other public health members of the interprofessional team
such as nutritionists, health educators, planners, physicians, and epidemiologists also use these interventions.
• Implementing the interventions ultimately contributes to the achievement of the 10 essential public health services.
• The Cornerstones of Public Health Nursing was developed as a companion document to the Intervention Wheel.
• The original version of the Wheel resulted from a grounded theory process carried out by public health nurse consultants at the Minnesota Department of Health in the mid-1990s.
• The interventions were subjected to an extensive review of supporting evidence in the literature.
• The Wheel is a conceptual model. It was conceived as a common language or catalog of general actions used by public health nurses across all practice settings.
• The Intervention Wheel serves as a conceptual model for public health nursing practice and creates a structure for identifying and documenting interventions performed by public health nurses and captures the nature of their work.
• The Wheel has three main components: a population basis, three levels of practice, and 17 interventions.
made. During this process the apartment owner became aware of these issues and dismissed the manager, who was discovered to have been acting fraudulently. A new manager was employed who worked to improve the living conditions of the apartments.
215CHAPTER 9 Population-Based Public Health Nursing Practice: The Intervention Wheel
K E Y P O I N T S — cont’d • The Wheel has led to numerous innovations in practice and
education since the original Intervention Wheel was first published in 1998.
• Public health nurses in the Shiprock Service Unit of the Indian Health Service adapted the Intervention Wheel to reflect the Navajo culture.
• Numerous graduate and undergraduate schools of nursing throughout the United States have adopted the Intervention Wheel as a framework for teaching public health nursing practice.
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C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Describe the three components of the Intervention Wheel.
How do the components relate to each other? Explain how you can apply them to your clinical practice.
2. Go to Chapter 1 and reread the definitions of the core func- tions of public health practice and look at the 10 essential services. How does the Wheel address the core functions? How does it relate to the 10 essential services?
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10
Environmental Health
Barbara Sattler, RN, DrPH, FAAN Dr. Barbara Sattler has a diploma in nursing from Pilgrim State Psychiatric Center School of Nursing, a BS in political science from the University of Baltimore, and the MPH and DrPH from the Johns Hopkins University. She is a Professor at the University of San Francisco. She is a founding member of the Alliance of Nurses for Healthy Environments (www.enviRN.org), a national network of nurses who are addressing the integration of environ- mental health into our nursing education, practice, research, and policy/advocacy efforts. She has been working in the area of environmental health and nursing for three decades and has been involved in issues associated with air, water, food, and products, as well as climate change and energy policies as they relate to human health.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Explain the relationship between the environment and
human health and disease. 2. Understand the key disciplines that inform nurses’ work in
environmental health. 3. Apply the nursing process to the practice of environmental
health.
4. Describe legislative and regulatory policies that have influenced the impact of the environment on health and disease patterns in communities.
5. Explain and compare the environmental health roles and skills for nurses practicing in public health, as well as those practicing in practice settings.
6. Incorporate environmental principles into practice.
K E Y T E R M S agent, p. 222 bioaccumulated, p. 236 biomonitoring, p. 221 climate change, p. 223 compliance, p. 236 consumer confidence reports, p. 228 environment, p. 222 environmental justice, p. 236 environmental standards, p. 236 epidemiologic triangle, p. 222 epidemiology, p. 222 epigenetics, p. 221 geographic information systems, p. 222 host, p. 222 indoor air quality, p. 227 Industrial Hygiene Hierarchy of Controls, p. 232 methylmercury, p. 236
monitoring, p. 236 non–point sources, p. 226 permit, p. 236 permitting, p. 234 persistent bioaccumulative toxins, p. 236 persistent organic pollutants, p. 236 point sources, p. 226 precautionary principle, p. 231 right to know, p. 228 risk assessment, p. 228 risk communication, p. 233 risk management, p. 232 route of exposure, p. 233 toxicants, p. 229 toxicology, p. 221 —See Glossary for definitions
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks—Of special note see the link for these sites:
• Envirotools • www.enviRN.org: Alliance of Nurses for Healthy
Environments • National Library of Medicine online toxicology tutorial
• Case Studies • Glossary • Answers to Practice Application Appendix • Appendix F.3: Comprehensive Occupational and
Environmental Health History
218 PART 3 Conceptual and Scientific Frameworks
forms of pesticides comes with a potential health risk. If you have children and regularly use pesticides in your home, you increase their risk of contracting leukemia. The more you use insecticides, the greater the risk of leukemia (Metayer et al, 2013; Wigle et al, 2009; Turner et al, 2010; Brown, 2004). The childhood risk for leukemia increases if the mother was exposed to pesticides, including occupational exposures (Bailey et al, 2014). Many playing fields where children compete in sports are regularly sprayed with pesticides (Gilden et al, 2012).
In May 2010, the President’s Cancer Panel proclaimed that the contribution environmental carcinogens have made to the burden of cancer in the United States has been grossly underestimated. In addition to the main focus on chemical carcinogens, the panel noted the importance of radiation sources—ionizing and nonionizing. In a letter to President Obama, they wrote: “The Panel urges you most strongly to use the power of your office to remove the carcinogens and other toxins from our food, water, and air that needlessly increase our health care costs, cripple our Nation’s productivity and devas- tate American lives” (President’s Cancer Panel, 2010). With this call came a range of recommendations for reducing the risk of cancer, both through individual choices and through national policy. The recommendations for individuals are found in Resource 10.A on the Evolve resources website.
Cancer is not the only health endpoint of environmental exposures. An estimated 52 million homes in the United States contain some lead-based paint that is associated with risks for premature births, learning disabilities in children, hypertension in adults, and many other health problems. Lead poisoning is a completely preventable disease (Figure 10-1). Of the top 20 environmental pollutants that were reported to the Environ- mental Protection Agency (EPA), nearly three fourths were known or suspected neurotoxins. Thirty million Americans drink water that exceeds one or more of the EPA’s safe drinking
“Environmental health comprises those aspects of human health, including quality of life, that are determined by physical, chemical, biological, social, and psychosocial factors in the environment. It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of present and future generations.”
United Nations University, 1993 (UNU)
An estimated 24% of the global burden of disease and 23% of all deaths can be attributed to environmental factors (WHO, 2015). As nurses there are a number of ways in which we can define our environment. Our homes, schools, workplaces, and communities are the environments in which most of us can be found at any given time. Each location holds potential health risks. As nurses, who are among the most trusted conveyors of information to the public, it is our responsibility to understand as much as possible about these risks—how to assess them, how to eliminate or reduce them, how to communicate and educate about them, and how to advocate for policies that support healthy environments.
We can also divide and examine the environment from the perspective of the media in which environmental degradation takes place: air, water, soil, and food. And a third approach would be to divide environmental exposures into categories: biological, chemical, and radiological. In this chapter we will look at the environment as comprehensively as possible and consider the roles that nurses can have in assessing and address- ing environmental health.
Environmental exposures are rarely limited to one location or to one source. For example, the broad category of pesticides includes the insecticides we may use in our homes, the herbi- cides we may use in our gardens, the pesticide residues on fruits and vegetables, and our antimicrobial soaps. Each of these
C H A P T E R O U T L I N E Healthy People 2020 Objectives for Environmental Health Historical Context Environmental Health Sciences
Toxicology Epidemiology Geographic Information Systems Multidisciplinary Approaches
Climate Change Environmental Health Assessments
Information Sources Applying the Nursing Process to Environmental Health
Individual Environmental Exposure History Community-wide Environmental Health Assessment Tools
Environmental Exposure by Media Air Water Land and Soil Food
Right to Know Risk Assessment Vulnerable Populations
Children’s Environmental Health Precautionary Principle Environmental Health Risk Reduction
Industrial Hygiene Hierarchy of Controls Risk Communication
Governmental Environmental Protection Policy and Advocacy
Environmental Justice and Environmental Health Disparities
Environmental Health Threats from the Health Care Industry: New Opportunities for Advocacy
Referral Resources Roles for Nurses in Environmental Health
219CHAPTER 10 Environmental Health
lead-based paint because it is most likely found in homes built before 1978, when the use of lead was banned in household paint.) Is the paint chipping or peeling? Are any of your appli- ances or heat sources producing unhealthy levels of carbon monoxide? Have you checked your home for radon, the second largest cause of lung cancer in the United States? How about your workplace? Do you eat fish on a regular basis? (Some fish can have unhealthy levels of mercury.) A more comprehensive home assessment tool can be found in the Resources.
water standards, and 50% of Americans live in an area that exceeds current national ambient air quality standards. When these standards are exceeded, there is an increased risk to the public for a wide range of health effects.
Although food labeling includes nutrition information, there is no requirement to label whether pesticides are used in the food production; whether nontherapeutic antibiotics were given to the livestock, poultry, or farmed fish; the presence of genetically modified organisms (GMOs) in a product; or whether recombinant bovine growth hormone (rBGH) was given to the dairy cows. Nurses have declared that the “right to know” about potentially hazardous exposures is one of the basic principles of environmental health (see Box 10-1). Nurses have a range of potential public health responsibilities in protecting the public from exposures and environmental health risks (ANA 2007).
A range of influences including genetics, socioeconomic status, and environmental exposures impact environmental health. In evaluating environmental exposures in a home, nurses’ assessments can begin with a set of questions: What exposures can you identify in your own home? Do you use pesticides? Does your home have lead-based paint? (The age of a home is a good proxy for identifying the presence of
FIG 10-1 Although lead is no longer allowed in house paint, over 34 million homes in the United States have lead-based paint U.S. Department of Housing and Urban Development (US DHUD, 2011). Pregnant women and parents who live in homes built before 1978 should be encouraged to have their homes tested for lead-based paint dust. (From State of Hawaii Depart- ment of Public Health. Available at http://hawaii.gov/health/ environmental/noise/asbestoslead/images2/child.jpg. Accessed December 15, 2010.)
LINKING CONTENT TO PRACTICE
The Council on Linkages Between Academic and Public Health Practice, 2010 a key document that guides practice in both nursing and public health. Specifi- cally, the core competencies of the Council on Linkages includes, within the domain of public health science skills, a competency that says practitioners will apply “the basic public health sciences (including, but not limited to, environmental health sciences, health services administration, and social and behavioral health sciences) to public health policies and programs.” The Quad Council of Public Health Nursing Organizations (2011) further applies this competency specifically to public health nursing practice by adding that these skills are applied to public health nursing practice, policies, and programs. In 2007, the ANA adopted 10 principles of environmental health. Although all 10 are essential, three are highlighted here. Nurses should know about envi- ronmental health concepts, participate in assessing the quality of the environ- ment in which they practice, and live and use the Precautionary Principle (which is discussed later in the chapter) to guide their work. A third principle points out that healthy environments are sustained through multidisciplinary collaboration, which is a key concept discussed throughout the chapter.
In 2010, the American Nurses Association (ANA) established an environ- mental health standard within the Scope and Standards of Professional Prac- tice that define the profession of nursing. This means that all nurses are now expected to have knowledge of and skills associated with environmental health.
Underpinning many of these organizational decisions to include environmen- tal health in nursing were the recommendations made in the report Nursing, Health and Environment (Pope, Snyder, and Mood, 1995) from the Institute of Medicine (IOM) of the National Academy of Science, which recommended that all nurses have a basic understanding of environmental health principles and integrate these principles into our practice, education, advocacy, policies, and research. In this chapter, we will explore the basic competencies recom- mended by the IOM. Box 10-2 presents the competencies.
BOX 10-1 American Nurses Association’s Principles of Environmental Health for Nursing Practice The ANA calls for all nurses to understand basic environmental health con- cepts, invokes the Precautionary Principle, recognizes the multidisciplinary nature of environmental health, and promotes and supports nurses’ roles in developing and maintaining environmentally healthy workplaces for them- selves and their patients. Principles include knowledge about environmental health and its effect on nursing practice, the Precautionary Principle, nurses’ rights to work in a safe workplace and use materials, products, technology, and practices that reflect an evidence-based approach. Other principles relate to quality assessment of the environment, interdisciplinary work in environ- mental health, involvement in research, and support of nurses who advocate for a safe environment (ANA, 2007).
From American Nurses Association. Principles of environmental health for nursing practice, Silver Spring, MD, 2007.
220 PART 3 Conceptual and Scientific Frameworks
HISTORICAL CONTEXT Historically, nurses and physicians have been taught little about the environment and environmental threats to health. In the IOM report mentioned previously, quotes from Florence Night- ingale are used extensively, not only because she is a recognized symbol of nursing (i.e., the lady with the lamp), but also because of the central focus of environment in her practice and writings. She promoted the use of clean water and safe sanitary conditions and connected these elements to disease prevention. Early in the twentieth century, Lillian Wald, who coined the name “public health nurses,” spent her life improving the environment of the Henry Street neighborhood and encourag- ing her broad network of influential contacts to make changes in the physical environment, as well as social conditions that had direct health impacts. As modern day nurses are rediscover- ing environmental health, they are reintegrating many of the observations and skills that were practiced by early nurse pioneers.
There are still many communities like the ones that Lillian Wald served. Poverty is highly associated with health disparities and is also associated with disproportionately higher environ- mental exposure, which compounds the health disparities. Poverty is linked to living in substandard housing, living closer to hazardous waste sites, working in more hazardous jobs, having poorer nutrition, and having less access to quality health care (particularly preventative services). The term environmen- tal justice refers to the disproportionate environmental expo- sures that poor people and people of color experience in the United States and elsewhere, including lead paint dust exposure, the presence of pests (resulting in increased use of pesticides), and the use of supplemental heating sources that may cause dangerous carbon monoxide exposure. These combined cir- cumstances multiply the risk for health disparities.
It is important to note how we began to understand the relationship between environmental chemical exposures and their potential for harm. There are several ways in which we have historically made such discoveries: • When humans present with signs and symptoms that can be
connected to a specific chemical exposure. This may occur with acute pesticide poisoning or carbon monoxide poison- ing. It often occurs when workers are occupationally exposed. In such instances, the temporal and geographic relationships to the exposures and health effects help to identify health hazards in the environment (e.g., the diagnosis of mesothe- lioma from asbestos exposure).
• When large accidental releases of chemicals occur in a com- munity that contaminate air, water, soil, or food, resulting in health effects. Such events show us how toxic chemicals are to humans and animals. For example, in the Love Canal incident outside of Buffalo, NY, an entire community was affected by hazardous chemicals that were dumped on the land where a housing development was built.
• In rare instances, when human environmental (and occupa- tional) epidemiologic studies have been performed. Through such studies, we have learned about the toxic effects of chemicals.
HEALTHY PEOPLE 2020 OBJECTIVES FOR ENVIRONMENTAL HEALTH Environmental health is one of the priority areas of the Healthy People 2020 objectives. The federal government has long recog- nized the importance of the relationship between environmen- tal risks and the underlying factors contributing to diseases. Selected examples of the Healthy People 2020 environmental health objectives are outlined in the following Healthy People 2020 box (U.S. Department of Health and Human Services, Healthy People 2020, 2010).
HEALTHY PEOPLE 2020
• EH-8.1: Eliminate elevated blood lead levels in children. • EH-9: Minimize the risks to human health and the environment posed by
hazardous sites. • EH-10: Reduce pesticide exposures that result in visits to the health care
facility. • EH-11: Reduce the amount of toxic pollutants released into the environment. • EH-13: Reduce indoor allergen levels. • EH-18: Decrease the number of U.S. homes that are found to have lead-
based paint or related hazards.
Examples of Objectives Related to Environmental Health
From U.S. Department of Health and Human Services: Healthy People 2020. Available at http://www.healthypeople.gov/2020topicsobjectives 2020/default.aspx. Accessed January 1, 2011.
Basic Knowledge and Concepts All nurses should understand the scientific principles and underpinnings of the relationship between individuals or populations and the environment (includ- ing the work environment). This understanding includes the basic mechanism and pathways of exposure to environmental health hazards, basic prevention and control strategies, the interprofessional nature of effective interventions, and the role of research.
Assessment and Referral All nurses should be able to successfully complete an environmental health history, recognize potential environmental hazards and sentinel illnesses, and make appropriate referrals for conditions with probable environmental causes. An essential component is the ability to access and provide information to clients and communities and to locate referral sources.
Advocacy, Ethics, and Risk Communication All nurses should be able to demonstrate knowledge of the role of advocacy (case and class), ethics, and risk communication in client care and community interven- tion with respect to the potential adverse effects of the environment on health.
Legislation and Regulation All nurses should understand the policy framework and major pieces of leg- islation and regulations related to environmental health.
BOX 10-2 General Environmental Health Competencies for Nurses Recommended by the Institute of Medicine in Nursing, Health and the Environment
From Pope AM, Snyder MA, Mood LH, editors: Nursing, health, and environment, Washington, DC, 1995, Institute of Medicine, National Academy Press.
221CHAPTER 10 Environmental Health
of the exposure—over the human life span—can make a differ- ence. For example, during embryonic and fetal development, exposure to toxic chemicals can create immediate harm or create a critical pathway for future disease. Very young children, whose systems are still immature, are also more vulnerable to exposures. In Harm’s Way, an online report by Physicians for Social Responsibility (with associated training materials) describes the neurological damage that several common chemi- cals can cause to developing children (Schettler et al, 2000). Just as is true of medications, the same dose that one would give an adult will have a much greater effect on a child and certainly on a fetus. As we age our liver and renal functions slow, thereby creating opportunities for toxic chemicals to accumulate, and thus creating higher risks for harm.
Both drugs and pollutants can enter the body from a variety of routes. Most drugs are given orally and absorbed by the gastrointestinal (GI) tract. Water- and food-associated pollut- ants, including pesticides and heavy metals, enter the body via the digestive tract. Some drugs are administered as inhalants, and some pollutants in the air (including indoor air) enter the body via the lungs. Some drugs are applied topically. In work settings, employees can receive dermal exposures from toxic chemicals when they immerse their unprotected hands in chemical solutions, especially solvents. Pollution can enter our bodies via the lungs (inhalation), GI tract (ingestion), skin, and even the mucous membranes (dermal absorption). Most chem- icals cross the placental barrier and can affect the fetus, just as most chemicals cross the blood–brain barrier. In addition to direct damage to cells, tissues, organs and organ systems, there can be changes to the DNA from chemical exposures that can change gene expression, which in turn can predict disease. This latter effect is the focus of a relatively new field of bio- logical study: epigenetics. Scientists now understand that there are many variables that predict disease outcomes, including environmental exposures.
In the same way that we consider age, weight, other drugs taken, and underlying health status of a client when we admin- ister drugs, we must consider that these same factors can affect an individual’s response to environmental exposures. For example, children are much more vulnerable to virtually all pollutants. People who are immunosuppressed (people with HIV/AIDS or those on immunosuppressant drugs like steroids or anti-cancer medications) are especially at risk for foodborne and waterborne pathogens. Because our communities are com- prised of people of different ages and different health statuses, their vulnerabilities to the effects of pollution will also vary. When assessing a community’s environmental health status, be sure to review the general health status of the community and to identify members who may have higher risk factors.
Chemicals that are similar are often grouped into categories or “families” so that it is possible to understand the actions and risks associated with those groupings. Examples are metals and metallic compounds (e.g., arsenic, cadmium, chromium, lead, mercury), hydrocarbons (e.g., benzene, toluene, ketones, form- aldehyde, trichloroethylene), irritant gases (e.g., ammonia, hydrochloric acid, sulfur dioxide, chlorine), chemical asphyxi- ants (e.g., carbon monoxide, hydrogen sulfide, cyanides), and
However, the most common way in which the relationships between chemical exposures and health risks are identified is when toxicologists study the effects of chemicals on animals and then use models to estimate what the effects might be on humans. This estimation process is called extrapolation. More than 84,000 man-made (synthetic) chemical compounds have been developed and introduced to our environment since World War II, and we are most often reliant on the data that are created in animal studies to warn us about their potential toxic- ity to humans. For many of these chemicals, no toxicity data are available. Surprisingly, there is no current requirement for orig- inal toxicological research to be completed when a product or process is being brought to market.
We live in a radically different environment compared to a century ago. In addition to man-made pollutants contaminat- ing our air, water, and food, many of the same pollutants are now also found in our bodies (including breast milk). In 2001, the Centers for Disease Control and Prevention began biomonitoring—the testing of human fluids and tissues for the presence of potentially toxic chemicals, as part of its National Health and Nutrition Exam Study. For instance, most Ameri- cans carry pesticides, solvents, heavy metals and other poten- tially toxic chemicals in their bodies. In 2005, an Environmental Working Group tested the umbilical cord blood of newborn babies and found that they also contained a similar range of potentially harmful chemicals (EWG, 2005). Each of these potentially hazardous substances creates a health risk. Nurses need to understand the environmental exposures and the health effects that may be associated with chemicals in order to develop assessment tools, implement hazard reduction programs, and advocate for safe and healthy chemical policies. For example, when a woman is pregnant for the first time, this is an ideal time for a nurse to help her assess and reduce or eliminate prevent- able environmental health risks in her home and workplace. A good environmental health history can help uncover a number of exposures from the products she may use, the ways in which she addresses pests in her home and garden, to the way in which she may set up a new nursery room.
In the Resource Section under chemical policies, there are a number of links to organizations that track federal and state legislation on chemical issues.
ENVIRONMENTAL HEALTH SCIENCES Toxicology Toxicology is the basic science that contributes to our under- standing of health effects associated with chemical exposures. Historically, it was referred to as the “study of poisons.” Its corollary in health care is pharmacology, which studies the human health effects, both desirable and undesirable, associ- ated with drugs. In toxicology, only the negative effects of chem- ical exposures are studied. However, the key principles of pharmacology and toxicology are the same. Just as the dose of a drug makes the difference in its efficacy and its toxicity, the quantity of an air or water pollutant to which we may be exposed can determine whether or not (and the extent to which) we experience a risk of a health effect. In addition, the timing
222 PART 3 Conceptual and Scientific Frameworks
taking a data set that geographically notes where children under 10 years of age live and overlaying another data set that notes geographical areas designated by the age of housing stock, a public health nurse could see where there are the largest number of children who live in areas with older housing stock. With this information, the nurse could target a lead surveillance and edu- cational program. Nurse researcher Mona Choi used GIS to study the relationship between air pollution and emergency visits for cardiovascular and pulmonary diagnosis. Community- based maps that are created using GIS technologies are helpful in educating community members and local policy makers. The maps can provide useful graphic depictions of public health problems.
Environmental health requires a combination of tried and tested nursing tools mixed with new tools, such as GIS, and the recognition that many disciplines may be involved in the iden- tification and the resolution of environmental health issues.
Nurse scientists Wade Hill and Patricia Butterfield (2006) developed a model for environmental risk interventions, which can be provided by public health nurses, that improves chil- dren’s health by addressing home-related sources such as lead paint, contaminated drinking water, and environmental tobacco smoke, among others. These risks can cause health effects ranging from minor learning deficiencies to serious and life- threatening diseases such as cancer. Many of the environmental risks children encountered were prevented or reduced by taking practical and affordable steps. Butterfield developed an envi- ronmental justice framework by which to consider environ- mental exposures in rural areas (Butterfield & Postma, 2009).
Multidisciplinary Approaches In addition to toxicology and epidemiology, there are a number of earth sciences to help us understand how pollutants travel in air, water, and soil. Geologists, meteorologists, physicists, and chemists all contribute information to help explain how and when humans may be exposed to hazardous chemicals, radia- tion (e.g., radon), and biological contaminants. Key public health professionals include food safety specialists, sanitarians, radiation specialists, and industrial hygienists.
The nature of environmental health demands a multidisci- plinary approach to assess and reduce/eliminate environmental health risks. For instance, to assess and address a lead-based paint poisoning case we might include a housing inspector with expertise in lead-based paint or a sanitarian to assess the lead- associated health risks in the home; clinical specialists to manage the client’s health needs; laboratories to assess the blood lead levels, as well as lead levels in the paint and house dust and drinking water; and then lead-based paint remediation special- ists to reduce the lead-based paint risk in the home.
We might also add a health educator and outreach worker to educate the family and encourage compliance with environ- mental health behaviors and clinical treatments. And finally, we may need to work with public health lawyers to address non- compliant landlords. Such combined approaches could poten- tially involve the local health department, the state department of environmental protection, the housing department, a primary and tertiary care setting, public or private sector labs, and the
pesticides (e.g., organophosphates, carbamates, chlorinated hydrocarbons). Although some common health risks exist within these families of chemicals, the possible health risks for each chemical should be evaluated individually when a poten- tial human exposure exists. The best source of peer-reviewed information for this is the National Library of Medicine (NLM). The NLM has a set of databases that are focused on toxicology and environmental health called TOXNET. You will find the link to several of these helpful informational programs and data- bases in the Referral Resources.
Epidemiology Whereas toxicology is the science that studies the poisonous effects of chemicals, epidemiology is the science that helps us understand the strength of the association between exposures and health effects. Epidemiology is often used for occupation- ally related illnesses but has been used less often to study envi- ronmentally related diseases. It is difficult to characterize and/ or distinguish among the many exposures that we all experi- ence, and it can be challenging to find control groups when the environmental exposure of concern is in the air, water, or food.
Epidemiologic studies have helped us to understand the association between learning disabilities and exposure to lead-based paint dust, asthma exacerbation and air pollution (Smargiassi et al, 2014; Habre et al, 2014), and GI disease and waterborne Cryptosporidia (Yoder et al, 2012). Environmental surveillance, such as childhood lead registries, provides data with which to track and analyze incidence and prevalence of health outcomes. The results of such analyses can help to target scarce public health resources. Scientists are now approaching epidemiology at the molecular level, looking at gene/environment interactions.
As described in Chapter 12, three major concepts—agent, host, and environment—form the classic epidemiologic tri- angle. (See Figure 12-2, A in Chapter 12.) This simple model belies the often-complex relationships between agent, which may include chemical mixtures (i.e., more than one agent); host, which may refer to a community with people of multiple ages, genders, ethnicities, cultures, and disease states; and envi- ronment, which may include dynamic factors such as air, water, soil, and food, as well as temperature, humidity, and wind. Limitations of environmental epidemiologic data include reli- ance on occupational health studies to characterize certain toxic exposures. The occupational health studies were performed on healthy adult workers whose biological systems were different from those of neonates, pregnant women, children, people who are immunosuppressed, and the elderly. Nevertheless, nurses can review epidemiologic studies regarding exposures of concern to their communities and use epidemiologic tech- niques to assess environmental risks in communities.
Geographic Information Systems Another research tool for environmental health studies is geographic information systems (GIS), a methodology that requires the coding of data so that it is related spatially to a place on Earth. By layering geographically related data, maps can be created to note where the data may be related. For instance, by
223CHAPTER 10 Environmental Health
disruption in water supplies, agriculture, ecosystems, and coastal communities.
There are two concurrent categories of roles for nurses: miti- gation and response. There is still much we can do to mitigate the steep upward slope that we are now observing for tempera- tures, CO2 levels, desertification, and sea water levels. Working at the individual, community, institutional (school, hospital, etc.), and governmental levels, there is much work to be done to ensure energy-conserving policies and practices, rational transportation practices, and changes in our consumption patterns.
Regarding response preparation, public health nurses must lead the development of contingencies for long-term, high-heat weather conditions, as well as increased storm activities (that include more severe storm patterns), more extensive fires in areas prone to fires, and the associated disaster preparedness. For more on disaster preparedness, see Chapter 23 on nurses’ roles in disaster management. Nurses should also be prepared for threats to food security from shifting weather patterns that may deter/eliminate food production and for acute shifts of populations as they migrate away from low-lying, coastal regions or other areas acutely affected by storm or fire damage. These shifts are likely to create climate change–related refugee migrations.
The oil spill in the Gulf of Mexico was the largest in history and caused devastating damage. It is expected that its effects on birds, fish, and other sea animals, as well as the environment, will continue for many more years. Since fish populations were affected, many fishermen lost their jobs and the livelihood that they knew (Gulf Oil Spill, n.d.). This type of ecosystem destruc- tion and economic disruption will be typical if we do not address climate change and our associated need to reduce/ eliminate our reliance on fossil fuels (gas, oil, coal). It is impor- tant to explore the science underpinning climate change, con- sider the human and ecological health threats, and reflect on nurses emerging roles as climate change unfold.
ENVIRONMENTAL HEALTH ASSESSMENTS There are a number of ways to assess environmental health risks in a community. For example, risks can be assessed by medium: air, water, soil, or food. Or exposures could be listed according to urban, rural, or suburban settings, with many exposures being common to all three settings. Nurses may also divide the environment into functional locations such as home, school, workplace, and community. Each of these locations will have unique environmental exposures, as well as overlapping expo- sures. For instance, ethylene oxide, the toxic gas that is used in the sterilizing equipment in hospitals, is typically found only in a workplace. However, pesticides might be found in any of the four areas. When assessing environments, be sure to determine if an exposure is in the air, water, soil, and/or food and whether it is a chemical, biological, or radiological exposure.
Information Sources The NLM has developed some of the most useful, comprehen- sive, and reliable sources of environmental health information.
legal system. The nurse’s responsibility is to understand the roles of each respective agency and organization, know the public health laws (particularly as they pertain to lead-based paint poisoning in their communities), and work with the com- munity to coordinate services to meet their needs. The nurse also might set up a blood lead screening program through the local health department, educate local health providers to encourage them to systematically test children for lead poison- ing, and/or work with advocacy organizations to improve the condition of local housing stock. Note that although lead-based paint is no longer in use in the United States, it is still widely used in developing countries.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES Targeted Competency: Function effectively within nursing and interprofes-
sional teams, fostering open communication, mutual respect, and shared decision making to achieve quality client care.
Knowledge: Describe scopes of practice and roles of health care team members.
Skills: Assume the role of team member or leader based on the situation. Attitudes: Value the perspectives and expertise of all health team members. Safety Question: One of the objectives of Healthy People 2020 related to
environmental health is “Reduce pesticide exposures that result in visits to a health care facility” (ED 8-10). The public health nurse, who is working on a project to help mothers learn parenting skills, visits a new mother who lives and works on a large farm. When the nurse drives into the farm on her way to the housing where workers live, she sees that the fields are being sprayed with pesticides from a truck and that two young children are riding in the back of the truck. What action should she take?
Answer: At the individual level, she should talk with the owner or manager of the farm and remind him or her of the toxicity of pesticides and the danger to those who are in the vicinity of the spraying. She should recom- mend that he or she not allow anyone to ride in the open portion of the vehicle and that the driver should leave the window closed and wear a mask to protect his or her nose and mouth.
Systems level: She should identify areas where the workers on the farms congregate, such as churches, social halls, and so forth. Then she should ask if she could provide an educational program on the dangers of coming into contact with pesticides. She could distribute pamphlets about this hazard in local venues where both farm managers and workers will be able to access them. What else might the nurse do?
CLIMATE CHANGE According to the World Health Organization, “climate change is a significant and emerging threat to public health, and changes the way we must look at protecting vulnerable populations” (WHO, 2014b). The 2014 report of the Intergovernmental Program on Climate Change, a WHO-related group of scien- tists, concludes that “climate change will act mainly, at least until the middle of this century, by exacerbating health prob- lems that already exist, and the largest risks will apply in popula- tions that are currently most affected by climate-related diseases” (IPCC, 2014). In the United States we are already seeing some of the earlier climate change predictions materialize: long- term warming trends, extreme weather conditions, as well as
224 PART 3 Conceptual and Scientific Frameworks
without any further information about their chemical identity. Thus, it is sometimes impossible to make a true assessment about the health risks based on the information provided by the manufacturer.
One of the ANA Environmental Health Principles is the tenet of the “Right to Know,” which recommends the need for access to all information necessary to make informed decisions and protect our health. There are still a number of ways in which full disclosure of chemical exposure is lacking in terms of air and water pollution, food contents, and product ingredi- ents. Nurses, both individually and through their professional organizations, can advocate for increasing access to information through “right to know,” labeling, and other legislative and regulatory efforts.
APPLYING THE NURSING PROCESS TO ENVIRONMENTAL HEALTH If you suspect that a client’s health problem is being influenced by environmental factors, follow the nursing process and note the environmental aspects of the problem in every step of the process: 1. Assessment. Use your observational skills (e.g., windshield
surveys); interview community members; ask your individ- ual clients; and ask the families of your clients. Review web- based data on existing exposures, such as air and water pollution monitoring data, drinking water testing, and con- taminated soil. Relate the disease and the environmental factors in the diagnosis.
2. Planning. Look at community policy and laws as methods to facilitate the care needs for the client; include environmental health personnel in planning.
3. Intervention. Coordinate medical, nursing, and public health actions to meet the client’s needs. Ensure that the affected person or family is referred for appropriate clinical care.
4. Evaluation. Examine criteria that include the immediate and long-term responses of the client as well as the recidivism of the problem for the client.
Individual Environmental Exposure History When working with individuals, it is important to include envi- ronmental health risks as part of a client’s history. Ask certain questions to assess exposures that may occur in all of the set- tings in which they spend time. A helpful mnemonic was devel- oped to assist health professionals in remembering the areas of concern when taking an environmental history: “I PREPARE.” The mnemonic (see Box 10-3) can be used when interviewing an individual client or when assessing a family or it can be adapted for use with a group of community members.
Community-wide Environmental Health Assessment Tools Nurses have developed several exposure assessment tools, including forms for pregnant women, home and school assess- ments, community-wide assessments, and assessment tools for hospital-related exposures. The web links on the Evolve site for this book include several examples of environmental assess- ment tools.
FIG 10-2 Some of the chemicals in our personal care products can be hazardous to our health. You can look up the chemicals in your products and learn about the potential health risks by going to the SkinDeep database: http://www.ewg.org/skindeep/. (Photo from the U.S. Food and Drug Administration. Available at http://www.fda.gov/Cosmetics/default.htm?wvsessionid= 1724ec6bbda343c6b7d0e092db6c2f30.)
The NLM’s website for ToxTown (http://toxtown.nlm.nih.gov/) is one of the best places to start when developing environmental assessment skills. Within ToxTown, there is a Household Prod- ucts page where nurses can research common products such as those for personal care, cleaning, pet care, lawn care, and others to see the potential health risks that may be associated with them. Also, chemicals can be researched by brand or chemical name or by Chemical Abstract System number. (The NLM website can be accessed at www.nlm.nih.gov; at the website, search for the environmental assessment section.)
Also within ToxTown, you can search for general environ- mental health risks in the “city,” “town,” and “farm,” or even go to a “US–Mexico Border Community.” While in the virtual “city” you can visit a hair salon, hospital, or funeral home to see what kinds of environmental health risks are posed in such places. ToxTown brings together governmental and well-vetted nongovernmental sources for a rich web resource in which to learn about environmental health.
Another database that is specific to personal care products, which includes over 68,000 products that can be searched by brand name and specific product descriptors, is the Skin Deep database (http://www.ewg.org/skindeep/). The Safe Cosmetics website, which links to the Skin Deep database, additionally provides information on better protecting your health by select- ing products that have simpler ingredients and fewer synthetic chemicals. For example, the site points out that even top-selling brands of natural and organic products may have some toxic components. Specifically, they say that some top-selling herbal shampoos contain 1,4-dioxane, a synthetic chemical carcino- gen. They also comment on the number of lipsticks that they found to contain lead. Note that in both the NLM and the Safe Cosmetics databases, the information is predicated on what the manufacturers place on the label as ingredients (Figure 10-2). If the manufacturer claims that a component is a “trade secret,” it will not appear on the label. Rarely are the chemicals that make up a “fragrance” listed on the label; instead, it is likely to only read “fragrance” on the label. And finally (and this is espe- cially true with pesticides), the label may merely say “inerts”
225CHAPTER 10 Environmental Health
The Right to Know section of this chapter contains a descrip- tion of the types of information that are available to the public about air and water pollutants, drinking water quality, and other environmental sources or exposures. Armed with this informa- tion, a nurse can create a significant environmental health map of a community. In addition, Appendix F.3 presents an example of an occupational and environmental assessment.
While we observe environmental health risks in our com- munities, it is equally important for us to identify the positive environmental contributors to our communities. Settings that connect people to nature—parks, green spaces, and beaches— are incredible assets to communities. The term nature-deficit disorder was coined by author Richard Louv in his book Last Child in the Woods to describe what happens to young people who become disconnected from the natural world. Louv links this lack of nature to some of the most disturbing childhood trends, such as the rises in obesity, attention disorders, and depression (Louv, 2005). Policy makers, educators, and chil- dren’s health advocates are considering their roles in addressing
A windshield survey is a helpful first step in understanding the potential environmental health risks in a community. If the community is urban, the age and condition of the housing stock and potential trash problems (and the associated pest prob- lems) can be determined easily by driving around the neigh- borhood. Note proximity to factories, dump sites, major transportation routes, and other sources of pollution. In rural communities, note if and when there are aerial and other types of pesticide and herbicide spraying, if people rely on wood-burning stoves, if there are industrial-type agricultural practices, and/or if there are contaminated waterways. Using ToxTown can really help with identifying health risks associated with the observations from a windshield survey.
You may not be able to “see” the pollution that is in your community, but the U.S. Environmental Protection Agency’s website, EnviroFACTS, can help identify air, water, and soil pol- lution in your area by entering your ZIP code. Nurses are often surprised to find out what is being released into their neighbor- hood’s water and air.
Investigate Potential Exposures Present Work Residence Environmental Concerns Past Work Activities Referrals and Resources Educate
Do an Exposure History to: Identify current or past exposures. Reduce or eliminate current exposures. Reduce adverse health effects.
Taking an Exposure History: Questions to Consider I—Investigate Potential Exposures Investigate potential exposures by asking: Have you ever felt sick after coming in contact with a chemical, such as a
pesticide or other substances? Do you have any symptoms that improve when you are away from your home
or work?
P—Present Work At your present work: Are you exposed to solvents, dusts, fumes, radiation, pesticides, or other
chemicals? Are you exposed to loud noise? Do you know where to find material safety data sheets for chemicals with which
you work? Do you wear personal protective equipment? Are work clothes worn home? Do coworkers have similar health problems?
R—Residence When was your residence built? What type of heating do you have? Have you recently remodeled your home?
What chemicals are stored on your property? Where is the source of your drinking water?
E—Environmental Concerns Are there environmental concerns in your neighborhood (i.e., air, water, soil)? What types of industries or farms are near your home? Do you live near a hazardous waste site or landfill?
P—Past Work What are your past work experiences? What job did you have for the longest period of time? Have you ever been in
the military, worked on a farm, or done volunteer or seasonal work?
A—Activities What activities and hobbies do you and your family pursue? Do you burn, solder, or melt any products? Do you garden, fish, or hunt? Do you eat what you catch or grow? Do you use pesticides? Do you engage in any alternative healing or cultural practices?
R—Referrals and Resources Use these key referrals and resources: Environmental Protection Agency (www.epa.gov) National Library of Medicine—TOXNET Programs (www.nlm.nih.gov) Agency for Toxic Substances and Disease Registry (www.atsdr.cdc.gov) Association of Occupational and Environmental Clinics (www.aoec.org) Occupational Safety and Health Administration (www.osha.gov) EnviRN website (www.enviRN.umaryland.edu) Local Health Department, Environmental Agency, Poison Control Center
E—Educate (A Checklist) Are materials available to educate the client? Are alternatives available to minimize the risk of exposure? Have prevention strategies been discussed? What is the plan for follow-up?
BOX 10-3 The “I PREPARE” Mnemonic from the Agency for Toxic Substances and Disease Registry
Prepared by Grace Paranzino, RN, MPH, for the Agency for Toxic Substances and Disease Registry. For more information, contact ATSDR at 1-888-42-ATSDR or visit ATSDR’s website at http://www.atsdr.cdc.gov.
226 PART 3 Conceptual and Scientific Frameworks
effective. Nurses can have a role in addressing both the health problems and the policies affecting the exposures. Air pollution is divided into two major categories: point source and non– point source (see Figure 10-3). Point sources are individual, identifiable sources such as smokestacks. They are sometimes referred to as fixed sites. Non–point sources come from more diffuse exposures. For instance, the largest non–point source of air pollution is from mobile sources such as cars and trucks, which are the greatest single source of air pollution in the United States. The Clean Air Act regulates air pollution from point and non–point sources. Box 10-4 presents a list of the air pollutants that comprise the “criteria pollutants”—a set of pol- lutants that the EPA uses to gauge the overall air quality. The burning of fossil fuel (e.g., diesel fuel, industrial boilers, and coal-fired power plants) and waste incineration are two other major contributors. Health effects associated with air pollution include asthma and other respiratory diseases, cardiovascular diseases (including cardiac disorders and hypertension), cancer, immunological effects, and reproductive health problems including birth defects, infant death, and neurological prob- lems. For children with asthma the additional insult of living near a fixed source of pollution can create additional health risks (Smargiassi et al, 2014).
The single greatest source of mercury in our air is coal-fired power plants. Many people do not know that a pea-sized amount of mercury is sufficient to contaminate a 25-acre lake
this issue. The National Park Service works to bring more people to parks—local, state, and national.
Man-made “green” spaces such as community gardens, streetscapes, bike paths, and water features can positively contribute to a community’s health and sense of well- being. Recent attention has been paid to the importance of “walkable communities,” access to nature, and other concerns included in discussions about “Smart Growth” or “Sustainable Communities.”
Some new suburban developments are designing space for agriculture in the form of Community Sustainable Agriculture (CSA), a model of local agriculture in which community members purchase shares in the spring and receive fruits and vegetables as they are harvested. Also in this model, community members have the option to volunteer on the farm. This creative new community design addresses a number of public health issues—obesity, depression/social isolation, poor nutrition—by getting people outside and moving, creating opportunities for building supportive relationships, and pro- viding fresh produce.
ENVIRONMENTAL EXPOSURE BY MEDIA Many of the environmental protection regulations are based on the “medium” in which pollutants are carried—air, water, and soil. Additionally, chemical, biological, and radiological hazards can be found in food and consumer products. For air, water, and soil, the U.S. EPA and its state-level equivalents are the primary regulatory agencies. However, the EPA also regulates pesticides used in agriculture. The U.S. Department of Agricul- ture focuses substantially on pathogens in our food supply.
Air Air pollution is a significant contributor to human health prob- lems, and a sign that regulatory efforts are not completely
FIG 10-3 Air pollution comes from a wide range of sources. EPA’s EnviroFACTS site allows you to check the air and other pollutants in your ZIP code. http://www.epa.gov/enviro/. (Figure from the National Park Service, Sources of Air Pollution. Retrieved March 16, 2014 from http://www2.nature.nps.gov/air/aqbasics/sources.cfm.)
Lightning
Volcanos
Wildfires
Forests
Livestock
Cities
Airplanes
Cars, Trucks, Buses, Motorcycles
Fertilizer
Natural
Area
Mobile
Pollutant Emissions
Stationary
Industry, Power Plants, Sewage Treatment
Ozone (ground level) Sulfur dioxide Nitrogen dioxide
Particulate matter Carbon monoxide Lead
BOX 10-4 U.S. EPA Criteria Air Pollutants—National Ambient Air Quality Standards (NAAQS)
227CHAPTER 10 Environmental Health
17β-estradiol (an estrogen replacement hormone), and acet- aminophen (Tylenol), as well as a variety of endocrine disrupt- ing chemicals, in measurable quantities in U.S. streams and rivers.
Water quality is also affected by non–point sources of pollu- tion, such as storm water runoff from paved roads and parking lots, erosion from clear-cut tracts of land for timbering and mining, and runoff from chemicals added to soils such as pes- ticides and fertilizers. Soil erosion is another huge public health threat in the making as it is decreasing the amount of soil that can sustain agriculture and the global food supply. Eighty percent (80%) of the world’s forests are gone, which is contrib- uting to massive erosion of farmable soil and deterring the flow of and healthy biotic life in creeks and rivers.
Land and Soil Current and past land use can affect a community’s health. Local governments dictate land use through zoning laws. For instance, zoning decisions can determine if a community will have a hazardous waste site built in its neighborhood or whether the land can be used only for residential purposes (housing). Historically, communities in which poor people and people of color live have been more likely to have undesirable and unhealthy industries, railway lines, and hazardous waste sites. In many communities, prior use of the land has left a legacy of unhealthy contaminants. There are two designations for lands that may be contaminated: Superfund sites (highly contami- nated sites, with associated health threats that are designated by the EPA) and Brownfield sites (land that has been used previ- ously and which is now slated for redevelopment). Public health nurses can play an important role with both Superfund and Brownfield sites related to the health assessment. Funds are available through both the Superfund and Brownfield laws to engage the community and to do health assessments.
Food Many health risks are associated with food and food produc- tion. In recent years, we have seen foodborne illnesses associated with Salmonella and Escherichia coli H:0157:H7 in chicken, eggs, and meats. Good food preparation practices, such as proper washing and using adequate cooking temperatures and time, can prevent foodborne illnesses associated with most patho- gens. Local health departments are responsible for monitoring food establishments (restaurants, food trucks, etc.) in the com- munity, and the U.S. Department of Agriculture is responsible for oversight of meat, poultry, fish, and produce production.
However, there are also environmental health risks posed by the presence of pesticide residues in our food; the use of recom- binant bovine growth hormone (rBGH), which is given to many dairy cows; the administration of antibiotics to beef cattle, pigs, and chickens at nontherapeutic doses that are given to promote growth; and the use of genetically modified organisms (GMOs) for genetically engineered crops. In the Resources Section, there are a number of websites through which you can find out more information about food-related public health issues.
When assessing a community’s environmental health risks, a nurse must consider air, water, soil, and food. It is important
and make its fish unfit to eat. Mercury, like lead, is an element and it persists in our fresh waterways and oceans from which we continue to get our fish. We cannot readily take these ele- ments out once they have been released into the environment; our job is to focus on policies that prevent them from being released.
Indoor air quality (IAQ) is a growing public health concern in office buildings, schools, and homes and is reflected in the alarming rise in asthma incidence in the United States, particu- larly among children. The EPA and the American Lung Associa- tion both provide excellent materials on IAQ. The EPA has a free kit called IAQ: Tools for Schools, which includes a video and a number of helpful materials for people interested in improv- ing the air quality in a school building.
Radon, a naturally occurring radioactive element that is found in the earth’s crust and can seep into basements and into groundwater, is the second leading cause of lung cancer in the United States, second only to smoking. To learn more about this important environmental exposure, read more in the Resource Section. Other major culprits contributing to poor indoor air are carbon monoxide, formaldehyde, dusts, molds, pests and pets, pesticides, cleaning and personal care products (particu- larly aerosols), lead, and of course environmental tobacco smoke.
Because environmental health implies a relationship between the environment and our health, we must assess both the envi- ronmental exposures and the human health status within a community. Health status is assessed by using local, state, and national health data or by collecting our own data, or a combi- nation of the two. As we learn more about the exposures in our communities and their known or suspected health effects, we can target the health statistics we wish to review or collect.
Water Water is necessary for all life forms. Human bodies consist of 70% water. Only 2.5% of the water on this planet is fresh water; the rest is salt water. Much of the fresh water is in the polar icecaps, whereas groundwater makes up most of what remains, leaving only 0.01% in lakes, creeks, streams, rivers, and rainfalls. People’s lives are inextricably tied to safe and adequate water. Water is necessary for the production of food. In the United States, all public water suppliers must test their water in accor- dance with the EPA’s safe drinking water standards and they must summarize the results of their testing annually and make them available to their customers—those who pay water bills. The technical term for these reports is Consumer Confidence Reports (CCR). Nurses can request these summaries from the water suppliers that serve their communities. Private wells are not regulated and need not be tested except when they are first drilled. Nurses should encourage people with private wells to have them tested annually, especially in agricultural areas where pesticides are applied.
Pollution discharges into water bodies from industries and from wastewater treatment systems can contribute to the deg- radation of water quality. An additional source of pollution in our waters is pharmaceuticals used for humans and animals. The U.S. Geological Service has found antibiotics, codeine,
228 PART 3 Conceptual and Scientific Frameworks
assessment refers to a process to determine the probability of a health threat associated with an exposure. The following illus- tration of a chemical exposure demonstrates the four phases to a risk assessment: 1. Determining if a chemical is known to be associated with
negative health effects (in animals or humans). For this, we rely on toxicological and/or epidemiologic data. (Remember, the available toxicological data will probably be based on animal studies and these studies estimate the potential effects on humans, whereas the results of human epidemiologic studies will be for human health effects.)
2. Determining whether the chemical has been released into the environment—into the air, water, soil, or food. This is accomplished by testing for the presence of the suspected chemical in the various media (air, water, soil, food). Envi- ronmental professionals such as air and water pollution sci- entists, environmental engineers, meteorologists, and others might be involved in this activity. When doing a risk assess- ment, it is important to note if there are multiple sources of the chemical in question. For example, is lead found in the drinking water, the ambient air, and in the paint within the houses of a given community?
3. Estimating how much and by which route of entry the chem- ical might enter the human body—inhalation, ingestion, dermally, or in utero exposure. This estimate can be based on a one-time exposure, a short-term exposure, or a pro- jected lifetime exposure. (When federal standards are created for air, water, and other pollutants, they are based on an estimation of a lifetime exposure. However, in workplace settings the chemical exposure standards are based on an average exposure during a typical 8-hour work shift or set for a maximum exposure level that should not be exceeded.)
4. Characterizing the risk assessment process and taking into account all three of the previous steps. Is the chemical toxic? What is the source and amount of the exposure? What is the route and duration of the exposure for humans? The final synthesis attempts to predict the potential for harm based on the estimated exposure. All science is subject to interpretation, and so is risk assess-
ment. The reason that environmental laws are so often conten- tious is because there are economic interests at stake and not just public or ecological health concerns. In translating the risk assessment results for the purposes of policy development and recommendation for risk reduction activities, there are often several interpretations of each of the risk assessment steps that then result in differing recommendations for health-based stan- dards. There are also areas of scientific uncertainty that contrib- ute to variations in assessment of risk. It is critical to have public health voices in the debates. The American Public Health Asso- ciation is actively engaged on major policy debates through the Environment Section.
VULNERABLE POPULATIONS Many of the social determinants of health contribute to the risk levels associated with environmental exposures. Poor people who live in low-income communities are more often housed in
that nurses understand the term “organic” regarding food label- ing. If a food is labeled “Certified Organic” this is a meaningful term that has a legal USDA definition. The legal definition stands for foods that have been produced without the use of pesticides, genetically modified organisms (GMOs), or unnec- essary (nontherapeutic) use of antibiotics. If a food is merely labeled “organic,” the consumer does not have the same guar- antee for what chemicals or farming practices have been used. When purchasing foods directly from farmers through farm stands or farmers’ markets, consumers can directly ask about the chemicals and farm practices.
RIGHT TO KNOW Several environmental statutes give the public the right to know about the hazardous chemicals in the environment. Under one of the “right to know” laws, health professionals and commu- nity members can easily access key information by ZIP code regarding major sources of pollution that are being emitted into the air or water in their community. The EPA has an Envirofacts section on its website that provides several sources of exposure data by ZIP code (http://www.epa.gov/enviro/).
Nurses can access drinking water consumer confidence reports, sometimes referred to as “right to know” reports, to determine what pollutants have been found in the drinking water. If the drinking water poses an immediate health threat, the water provider must send emergency warnings out to the community via the local newspapers, radios, and television. If there is a biological hazard (microbial) in the water, the health notice may suggest boiling the water or not drinking it at all. If the hazard is chemical, boiling the water may not be helpful because that may simply concentrate the chemical. A federal law, the Freedom of Information Act, allows citizens to request many kinds of public documents, including information about environmental permits and inspections of facilities in your communities.
Employees have the right to know about the hazardous chemicals with which they work through the federal Hazard Communication Standard, which is under the purview of the Occupational Safety and Health Administration (OSHA). This standard requires employers (including hospitals) to maintain a list of all of the potentially hazardous chemicals that are used on site. Each of these chemicals should have an associated chemical information sheet known as a material safety data sheet (MSDS), which is written by the chemical manufacturer. These MSDSs are to be made available to any employee or his or her representative (e.g., a union) and should provide infor- mation about the chemicals that constitute the product, the health risks, and any special guidance on safe use or handling (e.g., requirements for protective gloves or respiratory protec- tion). For more extensive information on workplace health and safety, see http://www.osha.gov.
RISK ASSESSMENT Currently, the EPA uses a process referred to as “risk assess- ment” when they develop health-based standards. The term risk
229CHAPTER 10 Environmental Health
survival rate for children for all cancer sites improved from 58% for those diagnosed between 1975 and 1977 to 81% for children diagnosed between 1999 and 2007 (Jemal et al, 2010). The list of possible causes of children’s cancers includes the following: genetic abnormalities, ultraviolet and ionizing radiation, elec- tromagnetic fields, viral infections, certain medications, food additives, tobacco, alcohol, and industrial and agricultural chemicals (Ross and Olshan, 2004; Bassil et al, 2007). Clearly, the environment is playing an important role.
substandard housing (with attendant risks of chipping and peeling paint, pests, and unsafe neighborhoods), live closer to pollution sources, are employed in more dangerous occupations, and have less access to healthy food options. In addition, vulner- ability is variable through the human life cycle. The embryo and fetus are the most vulnerable to chemical exposures because of the rapid growth of cells and the development of tissues, organs, and organ systems. Following is a section on children’s special vulnerabilities. The very young and the very old also are vulner- able because their body systems are either still developing or are less efficient, respectively. For more information about the special vulnerabilities of the elderly, see the EPA’s dedicated information site on older Americans (www.epa.gov/aging/) and look at their report “Growing Smarter/Living Healthier: A Guide to Smart Growth and Active Aging (http://www.epa.gov/aging/ docs/growing-smarter-living-healthier.pdf ). For more informa- tion on the effects of perinatal exposures, the University of California San Francisco has a Program on Reproduction and Environment that provides informational webinars, factsheets, the latest research and policy/advocacy information available at http://www.prhe.ucsf.edu.
Children’s Environmental Health Consider some of the current childhood health statistics with which environmental factors are associated: approximately 9% of American children suffer from asthma, with higher rates in black children (CDC, 2012). About 20% of the world’s children and adolescents suffer from a mental health problem (WHO, n.d.), and this statistic is mirrored in the United States (DHHS, 2005). The CDC monitoring system for autism spectrum dis- orders reports that the prevalence of autism among 8-year-olds in the United States is 1 in every 68 children (CDC, 2014a). The global prevalence of autism has increased twentyfold to thirty- fold since the earliest epidemiologic studies were conducted in the late 1960s and early 1970s. And millions of homes in the United States continue to have chipping and peeling lead-based paint.
Developmental disorders and attention deficit hyperactivity disorder (ADHD) collectively are estimated to affect 17% of school-age children (AHRQ, 2002; Anney et al, 2006). Child obesity has doubled and adolescent obesity has more than qua- drupled in the last 30 years (CDC, 2014b). From 1975 to 2010 the incidence rates for 4 cancer types, acute lymphocytic leuke- mia, non-Hodgkin lymphoma, acute myeloid leukemia, and testicular germ cell tumors, increased in children (ACS, 2014). The most common cancers among children ages 0 through 14 are acute lymphocytic leukemia, brain and CNS, neuroblas- toma, and non-Hodgkin lymphoma (ACS, 2014, p. 25). “All cancers involve the malfunction of genes that control cell growth and division. Only a small proportion of cancers are strongly hereditary…” (ACS, 2014, p. 1). According to the American Cancer Society (ACS), about 5% of all cancers are strongly associated with heredity (ACS, 2010). The rest occur from environmental exposures, lifestyle choices (diet, smoking, etc.), and other factors during our lifetimes.
Over the past 25 years there has been great improvement in the 5-year survival rate of major childhood cancers. The 5-year
Gilden R, Friedmann E, Sattler B, et al: Potential health effects related to pesticide use on athletic fields. Public Health Nursing 29(3):198-207, May/June 2012.
Gilden et al examined the use of pesticides on athletic fields where children play sports. This cross-sectional descriptive study used a survey to assess playing field maintenance practices related to the use of pesticides on the field. The authors gave the survey to 33 field managers in order to assess maintenance practices. Their data were analyzed using descriptive statistics and generalized estimating equations.
They found that 65.3% of the managers said they applied pesticides, primar- ily herbicides, to the fields. They also found that managers of urban and suburban fields were less likely to apply pesticides than were managers of rural fields. The use of pesticides presents many health hazards, and the results of this study demonstrated that children who engage in sports activi- ties on athletic fields are exposed to health hazards. • Nurse Use: Nurses can inform people such as school officials, coaches, and
field managers of the dangers of using pesticides on athletic fields.
EVIDENCE-BASED PRACTICE
Children are not just little adults. They are different in many ways, particularly with regard to their exposures and responses to the environment. As nurses, we know that infants and young children breathe more rapidly than adults, and this increase in respiratory rate translates to a proportionately greater exposure to air pollutants. While infants’ lungs are developing they are particularly susceptible to environmental toxicants. Although full function of the lungs is attained at approximately age 6, changes continue to occur in the lungs through adolescence (Dietert et al, 2000). Children are short and, as such, their breathing zones are lower than adults, causing them to have closer contact to the chemical and biological agents that accu- mulate on floors and carpeting. Children of color and poor children in America are disproportionately affected by a range of environmental health threats, including lead, air pollution, pesticides, incinerator emissions, and exposures from hazard- ous waste sites (Suk and Davis, 2008; Landrigan et al, 2010).
In clinical settings, there is little that can be done to address a child’s body burden of toxic chemicals; however, the nursing community as a profession has a weighty obligation to under- stand the science and risks associated with environmental pol- lutants and to engage in the political and economic decisions regulating the environment that have a profound effect on human health, especially the health of our children. This engagement occurs in policy-making arenas including legisla- tive, regulatory, and international treaties. Nurses have increas- ingly become involved in the policy arena. The Alliance of Nurses for Healthy Environments is actively engaging nurses in
230 PART 3 Conceptual and Scientific Frameworks
Toxic chemicals can have different effects depending on the timing of exposure. During fetal development, there are periods of exquisite sensitivity to the effects of toxic chemicals. During such times, even extraordinarily small exposures can prevent or change a process that may permanently affect normal develop- ment. The brain undergoes rapid structural and functional changes during late pregnancy and in the neonatal period. Therefore, it is extremely important to safeguard women’s envi- ronments when they are pregnant (Table 10-1).
Alarmingly, 27 states have issued mercury contamination advisories for fish in every lake and river within their state’s borders (EPA, 2009). According to the EPA, more than 1 million women in the United States of childbearing age eat sufficient amounts of mercury-contaminated fish to risk damaging brain development of their children. Nurses in all settings need to understand the implications that the fish advisories have for their clients and communities, and the contribution that the health sector has in creating this health risk, while at the same time counseling on the positive contribution of fish to a nutri- tionally balanced diet.
About 84,000 chemicals are used in commerce in the United States (EPA, 2014). Almost all are man-made; 15,000 of them are produced annually in quantities greater than 10,000 lb and 2800 of them are produced in quantities greater than 1 million pounds per year (Goldman and Koduru, 2000). Of the 2,800, only 7% have been tested for developmental effects and only 43% have been tested for any human health effects.
Companies are not required to divulge the results of their private testing. A full battery of neurotoxicity tests is not required even for pesticides that may be sprayed in nurseries and labor and delivery areas, not to mention in homes. To make things even more complicated, risks from multiple chemical exposures are rarely considered when regulations are drafted. Such an omission ignores the reality that both children and adults are exposed to many toxic chemicals, often concurrently. The only exception to this rule is in the case of regulations regarding pesticides that are used on food (Figure 10-4). This exception was created by the 1996 FQPA, in which Congress acknowledged that children eat foods that may be contaminated by more than one pesticide residue. See Box 10-5 for the provi- sions under the FQPA.
PRECAUTIONARY PRINCIPLE With thousands of chemical compounds now creating a chemi- cal soup in our air and water (and in our bodies, in our breast milk), it is increasingly difficult to prove specific hypotheses regarding the relationship of exposure to a singular chemical and disease outcome in humans. It has been suggested that we adopt a precautionary approach when research and other indi- cators demonstrate a possible toxic relationship between a chemical and health. Box 10-6 presents the Wingspread State- ment on the Precautionary Principle. This precautionary approach calls for action to reduce potentially toxic exposure to humans in light of data or other indicators, rather than delaying until more “conclusive” studies are performed. We will never have the perfect studies. Nurses, who are trained in disease
state and federal chemical policies and energy policies (includ- ing fracking) as they relate to health, and policies related to sustainable foods.
Children’s bodies also operate differently. Some of the pro- tective mechanisms that are well developed in adults, like the blood–brain barrier, are immature in young children, thereby increasing their vulnerability to the effects of toxic chemicals. And finally, the kidneys of young children are less effective at filtering out undesirable toxic chemicals, and these chemicals then continue to circulate and accumulate.
Infants and young children drink more fluids per body weight than adults, thus increasing the dose of contaminants found in their drinking water, milk (hormones and antibiotics), and juices (particularly pesticides). If an adult were to drink a proportionate amount of water to an infant, the adult would have to drink about 50 glasses of water a day. Children also eat more per body weight, eat different proportions of food, and absorb food differ- ently than adults (EPA, 2013). How many adults could eat the same amount of raisins pound-for-pound as the average 2-year- old? Children consume much greater quantities of fruits and fruit juices than adults, once again adding exposure to doses of pesti- cide residues. The average 1-year-old drinks 21 times more apple juice, 11 times more grape juice, and nearly 5 times more orange juice per unit of body weight than the average adult (Rawn et al, 2004). The Food Quality Protection Act (FQPA) was passed to specifically address the consumption patterns and special vulner- abilities of children (Box 10-5).
New provisions under the Food Quality Protection Act of 1996 related to protection of infants and children: Health-based standard: A new standard of a reasonable certainty of “no harm”
that prohibits taking into account economic considerations when children are at risk.
Additional margin of safety: Requires that the EPA use an additional 10-fold margin of safety when there are adequate data to assess prenatal and postnatal development risks.
Account for children’s diet: Requires the use of age-appropriate estimates of dietary consumption in establishing allowable levels of pesticides on food to account for children’s unique dietary patterns.
Account for all exposures: In establishing acceptable levels of a pesticide on food, the EPA must account for exposures that may occur through other routes, such as drinking water and residential application of the pesticide.
Cumulative impact: The EPA must consider the cumulative impact of all pes- ticides that may share a common mechanism of action.
Tolerance reassessments: All existing pesticide food standards must be reas- sessed over a 10-year period to ensure that they meet the new standards to protect children.
Endocrine disruption testing: The EPA must screen and test all pesticides and pesticide ingredients for estrogen effects and other endocrine disruptor activity.
Registration renewal: Establishes a 15-year renewal process for all pesticides to ensure that they have up-to-date science evaluations over time.
BOX 10-5 Provisions Under the Food Quality Protection Act Regarding Pesticide Exposure to Children from Multiple Sources
From Environmental Protection Agency: Food Quality Protection Act of 1996. Available at http://www.epa.gov/pesticides/regulation/laws/ fgpa/. Accessed December 15, 2010.
231CHAPTER 10 Environmental Health
on the seventh generation? A quote (Myths-Dreams-Symbols, 2006) attributed to Chief Seattle, a nineteenth-century Native American, illustrates the need to think more holistically when we consider environmental impacts: “Whatever befalls the earth befalls the sons of the earth. Man did not weave the web of life; he is merely a strand in it. Whatever he does to the web, he does to himself.” McDonough suggests that, as we make policies, plans, and designs, we ask ourselves how these decision are evidence that “we love all the children of all the species for all times” (Huff interview with McDonough, 2013).
Mary O’Brien, in her book Making Better Environmental Decisions: An Alternative to Risk Assessments, notes that we are repeatedly given a very short list of risk reduction choices, and that the public is not effectively engaged in the decision-making process. She suggests that a broader range of options would allow us to see the possibilities for further reducing (or even eliminating) risks and that the process should be much more democratic in nature. O’Brien suggests the best approach to making effective environmental decisions is to use information, emotion, and a sense of relationship to others concurrently. By “others” she means other species, cultures, and generations (O’Brien, 2000). Her method is consistent with a nursing approach. Using her approach will require that nurses more actively engage in environmental health—assessing environ- mental health risks, developing risk reduction strategies, and supporting policies that embrace the precautionary principle and care for all of the children of all of the species for all times.
ENVIRONMENTAL HEALTH RISK REDUCTION Prevention is a core goal in every public health intervention. Preventing problems is less costly whether the cost is measured in resources consumed or in human health effects. Policies, as well as practices, can promote primary prevention. After we have assessed the environmental risks in our communities, we
prevention, appreciate and should advocate for a precautionary approach when it may prevent injuries or illnesses. The ANA has adopted the precautionary principle as the basic tenet on which to guide its environmental advocacy work.
The bottom line is that life depends on the environment, and what humans do collectively can affect this vital resource for present and future generations. A central concept in Native American cultures is that humans are stewards, not proprietors, of the environment. Native Americans make the “Rule of Seven” central to all environmental decisions: What will be the effect
FIG 10-4 Aerial application of agricultural pesticides makes it very difficult to control exposures. The chemicals get tracked into homes in farming communities. (Copyright © 2011 Photos. com, a division of Getty Images. All rights reserved. Photo #87531230.)
Source: National Institute for Occupational Safety and Health (www.cdc.gov/niosh/99-104.html)
Agent Observed Effects Potentially Exposed Workers
Cancer treatment drugs (e.g., methotrexate) Infertility, miscarriage, birth defects, low birth weight Health care workers, pharmacists Organic solvents (e.g., toluene, xylene,
formaldehyde) Miscarriage Health care workers, laboratory workers, print shop
and manufacturing employees Lead Infertility, miscarriage, low birth weight, developmental
disorders Battery makers, solderers, welders, bridge
repainters, firing range workers, home remodelers Strenuous physical tabor (e.g., prolonged
standing, shift/night work) Miscarriage, preterm delivery Many types of workers
Cytomegalovirus Birth defects, low birth weight, developmental disorders Health care workers, workers who have contact with infants and children
Parvovirus B19 Miscarriage Health care workers, workers who have contact with infants and children
Rubella Birth defects, low birth weight Health care workers, workers in who have contact with infants and children
Toxoplasmosis Miscarriage, birth defects, developmental disorders Animal care workers, veterinarians Varicella zoster Birth defects, low birth weight Health care workers, workers who have contact
with infants and children
TABLE 10-1 Workplace Hazards to Women of Reproductive Age*
*This list is not complete. Information about these hazards is constantly being revised. Readers should not assume that a substance is safe if it is missing from this list.
232 PART 3 Conceptual and Scientific Frameworks
exposures to potentially hazardous chemicals. Industrial hygien- ists are public health professionals who specialize in workplace exposures to hazards—physical, chemical, and biological—that create the conditions for health risks (Box 10-8 presents the industrial hygiene hierarchy of controls). Once it is estab- lished that a human health threat exists, develop a plan of action—a way of eliminating or managing (reducing) the risk. Risk management should be informed by the risk assessment process and involves the selection and implementation of a strategy to eliminate or reduce risks.
Box 10-9 lists the 3 Rs for reducing environmental pollution.
Nursing interventions to reduce environmental health risks can take many forms. Education is one example of a nursing intervention. By working with a wide array of community
can apply the basic principles of disease prevention when plan- ning intervention strategies. For lead exposure, remediating a home with lead-based paint to make it lead safe applies the primary prevention strategy of removing the exposure (at least from that specific source of lead) (Figure 10-5). Even good lead poisoning surveillance will not prevent lead exposure, but may help with early detection of rising blood lead levels. Such sur- veillance is a secondary prevention strategy. Finally, when a symptomatic child is seen, it is important to have a health care system readily available in which specialists familiar with lead poisoning will provide swift medical interventions to reduce blood lead levels, thus reducing the risk of further harm. This is a tertiary prevention response. Box 10-7 presents examples of risk reduction strategies for nurses in the health care setting.
Industrial Hygiene Hierarchy of Controls For workplace exposures, industrial hygienists have developed a “hierarchy of control” for avoiding or minimizing employee
FIG 10-5 Lead can be found in many places in a home. Nurses should help families learn about these sources and take actions to remove any lead-based paint using certified professionals. Good hygiene is key to reducing lead dust exposure, especially given that urban soot will often have lead from the legacy of lead used in gasoline for many decades. (From U.S. Environ- mental Protection Agency. Available at http://www.epa.gov/ lead/pubs/leadpdfe.pdf. Accessed December 29, 2010.)
Protect Your Family From Lead In Your Home
United States Environmental Protection Agency
EPA United States Consumer Product Safety Commission
United States Department of Housing and Urban Development
Available at http://www.gdrc.org/u-gov/precaution-3.html. Retrieved March 12, 2015.
In 1998 an international group of health and public health professionals, scientists, government officials, lawyers, grassroots activists, and labor activ- ists met at a conference center called “Wingspread” in Wisconsin to define the “precautionary principle.” The group issued the following consensus statement:
The release and use of toxic substances, the exploitation of resources, and physical alterations of the environment have had substantial unintended consequences affecting human health and the environment. Some of these concerns are high rates of learning deficiencies, asthma, cancer, birth defects and species extinctions, along with global climate change, stratospheric ozone depletion and worldwide contamination with toxic substances and nuclear materials.
We believe existing environmental regulations and other decisions, par- ticularly those based on risk assessment, have failed to protect ade- quately human health and the environment the larger system of which humans are but a part.
We believe there is compelling evidence that damage to humans and the worldwide environment is of such magnitude and seriousness that new principles for conducting human activities are necessary.
While we realize that human activities may involve hazards, people must proceed more carefully than has been the case in recent history. Corpo- rations, government entities, organizations, communities, scientists and other individuals must adopt a precautionary approach to all human endeavors.
Therefore, it is necessary to implement the Precautionary Principle: When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof.
The process of applying the Precautionary Principle must be open, informed and democratic and must include potentially affected parties. It must also involve an examination of the full range of alternatives, including no action.
BOX 10-6 Wingspread Statement on the Precautionary Principle
Wingspread Statement on the Precautionary Principle, Racine WI, 1998.
233CHAPTER 10 Environmental Health
members, nurses can help a community understand the rela- tionship between harmful environmental exposures and human health and guide the community toward risk reduction on the basis of both individual behavior changes, as well as community- wide approaches. In communities in which radon is likely to be a naturally occurring exposure, nurses can educate the com- munity about the health risks, methods to measure radon levels in a home, and how to address unhealthy radon levels.
Nurses work with individuals, families, and communities in all three levels of prevention. For example, in Planned Parent- hood Clinics in the United States, as a form of primary preven- tion, clinicians ask clients about possible environmental health risks in their everyday lives and then direct them to safer prod- ucts and healthier behaviors to decrease potentially toxic expo- sures. Secondary prevention takes place when pediatric clinics include lead screening as part of their protocols. By doing so they are apt to find children with elevated blood lead levels, which then allow them to act to decrease the child’s environ- mental lead exposures. This form of secondary prevention does not actually prevent the exposure but calls for action based on evidence of exposure. If a child has a seriously high blood lead level, the child would be admitted to the hospital for chelation therapy which is a process used to decrease the body’s burden of lead.
In the health care setting (hospital, clinic, home health), we have many oppor- tunities to make environmentally friendly and healthy choices: • Shift to electronic records, thus avoiding the use of paper. When paper is
a must, use products that are made from recycled ingredients • Recycle: paper, glass, cans, plastic, small batteries, blue wrap, electronic
equipment • Work with suppliers to get products with minimum packaging and the
safest ingredients possible: “environmentally preferable purchasing” • Promote the use of green cleaners • Go fragrance free by using fragrance-free products in the hospital and
creating a policy that requires employees to use fragrance-free personal care products (shampoos, creams, etc.)
• Turn off lights AND computers AND patient monitoring equipment when rooms are not being used
• Report leaky sinks, toilets, and other plumbing sources • Promote the purchase of local, sustainably grown foods (with a preference
for organic, no use of GMOs, no use of unnecessary antibiotics, and no pesticides)
• Start a hospital/clinic/health department garden • Start a Green Team, or join the existing one in your institution • Create community while doing these activities and build relationships—it
makes the whole process more meaningful and fun!
BOX 10-7 Risk Reduction: Every Nurse’s Role
LEVELS OF PREVENTION
Primary Prevention Eliminate lead-based paint and lead-based paint dust from the home.
Secondary Prevention Provide blood lead testing of children in communities with older housing stock.
Tertiary Prevention When a child presents with extremely elevated blood lead levels, make sure the child is being cared for by a health professional who is familiar with clini- cal interventions to reduce blood lead levels using clinical (chelating medica- tions) interventions, while concurrently assuring that the child returns to a lead-safe place.
The clinical intervention is tertiary prevention. It neither prevents the expo- sure, nor focuses on decreasing the exposure, but rather focuses on decreas- ing the potential health sequela associated with elevated lead levels.
Example Applied to Lead-Based Paint Exposure
Risk Communication Risk communication is both an area of practice and a skill that is a composite of two separate words: “risk” and “communica- tion.” Risk is a familiar term in nursing practice. It is understood in the health context when we counsel patients about the risks of pregnancy, communicable disease (especially sexually trans- mitted disease), unintentional injury, and risk associated with personal choices (e.g., smoking, alcohol consumption, and diet). Risk assessment in environmental health focuses on char- acterizing the hazard (the “source”), its physical and chemical properties, its toxicity, and the potential exposure pathways— mode of transmission, route of exposure, receptor population, and dose. In their seminal work on risk communication,
The “3 Rs” adage of the environmentalist community—reduce, reuse, and recycle—helps us consider ways to decrease our personal impact on the environment, and thereby decrease environmental health risks. These con- cepts can apply to our health care settings, as well as our homes. By recycling, we prevent the need to extract more resources from the earth to manufacture products. By recycling, we also prevent products from unnecessary landfilling or incineration. Choosing reusable products, versus single-use devices and products, similarly prevents the need for manufacturing more products and decreases the waste stream. Reducing our waste stream can also be accom- plished generally by a reduction in consumption (buying less “stuff,” as well as by reducing unnecessary packaging and other nonessential goods). The “Story of Stuff” (www.thestoryofstuff.org) provides an excellent overview of the “cradle to grave” travels of products and the full range of their human and ecological impacts.
BOX 10-9 The 3 Rs for Reducing Environmental Pollution
Eliminate unnecessary toxic chemicals. Substitute less hazardous or nonhazardous substances (e.g., using water-
based vs. solvent-based products). Isolate the hazardous chemicals from human exposure (e.g., use closed
systems). Apply engineering controls (e.g., ventilation systems, including exhaust
hoods). Reduce the exposures through administrative controls (e.g., rotating
employees in areas with high exposures). Use personal protective equipment (e.g., gloves, respirators, protective
clothing).
BOX 10-8 Industrial Hygiene Hierarchy of Controls*
*In addition, education is a critical tool in the hierarchy of controls. Modified from Levy B, Wegman D: Occupational health: recognizing and preventing work-related disease and injury, ed 4, Philadelphia, 2000, Lippincott Williams & Wilkins.
234 PART 3 Conceptual and Scientific Frameworks
victims of passive smoking (involuntary) to stimulate public policy that limits or bans smoking in public places. When the emphasis on risk went from a voluntary choice of smokers to an involuntary exposure of nonsmokers, the outrage level of the nonsmoking public became high enough to result in legislation guaranteeing smoke-free public spaces (e.g., public buildings, airplanes, and restaurants).
On the other hand, outrage decreases when people receive information on the situation from a trusted source, and physi- cians and nurses are often cited in surveys as trusted sources of information on environmental risks (Kaiser Foundation, 2013). The public trust is a compelling incentive to match professional knowledge and skills to a community’s expectations. The outrage factor can also be a driving force in building credibility and trustworthiness in every person whose work involves inter- acting with the public.
Risk communication includes all the principles of good communication in general. It is a combination of the following: • The right information: Accurate, relevant, in a language that
audiences can understand. A good risk assessment is essen- tial information for shaping the message.
• To the right people: Those affected and those who are worried but may not be affected. Information on the community is essential: geographic boundaries, who lives there (i.e., demographics), how they obtain information (e.g., flyers or newspapers, radio, television, word of mouth), where they congregate (e.g., school, church, community center), and who within the community can help plan the communication.
• At the right time: For timely action or to allay fear.
GOVERNMENTAL ENVIRONMENTAL PROTECTION The government has a variety of tools to address environmental exposures. In addition to passing legislation, creating and enforcing standards and regulations, deciding how land should be used, providing permits, and supporting research, the gov- ernment is actively engaged in educating the public. Many federal agencies are involved in environmental health regula- tion, such as the EPA, the FDA, and the Department of Agricul- ture. The Department of Health and Human Services (DHHS) has two major research institutes, the National Institute of Environmental Health Science (NIEHS) and the National Insti- tute of Occupational Safety and Health (NIOSH). Within DHHS is the CDC (which includes the National Center for Environmental Health [NCEH] that is responsible for tracking environmental health trends, recommending clinical and public health practices, and also engaging in research). Every state has an agency responsible for environmental quality. At the city or county level, the local health department most often manages environmental health issues. However, environmental protec- tion issues are typically directed by the state using both federal and state laws. Box 10-12 lists key environmental protection laws.
Potentially harmful pollution that cannot be prevented must be controlled. An important step in the process of controlling pollution is permitting, a process by which the government
Sandman, Chess, and Hane (1991) noted that risk has tradition- ally been formulated as magnitude (the size, severity, extent of area, or population affected) multiplied by the probability (how likely exposure or damage is to occur) (Box 10-10). For example, an environmental risk assessment of a contaminated site would involve a calculation of the dose that might be received through all routes of exposure, the toxicity of the chemical, the size and vulnerability (age, health) of the population potentially exposed (resident, future resident, transient), and the likelihood of expo- sure. Sandman et al (1991) also noted that the reaction to things that scare people and the things that kill people are often not related to the actual hazard. They have gone further to probe what is behind those differences and identified a list of “outrage factors” to explain people’s responses to risk (Box 10-11). They maintain that the outrage is just as predictable and open to intervention as the science of addressing the hazard.
“Communication” of risk involves understanding the outrage factors relevant to the risk being addressed so they can be incor- porated in the message—the information—either to create action to ensure safety or prevent harm or to reduce unneces- sary fear. An example of raising outrage to produce action can be seen in the shift from emphasis on smokers (voluntary) to
Safer = Less Outrage Less Safe = More Outrage
12 Principal Outrage Components Voluntary Involuntary (coerced) Natural Industrial (artificial) Familiar Exotic Not memorable Memorable Not dreaded Dreaded Chronic Catastrophic Knowable (detectable) Unknowable (undetectable) Individually controlled Controlled by others Fair Unfair Morally irrelevant Morally relevant Trustworthy sources Untrustworthy sources Responsive process Unresponsive process
BOX 10-11 Outrage Factors: Characteristics of Risk That Contribute to the Public’s Feeling of Outrage
Risk has traditionally been defined by the following equation:
Risk magnitude probability= ×
There is a growing body of literature from practitioners and researchers who have studied the human reaction to risk—real and perceived. Sandman et al (1991) were the first to examine the “outrage” factor that can influence the way in which we perceive risk, particularly to environmental risks.
Risk hazard outrage= +
Addressing only the hazard is doing only half of the necessary work; addressing the response (outrage) is equally important.
BOX 10-10 Definitions of Risk
From Sandman PM, Chess C, Hane BJ: Improving dialogue with communities, New Brunswick, NJ, 1991, Rutgers University.
235CHAPTER 10 Environmental Health
National Environmental Policy Act (NEPA) The NEPA established the Environmental Protection Agency (EPA) and a national policy for the environment and provides for the establishment of a Council on Environmental Policy. All policies, regulations, and public laws shall be inter- preted and administered in accordance with the policies set forth in this act.
Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) FIFRA provides federal control of pesticide distribution, sale, and use. The EPA was given the authority to study the consequences of pesticide usage and requires users such as farmers and utility companies to register when using pesticides. Later amendments to the law required applicators to take certifica- tion examinations, registration of all pesticides used in the United States, and proper labeling of pesticides that, if in accordance with specifications, will cause no harm to the environment (summary from FIFRA, 1972).
Clean Water Act (CWA) The CWA sets basic structure for regulating pollutants to U.S. waters. The law gave the EPA the authority to set effluent standards on an industry basis and continued the requirements to set water quality standards for all contaminants in surface water. The 1977 amendments focused on toxic pollutants. In 1987 the CWA was reauthorized, and again focused on toxic pollutants, authorized citizen suit provisions, and funded sewage treatment plants.
Clean Air Act (CAA) The Clean Air Act regulates air emissions from aerial, stationary, and mobile sources. The EPA was authorized to establish National Ambient Air Quality Standards (NAAQS) to protect public health and the environment. The goal was to set and achieve the NAAQS by 1975. The law was amended in 1977 when many areas of the country failed to meet the standards. The 1990 amendments to the Clean Air Act intended to meet unaddressed or insufficiently addressed problems such as acid rain, ground level ozone, stratospheric ozone depletion, and air toxics. Also in the 1990 reauthorization was a mandate for Chemical Risk Management Plans. This mandate requires industry to identify “worst case scenarios” regarding the hazardous chemicals that they transport, use, or discard (summary from Clean Air Act, 1970).
Occupational Safety and Health Act (OSHA) The OSHA was passed to ensure worker and workplace safety. The goal was to make sure employers provide an employment place free of hazards to health and safety such as chemicals, excessive noise, mechanical dangers, heat or cold extremes, or unsanitary conditions. To establish standards for the workplace, the Act also created NIOSH (National Institute for Occupational Safety and Health) as the research institution for OSHA.
Safe Drinking Water Act (SDWA) The SDWA was established to protect the quality of drinking water in the United States. The Act authorized the EPA to establish safe standards of purity and required all owners or operators of public water systems to comply with primary (health-related) standards.
Resource Conservation and Recovery Act (RCRA) The RCRA gave the EPA the authority to control the generation, transportation, treatment, storage, and disposal of hazardous waste. The RCRA also proposed a framework to manage nonhazardous waste. The 1984 Federal Hazardous and Solid Waste Amendments to this Act required phasing out land disposal of hazardous waste. The 1986 amendments enabled the EPA to address problems from underground tanks storing petroleum and other hazardous substances.
Toxic Substances Control Act (TSCA) The TSCA gives the EPA the ability to track the 75,000 industrial chemicals currently produced in or imported into the United States. The EPA can require
reporting or testing of chemicals that may pose environmental health risks and can ban the manufacture and import of those chemicals that pose an unreason- able risk. TSCA supplements the Clean Air Act and the Toxic Release Inventory.
Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA or Superfund) This law created a tax on the chemical and petroleum industries and provided broad federal authority to respond directly to releases or threatened releases of hazardous substances that may endanger public health or the environment.
Superfund Amendments and Reauthorization Act (SARA) SARA amended the Comprehensive Environmental Response, Compensation, and Liability Act with several changes and additions. These changes included increased size of the trust fund; encouragement of greater citizen participation in decision making on how sites should be cleaned up; increased state involve- ment in every phase of the Superfund program; increased focus on human health problems related to hazardous waste sites; new enforcement authorities and settlement tools; emphasis on the importance of permanent remedies and inno- vative treatment technologies in clean-up of hazardous waste sites; and Super- fund actions to consider standards in other federal and state regulations. (Under Superfund legislation, the Federal Agency for Toxic Substances and Disease Registry was established.)
Emergency Planning and Community Right to Know Act (EPCRA) The EPCRA, also known as Title III of SARA, was enacted to help local communi- ties protect public health safety and the environment from chemical hazards. Each state was required to appoint a State Emergency Response Commission that was required to divide their state into Emergency Planning Districts and establish a Local Emergency Planning Committee (LEPC) for each district.
National Environmental Education Act The National Environmental Education Act created a new and better coordinated environmental education emphasis at the EPA. It created the National Environ- mental Education and Training Foundation.
Pollution Prevention Act (PPA) The PPA focused industry, government, and public attention on reduction of the amount of pollution through cost-effective changes in production, operation, and use of raw materials. Pollution prevention also includes other practices that increase efficient use of energy, water, and other water resources, such as recycling, source reduction, and sustainable agriculture.
Food Quality Protection Act (FQPA) The FQPA amended the Federal Insecticide, Fungicide, and Rodenticide Act and the Federal Food, Drug, and Cosmetic Act. The Act changed the way the EPA regulates pesticides. The requirements included a new safety standard of rea- sonable certainty of no harm to be applied to all pesticides used on foods.
Chemical Safety Information, Site Security, and Fuels Regulatory Act (Amendment to Section 112 of Clean Air Act) This act removed from coverage by the Risk Management Plan (RMP) any flam- mable fuel when used as fuel or held for sale as fuel by a retail facility (flam- mable fuels used as a feedstock or held for sale as a fuel at a wholesale facility are still covered). This Act required certain facilities to have in place a risk management program and submit a summary of that program, called a Risk Management Plan (RMP) to the EPA. The law has two distinct parts that pertain to: flammable fuels and public access to Off-Site Consequence Analysis (OCA) data. OCA is “worst-case scenario” data.
BOX 10-12 Environmental Laws
236 PART 3 Conceptual and Scientific Frameworks
places limits on the amount of pollution emitted into the air or water. A permit is a legally binding document.
Environmental standards may describe a permitted level of emissions, a maximum contaminant level (MCL), an action level for environmental clean-up, or a risk-based calculation; environmental standards are required to address health risks. It is the responsibility of potential polluters to operate within the regulations and standards. Compliance and enforcement are the next building blocks in controlling pollution. Compliance refers to the processes for ensuring that permit/standard/regu- latory requirements are met. Clean-up or remediation of envi- ronmental damage is another control step. Public information and involvement processes, such as citizen advisory panels or community forums, are integral to the development of stan- dards, on-going monitoring, and remediation.
POLICY AND ADVOCACY There are almost 3 million nurses in the United States today— approximately 1 in every 100 Americans is a registered nurse! Nurses can and should be a strong voice for a healthy environ- ment. As informed citizens, nurses can take a variety of actions to protect the environmental health of families, clients, and communities. Nurses are perceived as trusted messengers and as reliable sources of environmental health information and as such, have a responsibility to be informed and take action in the best interest of public health. Often, legislators are called to vote on environmental legislation without a sound understand- ing of how the legislation may affect public health. Nurses can serve as a resource for state and federal legislators and their staff. Although every nurse may not be an expert in all aspects of environmental health, every nurse does have a basic education in human health and has a sufficient understanding of who may be most vulnerable to environmental insult. Nurses’ thoughts about the potential impacts of new laws on the health of indi- viduals and communities are valuable to legislators and other policy makers, as well as the public.
Grounded in science and using sound risk communication skills, nurses become the most credible sources of information at community gatherings, formal governmental hearings, and professional nursing forums. Nurses work as advocates for envi- ronmental justice so that all members of the community have a right to live and work in an environment that is healthy and safe (Mood, 2002). Public health nurses also volunteer to serve on state, local, or federal commissions, and they know about zoning and permit laws that regulate the impact of industry and land use on the community. Many nurse legislators began their careers by advocating for the rights of others. Nurses must read, listen, and ask questions. Then, as informed citizens, they will be leaders, fostering community action to address environmen- tal health threats.
In 2008 the Alliance of Nurses for Healthy Environments was created to coalesce individual nurses and nursing organizations around issues associated with the environmental exposures and human health. This organization addresses the integration of environmental health into nursing education, practice (includ- ing greening the health care sector), research, and advocacy.
Environmental Justice and Environmental Health Disparities Some diseases differentially affect different populations. Certain environmental health risks disproportionately affect poor people and people of color in the United States. If you are a poor person of color, you are more likely to live near a hazard- ous waste site or an incinerator, and more likely to have children who are lead poisoned. You are also more likely to have children with asthma, which has a strong association with environmen- tal exposures. Campaigns to improve the unequal burden of environmental risks in communities of color and in poor com- munities are striving to achieve environmental justice or envi- ronmental equity.
In 1993 the Environmental Justice Act was passed, and in 1994 Executive Order 12898, “Federal Actions to Address Envi- ronmental Justice in Minority Populations,” was signed. This Act and the subsequent actions created policies to more com- prehensively reduce the incidence of environmental injustice by mandating that every federal agency act in a manner to address and prevent illnesses and injuries. Nursing interventions and involvement in environmental health policies can have a signifi- cant effect on the health disparities experienced by our most challenged communities.
Environmental Health Threats from the Health Care Industry: New Opportunities for Advocacy Many choices in the health care setting affect environmental health. Nurses often lead in reducing the use of mercury- containing products in hospitals. The use of mercury-containing thermometers and sphygmomanometers leads to a risk of breakage, which releases a highly toxic substance into the work- place. Further, when a hospital uses incineration to dispose of their waste, the mercury-containing products will create signifi- cant releases of mercury into the air, thus contaminating com- munities. This airborne mercury will be present in raindrops; when the airborne mercury lands on water bodies (e.g., lakes, rivers, or oceans), it is converted by the microorganisms in the water to methylmercury, which is highly toxic to humans. The methylmercury is then bioaccumulated in the fish: as larger fish eat smaller fish, the body burden of methylmercury increases significantly.
Many synthetic chemicals that contaminate the environment are referred to as persistent bioaccumulative toxins (PBTs) or persistent organic pollutants (POPs). These are chemicals that do not break down in air, water, or soil, or in the plant, animal, and human bodies to which they may be passed. Ultimately, since humans are at the top of the food chain, these chemicals may come to reside in our bodies. For instance, lead, which should not be found in the human body, can be found in the long bones of almost any human in the world because of its ubiquitous use and presence in our environment.
Dioxin, another pollutant that contaminates our communi- ties, is created, in part, by the health care industry. Dioxins are created when we manufacture or burn (incinerate) products that contain chlorine, such as bleached white paper or polyvinyl chloride (PVC) plastics. When dioxins are released into the
237CHAPTER 10 Environmental Health
makes information widely accessible, but finding an actual person to assist you or the communities you serve may not be as easy. One starting point may be the environmental epidemi- ology unit or toxicology unit of the state health department or department of environmental quality. The Association of Occu- pational and Environmental Clinics (AOEC) (http://www.aoec .org) is a national network of specialty clinics and individual practitioners available for consultation and sometimes for pro- vision of educational programs for health professionals. Through AOEC, you can also find the Pediatric Environmental Health Specialty Units; there are 10 throughout the country. These specialty units were specifically established to provide consultation on environmental health issues. Another local or state resource may be environmental health experts in nursing or medical schools or schools of public health.
Local resources include local health and environmental pro- tection agencies; poison control centers; agricultural extension offices; and occupational and environmental departments in schools of medicine, nursing, and public health. Some local and state agencies have developed topical directories to assist in accessing the appropriate staff for specific questions. Many of the resources have websites that allow ready access through the Internet and can be located by using any of the popular search methods. Box 10-13 presents an extensive list of environmental health agency resources.
The most active advocates for environmental health policies are grassroots organizations, the big environmentalist organiza- tions, and environmental justice organizations. To learn more about who these organizations are, see the Resource Section under nongovernmental organizations.
ROLES FOR NURSES IN ENVIRONMENTAL HEALTH Nurses can be involved in many environmental health roles, in full-time work, as an adjunct to existing roles, and as informed citizens. Nurses who are passionate about this issue can develop
environment, they are consumed by agricultural animals (e.g., beef and dairy cows, hogs, and poultry) and fish, where they are stored in fat cells as they work their way up the food chain. This phenomenon has resulted in dioxin deposition in breast tissue and been found in both cow and human milk. Virtually all women now have dioxin in their breast tissue. Dioxin, an endocrine-disrupting chemical and a strong carcinogen, is asso- ciated with several neurodevelopmental problems including learning disabilities and is now in every human’s body. The solution to this problem is to stop releasing dioxins into the environment. In the health care setting, one way to eliminate the creation and release of dioxins is to stop using products like PVC plastics and selecting safer alternatives by employing envi- ronmentally preferable purchasing policies and practices.
An international campaign called Health Care Without Harm is working to reduce and eliminate mercury and PVC plastic in the health care industry, as well as the elimination of incineration of medical waste. The ANA was a founding member of the Health Care Without Harm campaign, and nurses have taken many leadership roles in the activities in the United States and around the world. The Health Care Without Harm website (http://www.noharm.org) provides outstanding information on greening hospitals and resources about pollution prevention in the health care sector.
REFERRAL RESOURCES There is no one source of information about environmental health nor is there a single resource to which a public health nurse can refer an individual or community should an environ- mentally related problem be suspected. As mentioned earlier, the NLM’s ToxTown is a great starting place, and it allows the interested browser to dig deeply into environmental health content. TOXNET has an amalgamation of important databases and environmental health literature and additional peer- reviewed environmental health literature. The EPA is another rich source of information (www.epa.gov). Use of the Internet
The websites for each of these agencies can be accessed directly through the WebLinks feature on the book’s website at http://evolve.elsevier.com/ Stanhope.
Federal Agencies Agency for Toxic Substances and Disease Registry Centers for Disease Control and Prevention Consumer Product Safety Commission Environmental Protection Agency Office of Children’s Environmental Health Food and Drug Administration National Institute for Occupational Safety and Health National Institute of Environmental Health Sciences National Institutes of Health National Cancer Institute National Institute of Nursing Research Occupational Safety and Health Administration National Library of Medicine—TOXNET
State Agencies State Health Departments State Environmental Protection Agencies
Associations and Organizations American Association of Poison Control Centers American Association of Occupational Health Nurses Association of Occupational and Environmental Clinics Beyond Pesticides Center for Health and Environmental Justice Children’s Environmental Health Network Environmental Defense Environmental Working Group Health Care Without Harm National Environmental Education Foundation Natural Resources Defense Council Pediatric Environmental Health Specialty Units Society for Occupational and Environmental Health
BOX 10-13 Information and Guidance Sources for Referrals
238 PART 3 Conceptual and Scientific Frameworks
within agencies, working for industries or working as inde- pendent practitioners. Amendments to the Clean Air Act require major industrial sources of air emissions to have risk management plans and to inform their neighbors of specifics of the risks and plans (Clean Air Act, 1996).
• Epidemiologic investigations. Nurses need to have the skills to respond in scientifically sound and humanely sensitive ways to community concerns about cancer, birth defects, and still- births when citizens fear environmental causation.
• Policy development. Proposing, informing, and monitoring action from agencies, communities, and organization perspectives. The assimilation of the concepts of environmental health
into a nurse’s daily practice gives new life to traditional public health values of prevention, community building, and social justice. Box 10-14 presents the work of three nurses currently working in environmental health.
As nurses learn more about the environment, opportunities for integration into their practice, education programs, research, advocacy, and policy work will become evident and will evolve. Opportunities abound for those pioneering spirits within the nursing profession who are dedicated to creating healthier envi- ronments for their clients and communities.
research expertise, sit on commissions, write articles, and take national leadership roles. All nurses can include environmental exposures in their history taking; consider the environmental impacts of the products they select for their clinics, hospitals, schools, and other settings; promote recycling and reuse of products; and promote environmentally preferable purchasing. Each type and level of engagement is important. The following are some ways in which nurses can get involved both profes- sionally and as informed citizens: • Community involvement/public participation. Organizing,
facilitating, and moderating; making public notices effective and public forums accessible; welcoming input. Making information exchange understandable and problem solving acceptable to culturally diverse communities are valuable assets a nurse contributes. Skills in community organizing and mobilizing can be essential for a community to have a meaningful voice in decisions that affect them.
• Individual and population risk assessment. Using nursing assessment skills to detect potential and actual exposure pathways and outcomes for clients cared for in the acute, chronic, and healthy communities of practice.
• Risk communication. Interpreting, applying principles to practice. Nurses may serve as skilled risk communicators
In Baltimore, MD, Dr. Claudia Smith (a nurse who is on the faculty at the University of Maryland) directed a project in which nurses worked with com- munity members to address a variety of health problems associated with poor housing conditions. For this project, which was funded by the U.S. Department of Housing and Urban Development, Dr. Smith hired and trained community members to assess and reduce unhealthy conditions caused by lead-based paint, high levels of carbon monoxide, and asthma triggers (e.g., dust mites, pet dander, and pests); she taught community members about safer choices for pest control using the least toxic approach to pest management by using an inte- grated pest management approach.
After Denise Choiniere, a graduate student in community health who was working in the cardiac care unit (CCU) at the University of Maryland Medical Center, learned about the health effects associated with heavy metals, she was very uncomfortable with simply throwing away the batteries that were used in the many small devices, such as Holter monitors. Instead, she developed a battery recycling program for the CCU and the telemetry unit. She then discov- ered that her hospital purchased 97,000 small batteries every year. Each of these small batteries contains a heavy metal—mercury, lithium, cadmium, or lead. She was the driving force in developing a hospital-wide, small battery recycling program. This activity created a whole new career trajectory for Ms. Choiniere, who was recently appointed to the executive position of Sustainability Coordina- tor for the whole hospital. She has since addressed green cleaning products, promoted the recycling of “blue wrap” used in the operating rooms, and orga- nized a farmers’ market that meets weekly in front of the hospital, thus bringing locally grown and sustainably farmed products to hospital employees and the surrounding community. She then was given oversight for all of the 650-bed hospital’s purchases.
Dr. Robyn Gilden is a nursing faculty member who worked for 5 years with communities that knew or suspected that they were living near a hazardous waste site. She learned about the many laws and agencies involved in hazardous waste site assessments and clean-ups. Hazardous wastes can affect soil, water,
and air. Sources of contamination may come from old, unlined landfills; uncon- trolled dump sites; spills or discharges from industry; leaking underground storage tanks (like gasoline tanks); or runoff from fields. The Agency for Toxic Substances and Disease Registry (ATSDR), a federal agency responsible for documenting the health hazards associated with environmental exposures, maintains a listing of the most problematic contaminants found at polluted sites. They include a wide range of highly toxic chemicals including arsenic, lead, mercury, vinyl chloride, benzene, polychlorinated biphenyls (PCBs), and cadmium. These toxic chemicals top the list because they are the most commonly found contaminants and pose a significant threat to human health based on routes of exposure and level of toxicity. Dr. Gilden learned about the resources that are available for the best and most current toxicological information. The National Library of Medicine’s TOXNET and ATSDR’s websites, including their ToxFAQs, are some of the best sources of navigable information.
In working with communities, Dr. Gilden met with government officials, includ- ing mayors of small towns, as well as concerned parents, people from local governments, health departments, educational institutions, businesses, devel- opers, bankers, realtors, and other community members. She has also learned about the many statutes that cover hazardous waste sites, such as the Super- fund legislation (which covers the most polluted waste sites) and Brownfields legislation (which covers contaminated sites where economic development is involved). Both these pieces of legislation mandate community involvement, which is where Dr. Gilden’s community health and risk communication skills are used. Regardless of who is responsible for or in charge of a contaminated site, the nurse understands that the community must be an active and equal partici- pant. It is the community members who will be impacted by decisions and have to live with the results of clean-up and redevelopment. As is true of most nurses, Dr. Gilden quickly became a trusted person to the community members.
When she discovered the “Pesticide Warning” signs on the playing fields where her children played sports, this launched Dr. Gilden into a new area of research and advocacy regarding children’s exposures.
BOX 10-14 Examples of Three Modern-Day Environmental Health Nursing Pioneers
239CHAPTER 10 Environmental Health
P R A C T I C E A P P L I C A T I O N Following are two case scenarios related to exposure pathways. The first involves lead poisoning and the second, fracking- related concerns.
At the county health department, a 3-year-old boy named Billy presents with gastric upset and behavioral changes. These symptoms have persisted for several weeks. During your history taking, you discover that Billy’s parents have been renovating their old home. A parent in Billy’s daycare center suggested that Billy’s symptoms might be associated with lead, so Billy’s parents have brought him in to the clinic.
You relay this information to the primary care practitioner who, in turn, orders a blood lead level, which comes back at 45 mcg/dL. This is a very high value.
You research lead poisoning and discover that there are many potential health effects of lead exposure and that children are at greatest risk because their bodies, especially their nervous systems, are still developing. You also find that chronic lead poisoning may lead to long-term effects, such as developmental delays and impaired learning ability.
You let the health professional know about the lead poison- ing specialists in the nearby children’s hospital. On further investigation, you find that Billy’s home was built before 1950 and is still under renovation. Billy should not return to the home. At this point, the sanitarian from the local health depart- ment tests the dust in the home and finds high lead levels. Because of Billy’s age and associated behaviors, such as
hand-to-mouth activities, you determine that the lead dust in the home is the probable exposure. However, you must also consider multiple sources of exposure. 1. What other sources of exposure might exist? 2. What would you include in an assessment of this
situation? 3. What prevention strategies would you use to resolve this
issue? At the individual level? At the population level? Mrs. Bell calls the local health department to report that her
drinking water, from their private well, is discolored and that her son has been experiencing headaches and nose bleeds. You talk with Dan, the health department’s environmental health professional (sanitarian) who tells you that there is new “frack- ing” activity on the east side of your rural county, where Mrs. Bell and her family live, and that this may be the reason for the water discoloration and the child’s symptoms. You look up “fracking” and discover that the word is shorthand for hydraulic fracturing, a new technique for extracting natural gas that is fraught with community and health concerns. (For more infor- mation on fracking, see the Resource Section.) Dan and you agree to make a site visit to the Bell’s farm. 1. What will you be looking for on your visit? 2. How can you help the Bells, if any of their issues seem to be
associated with the nearby fracking site? 3. What other experts are available to you and the Bells?
Answers can be found on the Evolve site.
K E Y P O I N T S • Nurses need to be informed professionals and advocates for
citizens in their community regarding environmental health issues.
• Models describing the determinants of health acknowledge the role of the environment in health and disease.
• Climate change is creating profound risks to human health globally and in the United States.
• For most chemicals in our homes, work, schools, and com- munities, no research has been completed to determine whether or not they will cause health effects.
• Prevention activities include education, reduction/elimina- tion of exposures, waste minimization, energy policies, and land use planning.
• Pollution control activities include use of technologies; environmental permitting; environmental standards, moni- toring, compliance, and enforcement; and clean-up and remediation.
• Each nursing assessment should include questions and observations concerning potential and existing environmen- tal exposures.
• Useful environmental exposure data are difficult to acquire. Those data that exist can be used to aid in the assessment, diagnosis, intervention, and evaluation of environmentally related health problems.
• Both case advocacy and class advocacy are important skills for nurses in environmental health practice.
• Risk communication is a critical skill and must acknowledge the outrage factor experienced by communities with envi- ronmental hazards.
• Federal, state, and local laws and regulations, as well as inter- national treaties, exist to protect the health of people from environmental hazards.
• Environmental health practice engages multiple disciplines, and nurses are important members of the environmental health team.
• Environmental health practice includes principles of health promotion, disease prevention, and health protection.
• Healthy People 2020 objectives address both targets for the reduction of risk factors and diseases related to environmen- tal causes.
240 PART 3 Conceptual and Scientific Frameworks
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C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Explain why the source of drinking water is important to
investigate in the assessment of an unusually high number of infertility cases in a community; in increased lead levels in children from a certain school; and in an outbreak of a gastrointestinal epidemic in an agricultural community.
2. Discuss the use of the epidemiologic triangle in explaining the determinants of health.
3. Discover if your jurisdiction has a law or regulation for the disclosure of lead-based paint or radon levels for personal property as part of the act of sale for real estate. If your com- munity does not, investigate with the government officials of the community the reasons for the lack of a disclosure requirement.
241CHAPTER 10 Environmental Health
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242
Genomics in Public Health Nursing*
11
Elke Jones Zschaebitz, DNP, FNP-BC Elke Jones Zschaebitz is a nurse practitioner who has worked in the fields of school health, pediatrics, and women’s health, as well as in a telehealth practice in primary care. She received her BSN from Villanova University, her MSN-FNP from Midwestern State University in Wichita Falls Texas, and her DNP from Duquesne University in Pittsburgh, Pennsylvania. She currently is employed at the University of Virginia Student Health Center in Charlottesville, VA, and is part-time faculty for the Family Nurse Practitioner program at Georgetown University.
Dr. Lancaster is Professor and Dean Emerita of Nursing at the University of Virginia. She has edited this book with Dr. Marcia Stanhope through its previous eight editions.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Define key terms related to genetics and genomics. 2. Discuss the history of genomics and its integration into
public health nursing. 3. Describe the relationship between genomics, genetics, and
nursing.
4. Explain the core competencies related to genomics that nurses and selected other public health professionals should integrate into their practice.
5. Describe at least three potential implications of persons knowing their genetic information on clients, families, and communities.
K E Y T E R M S DNA, p. 245 epigenetics, p. 253 family health history, p. 251 genes, p. 245 genome, p. 243 genomics, p. 243 genetics, p. 243
genetic susceptibility, p. 254 Human Genome Project, p. 244 multifactorial diseases, p. 253 mutations, p. 245 pedigree, p. 251 —See Glossary for definitions
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz
• Case Studies • Glossary • Answers to Practice Application
*Special thanks are given to Gia Mudd-Martin, RN, MPH, PhD, Assistant Professor, College of Nursing, University of Kentucky for reviewing the manuscript, providing public health nursing input, and providing two of the case examples for the 8th edition of the chapter.
Jeanette Lancaster, PhD, RN, FAAN
243CHAPTER 11 Genomics in Public Health Nursing
“Mapping the human genome is the outstanding achieve- ment not only of our lifetime but in human history. This code is the essence of mankind, and as long as humans exist, this code is going to be important and will be used.”
T. Michael Dexter, Director of Wellcome Trust and contributor to the
Sanger Center for the Human Genome Project
THE HUMAN GENOME AND ITS TRANSFORMING EFFECT ON PUBLIC HEALTH The mapping of the human genome was a strategic inflection point in the history of health care that created a massive shift in how all health professionals provide care and how public health is approached. The understanding of the fundamental role genetics and genomics play in shaping the practice of public health nurses in the twenty-first century is in its early stages, although the rate of new knowledge is incredible. This chapter discusses the history of the field of genetics and genom- ics, what we know about genetics and genomics now, their impact on current nursing practice, and the prospects for sig- nificant changes in how nursing care is delivered. Clearly, nursing is being dramatically altered by new discoveries in molecular genetics. Examples of the effect on nursing include: (1) how nursing students are educated, (2) how nurses collect and use health histories, (3) how nurses learn and apply innova- tive biotechnology, (4) the role genetics and genomics will con- tinue to play in traditional nursing arenas such as prevention and health education, (5) the administration of innovative and evolving therapies, (6) the role epigenetics has in current research of disease, and (7) in ongoing public health debates including the moral, ethical, legal, and social issues around this powerful new field of knowledge.
It is important to recognize that the fields of genetics and genomics are continuously evolving, extremely complex, and involve personal health and ethical dilemmas surrounding the emergence of personal DNA discoveries. They have enormous implications for the detection, prevention, and treatment of human disease, not to mention educational and economic development. Learning about genomics and genetics opens many new possibilities, such as in the prevention and treatment
of human maladies ranging from cancer to cystic fibrosis and from autism to Alzheimer’s disease. To understand the effects of this knowledge in public health and in nursing, it is impor- tant to pull key snapshots from this highly detailed landscape in order to begin to describe this new territory that nursing practice occupies. This chapter provides a general overview of the history of the development of this new science and briefly discusses the current state of the science of genetics and genom- ics in relation to the role of the nurse and the future implica- tions for care of individuals, families, and populations. What is clear is that every nurse needs to become knowledgeable and to keep current with ongoing discoveries regarding genetics and genomics and their effects on populations.
In this chapter, the term genetics refers to the study of the function and effect of single genes that are inherited by children from their parents. Genomics is the study of all of a person’s genes, including their interaction with one another as well as the interaction of a person’s genes with the environment. Genomics examines the molecular mechanisms and the inter- play of genetic and environmental, and of cultural and psycho- social, factors in disease. Genomics deals with the functions and interactions of all genes in an organism and is the study of the total DNA structure (Perry, 2011).
A BRIEF HISTORY OF THE SCIENCE It is important to understand the evolution of genetic and genomic knowledge. The concept of this hereditary informa- tion began with agriculture in the eighteenth century by Gregor Mendel, an Austrian monk who is usually considered to be the father of genetics. At about the same time, Charles Darwin expounded on the theories of evolution, and Darwin’s cousin, Francis Galton, performed family studies using twins in an effort to understand the influence of heredity on various human characteristics.
A major breakthrough occurred on February 28, 1953, in Cambridge, England, when James Watson and Francis Crick announced that they had figured out the structure of deoxyri- bonucleic acid (DNA), and that this double-helix structure could unzip to make copies of itself—thus confirming that DNA carries life’s hereditary information, or the secret to life (McKusick, 2007). H.J. Muller later demonstrated the genetic
C H A P T E R O U T L I N E The Human Genome and Its Transforming Effect on
Public Health A Brief History of the Science DNA and Its Relationship to Genomics and Genetics
The Challenges of Genetic and DNA Testing Current Issues in Genomics and Genetics
Ethical and Legal Considerations Personalized Health Care Genomic Competencies for the Public Health Workforce
Incorporating Genomics and Genetics into Public Health Nursing Practice
Professional Practice Domain: Nursing Assessment: Applying/Integrating Genetic and Genomic Knowledge
Identification Referral Provision of Education, Care, and Support
Application and Practice: Mapping out a Pedigree The Future
244 PART 3 Conceptual and Scientific Frameworks
for families, and it is important for nurses to help individuals and communities understand the purpose, limitations, poten- tial benefits, and potential risks of a test before submitting samples for analysis. The controversies surrounding the infor- mation derived from tests, particularly home testing, include the trust and decision making individuals might make depend- ing on the information derived. The Food and Drug Adminis- tration has urged the medical community to focus on educating health care providers and patients about the benefits—and limitations—of genetic testing (Szoka, 2013). The issues of genetic screening and prophylactic treatments alone are stag- gering and will require the full resources of the nursing profes- sion to find answers. The following case illustrates many of the complex issues in genetics and genomics.
consequences of ionizing radiation on the fruit fly, and the theoretical basis of population genetics was developed by three prominent individuals: Ronald Fisher, J.B.S. Haldane, and Sewall Wright. Genetic diseases and their mode of inherited anomalies such as phenylketonuria, sickle cell disease, Hunting- ton’s disease, and cystic fibrosis were established. In the same decade that Watson and Crick discovered DNA, the correct specification of the number of human chromosomes was deter- mined. Because of this 1956 discovery, one of the new findings in genetics included the discovery in 1959 that Down syndrome is caused by an extra copy of chromosome 21. The scientific revolution was underway.
To date, the Human Genome Project (HGP), an interna- tional research project funded by the U.S. Congress in 1988 and completed in 2003, has mapped all of the approximately 25,000 genes in human DNA. This enormous project reflects the work of scientists from 20 research centers in six countries: China, France, Germany, Japan, the United Kingdom, and the United States (National Institutes of Health, 2014). The stated goals of the HGP were determining the sequences of the 3 billion chemi- cal base pairs that make up human DNA; storing this informa- tion in databases; improving tools for data analysis; transferring related technologies to the private sector; and addressing the ethical, legal, and social issues (ELSI) that may arise. The direc- tor of the Project was Francis Collins, MD. Dr. Collins and his team developed a conceptual vision for their work that had three overarching themes: 1. Genomes to biology to look at how the study of genomics
would affect the future understanding of biology. 2. Genomes to health to help explain the underlying mecha-
nisms for human health and disease including the gene-gene, gene-environment, and their interactions.
3. Genomes to society to provide the foundation for research to improve the use and interpretation of genetic and genomic information and technologies (Collins et al, 2003). Interestingly, two key findings from early work to sequence
the human genome were that all humans are 99.9% identical at the DNA level and nearly 25,000 genes make up the human genome (Perry, 2011). Most of the 0.1% of genetic variations are found within and not among populations. These findings have implications for public health with its emphasis on popu- lation health. Francis Collins, who directed the HGP, compared the project to a book that had many different uses. He said, “It’s a history book: a narrative of the journal of our species through time. It’s a shop manual, with an incredibly detailed blueprint for building every human cell. And it’s a transformative book of medicine, with insights that will give healthcare providers immense new powers to treat, prevent, and cure disease” (Collins, 2006, p. 1).
Many implications for health care have emerged from this project, including ethical and moral dilemmas that continue to be challenging. As health information advances, genomics has influenced the availability of genetic tests. Clinical tests and home testing kits such as 23andMe, a direct-to-consumer per- sonal genome service, are giving individuals and families infor- mation regarding ancestry. See www.23andme.com/ for more information on this test. Many of these tests have implications
WHAT DO YOU THINK? Case Example: Screening for Breast or Ovarian Cancer Risk During an initial visit to the High Risk Breast and Ovarian Cancer Clinic, a 37-year-old, Ms. Brown, a Medicaid patient referred to this specialty clinic from a primary care provider, reports that she had found a mass during a self-breast examination in 2006. She subse- quently had the mass inspected by a clinician and underwent a mammogram, which showed a suspicious finding. A breast core- biopsy was performed and the pathology report indicated that she had atypical ductal hyperplasia. Ms. Brown then had a breast lumpectomy, and the lump was benign. In 1996, she had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. Ms. Brown briefly took hormone replacement therapy but stopped in 2006 when the breast mass was identified. She began Evista therapy as a breast cancer reduction measure, but after 6 months she stopped the medication because of the side effects. Ms. Brown reports that she is not entirely opposed to considering using Evista again. Her family history indicated that a paternal grandmother likely had a type of “female cancer.” This grandmother died in her middle 30s to early 40s. There were also three cousins on the paternal side of the family who had unilateral breast cancer when they were in their 30s and 40s.
On the maternal side of the family, her grandmother was diag- nosed with breast cancer when she was in her 40s. She is alive and doing well at age 72. One of the grandmother’s sisters had lymphoma and died in her late 60s. A maternal great-aunt who was a sister to her maternal grandfather, not maternal grandmother, died in her 70s of ovarian cancer. A sister to her maternal great-aunt (another mater- nal great-aunt) died in her 70s or 80s of a primary brain cancer.
Reflect on the following questions and see what implications they have for nursing action and for public health concerns: 1. What are some possible issues that could arise if Ms. Brown has
a positive test? What legal and ethical issues would you con- sider? What considerations would you take into account if she has a teenage daughter?
2. What effect would the client’s literacy level have on how you would handle this case?
3. What if Ms. Brown’s Medicaid insurance would not pay for this costly test?
4. If you were caring for a family with multiple family members who obtain genetic testing and some members are found to be genetic mutation carriers while others are not, what would you anticipate might occur in relation to family dynamics? What actions might you take? Consider the referrals you might make.
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normal cells of higher organisms. It is estimated that repair mechanisms correct at least 99.9% of initial errors.
Hundreds of chemicals are now known to be mutagenic in laboratory animals. Among these are nitrogen mustard, vinyl chloride, alkylating agents, formaldehyde, sodium nitrite, and saccharin. In addition, ionizing radiation, such as those pro- duced by x-rays and from nuclear fallout, can promote chemical reactions that change DNA bases or break the bonds of double- stranded DNA.
How does an understanding of DNA and the science of genetics relate to public health nursing? In essence, this brief history of the field of genetics shows that human disease comes from the collision between genetic variations and environmen- tal factors. As knowledge has evolved with the mapping of the human genome, our understanding of this interaction contin- ues to advance. This has increased knowledge about disease prevention and new methodologies for the practice of public health. We are learning to integrate more effectively our under- standing of biological determinism within a social context affecting the delivery of health care.
Most hereditary cancer syndromes are inherited in an auto- somal dominant pattern with variable expression and incom- plete penetrance, which means: • Genes exist as pairs. • A gene pair member can occur as either the normal, unal-
tered form or as a mutation. • A mutation in one member of the pair is associated with an
increased risk to develop certain types of cancer. If a person has a mutation in a hereditary cancer syndrome–related gene, she or he has both a normal form and an altered form of that gene in each of the cells.
• Both men and women carry, pass on to children, and inherit these mutations.
• For mutation carriers, the hereditary cancer syndrome can be mild or more severe.
• Whether or not cancer ever develops, the site at which it develops, or the seriousness of the cancer can vary among different people with the same mutation, even within the same family.
(See http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA.)
The Challenges of Genetic and DNA Testing Tests are now available to evaluate for more than 1600 genetic disorders ranging from single-gene disorders, such as cystic fibrosis, to more complex disorders, such as diabetes (CDC, 2013). As will be discussed in a later section of the chapter, taking a family history is a useful place to begin when consider- ing a genetic connection and prior to the onset of testing.
DNA testing was first used in the late 1970s; today, the indi- cations for a DNA test have expanded to include predicting the development of genetic disorders, screening populations, con- firming clinical diagnoses, prenatal testing, and DNA testing to develop and apply individualized medical treatment. The next few years will see an explosion in the number of DNA tests driven by information generated from the HGP. Improved tech- nology will make DNA testing more accessible. These advances in genetics/genomics will necessitate that nurses continue to
DNA AND ITS RELATIONSHIP TO GENOMICS AND GENETICS At the core of the issues related to genetics and genomics is deoxyribonucleic acid (DNA). The structure of DNA is a nucleic acid that contains the genetic instructions used in the develop- ment and functioning of all known living organisms and some viruses. DNA is the chemical inside the nucleus of a cell that has the genetic instructions for making living organisms. DNA can be compared to long-term storage or a blueprint or code to construct other components of cells such as proteins and ribo- nucleic acid (RNA) molecules. The DNA segments that carry the genetic information are called genes. Within cells, DNA is organized into long structures called chromosomes. These chromosomes are duplicated before cells divide, in a process called DNA replication. DNA is comprised of four bases: adenine (A), guanine (G), cytosine (C), and thymine (T). Genes are comprised of specific sequences of these bases.
Alterations in the usual sequence of bases that form a gene or changes in DNA or chromosomal structures are called muta- tions. A large number of agents are known to cause mutations (Jorde et al, 2010). These mutations, which are attributed to known environmental causes, can be contrasted with spontane- ous mutations, which arise naturally during the process of DNA replication. Approximately 3 billion DNA base pairs must be replicated in each cell division, and considering the large number of mutagens to which we are exposed, DNA replication is fascinatingly accurate (Jorde et al, 2010). A key reason for this accuracy is a mechanism called DNA repair, which occurs in all
Over 232,340 women in 2013 were diagnosed with new cases of invasive breast cancer, as well as an estimated 64,640 cases of in situ breast cancer (American Cancer Society, 2013). Epidemio- logic studies have established that family history is an important risk factor for both breast and ovarian cancer. “After gender and age, a positive family history of breast cancer is the strongest known predictive risk factor for breast cancer” (NCI, 2014, p. 2). It is important for the nurse to take a brief family pedigree as done above to identify inherited risk factors. If Ms. Brown were to have had a BRCA1 or BRCA2 mutation, many more implications for deci- sion making would arise, including prophylactic surgery for preven- tion of breast and/or ovarian cancer. In addition, men with a BRCA1 mutation are at increased risk to develop prostate cancer or colorec- tal cancer. Men who have the BRCA2 mutation are at risk for male breast cancer and pancreatic cancer. For women, both BRCA1 and BRCA2 mutation carriers have the greatest risk for breast and ovarian cancer. It is important when interpreting genetic informa- tion to be sensitive to the many issues involved, including emo- tional, socioeconomic, lifestyle, and environmental issues that may affect the onset of disease (Calzone et al, 2010).
“Life is a delicate balance based on a fragile harmony: moving only a little nitrogenous base, the whole structure will collapse. This is why every living organism, even the tiniest, is so important for science: it is an unrepeatable opportunity to study the diversity and the uniqueness of nature.”
L. Figarai quote from the European Society of Human Genetics
246 PART 3 Conceptual and Scientific Frameworks
individuals’ and family members’ decision-making processes. They must, at the same time, be well informed about genetic testing to provide accurate education to members of the public in order to support appropriate decision making.
Also, current methods of testing do not detect all of the mutations that can occur in some diseases, including hereditary cancer syndrome–related genes. If a mutation is detected during DNA testing, this would not confirm an absolute risk for cancer, but rather would indicate that a person is at increased risk to develop the cancers that are part of the particular hereditary cancer syndrome and may need high-risk management. Such a finding has implications for family members who might have inherited the same mutation, enabling them to undergo DNA testing specific to the identified mutation. Such focused testing is more accurate and cost-effective than testing for multiple potential mutations (NCI, 2014). In contrast, if DNA testing in a cancer-affected relative is negative, this does not indicate family members are not at risk. There might be a mutation in a different hereditary cancer syndrome gene than those tested. It is important to remember that many mutations associated with cancer susceptibility and familial syndromes have yet to be identified.
For these reasons, family history must also be considered. However, caution is needed in interpreting family history for several reasons: an inherited syndrome may not be evident for someone with a small family; not everyone is informed of their family’s history of disease; death of a family member may be unrelated to cancer, such as early accidental death; or members may have been adopted and this may not be known to others in the family. Finally, because most cancers are not hereditary, family history should be accompanied by assessment of shared familial environments.
Case Example 2 Sickle cell anemia is an autosomal recessive disease in which a gene mutation results in the production of structurally abnor- mal hemoglobin called hemoglobin S. Gene carriers have one normal form of the hemoglobin gene and one mutation, a condition called sickle cell trait. The highest rates of disease are among African Americans, with sickle cell anemia affecting approximately 1 in 500 African Americans and 8% of the popu- lation being carriers (anemia, sickle, National Center for Biotechnology Information [n.d.]; see http://www.ncbi.nlm.nih .gov/books/NBK22238).
Marge Covington is a public health nurse employed by a nonprofit, community-based organization that provides health care education and outreach services to members of the African American community in a large metropolitan area. The rate of sickle cell anemia among members of the community is higher than the national average. In response, Ms. Covington has implemented a program with the projected outcome to reduce disease rates among African Americans in the community. The program objectives are to (1) increase awareness of the disease in the community and (2) increase rates of carrier testing to support informed decision making regarding childbearing. To meet these objectives, Ms. Covington has initiated monthly educational sessions on sickle cell anemia and sickle cell trait at
learn about this area of science in order to respond effectively to the challenges of this new knowledge.
An example of this challenge is that of genetic testing for mutations associated with hereditary disease. The best way to identify whether there is a mutation in a family where a heredi- tary disease is suspected is to test the person who displays the most evidence of being a mutation carrier. This is usually a relative who has had a cancer that occurs typically as part of the hereditary cancer syndrome (e.g., breast or ovarian) that is sus- pected in the family.
The previous example could present a difficulty because family members who have had cancer may not agree to being tested for genetic mutations. This refusal presents challenges to the person who desires information that might affect decision making and his or her health. An additional ethical challenge encountered involves individuals without an insurance carrier that reimburses for genetic testing, or who may have a high deductible in the insurance policy. Some individuals also think that testing will decrease the quality of their life and make them anxious about the future if they were to discover they have a mutation. Other people fear a positive test result may lead to feelings of guilt about passing along a disease to children and grandchildren.
Case Example 1 K.N. is a 42-year-old mother with three daughters, ages 16, 18, and 22. She has an extensive family history of ovarian cancer. Because of her family history, K.N. is regularly screened per current treatment guidelines. K.N.’s mother, who was diagnosed with ovarian cancer at age 55, underwent genetic testing and was discovered to be a carrier of the BRCA2 gene mutation predisposing to breast and ovarian cancer. Despite undergoing frequent screening, several of K.N.’s aunts have died of ovarian cancer at an early age. K.N.’s husband wants her to be tested for the BRCA2 gene and, if positive, has encouraged her to undergo a prophylactic salpingo-oophorectomy. K.N. is concerned that a positive genetic test may result in loss of insurance coverage. She is also concerned that this will have a negative psychological impact on her children.
Joan Akins is a public health nurse at the county health department serving the area where K.N. resides. Ms. Akins has recently conducted a cancer awareness campaign that included public health education on hereditary cancer syndromes. K.N. contacts Ms. Akins to request advice on whether to undergo genetic testing. Ms. Akins actively listens to K.N.’s concerns and provides general information on genetic testing and the impli- cations of the test results for K.N. and for her children. She also discusses the newly enacted Genetic Information Nondiscrimi- nation Act (GINA) legislation that protects the public from genetic discrimination by employers and insurers. Ms. Akins encourages K.N. to talk with her gynecologist about her con- cerns and to make an appointment for genetic counseling, providing names and contact information for local genetic counselors who specialize in cancer genetics.
As mentioned, genetic testing decisions are personal and complex and can be controversial, leading to dissonance in families. It is important for public health nurses to respect
247CHAPTER 11 Genomics in Public Health Nursing
Federal Drug Administration (FDA) have oversight of genetic tests and products, whereas the Federal Trade Commission (FTC) has oversight of the advertising of these tests and prod- ucts. The National Institutes of Health (NIH), Health Resources and Services Administration (HRSA), and Agency for Health- care Research and Quality (AHRQ) support research related to genetic tests and products (CDC, 2014).
Keeping current with the changes in this scientific field with many complex systems in place is a challenging task. The National Human Genome Research Institute of the National Institutes of Health (NIH) provides reliable, up-to date genetics and genomics information related to patient management, cur- ricular resources, new National Institutes of Health and NHGRI research activities, and ethical, legal and social issues. Addition- ally, the Centers for Disease Control and Prevention (CDC) provides a “Genomics & Health Impact Update” periodically on their website for public use (NIH, 2014; CDC 2014).
Helping patients and families understand genetic predispo- sition to disease versus normal population risk and the impact of lifestyle and environment on health is another role for public health nurses. According to the CDC (2014), genomics plays a role in nine of the ten leading causes of death in the United Sates, most notably chronic diseases such as cancer and heart disease. There are multifactorial influences acting together to influence disease risk, physiological and mental health condi- tions, pathogenic DNA, and the therapies used to treat disease (Perry, 2011). For example, “common congenital malforma- tions, such as cleft lip and palate and neural tube defects, result from multifactorial inheritance, a combination of genetic and environmental factors” (Perry, 2011, p. 147). Box 11-1 presents examples of multifactorial diseases, or those caused by gene and environment interaction.
The issue of multifactorial interactions that lead to disease is becomingly increasingly recognized in occupational health. According to the CDC, advances in technology in the last few decades have increased our knowledge of the role that genetics plays in occupational diseases. In occupational health, one of the key issues relates to genetic changes that are acquired during a lifetime as a result of exposures and the interaction between genes and environmental factors. However, the use of genetic information in occupational safety and health research and
community centers throughout the area. She has also collabo- rated with a local hospital system to provide free biannual genetic counseling sessions with optional carrier screening at community health clinics.
Continuing education is important for public health nurses during this time of rapid integration of new genetic tests into health care practice. Only through ongoing education will public health nurses have the basis from which to appropriately educate the public regarding genetic testing. In addition, recog- nition of the role of gene–environment interactions in suscep- tibility to cancer and many other diseases underscores the importance of assessing risk from an environmental perspec- tive. Public health nurses offer this perspective as part of the larger interprofessional team needed to address the complex issues involved in genetic testing.
CURRENT ISSUES IN GENOMICS AND GENETICS
“Translating the knowledge we are gaining from gene dis- coveries into practical clinical and public health applications will be critical for realizing the potential of personalized health care and improving the health of the nation.”
Muin J. Khoury, MD, PhD, Director, CDC Office of Public Health Genomics
Many issues are involved in the growing field of genetics/ genomics. Selected issues are discussed in this section. Individu- als are learning the importance of having a family medical history. Some health care providers are unclear about how to accurately interpret the family history of a client who has had the initiative to collect it. Moreover, many clients are reluctant to disclose this family history for fear that it will affect their health insurance status or eligibility despite current laws in place designed to protect these clients.
Helping patients and families navigate through the disclo- sure process and uncovering their personal and family health history and understanding specific genetic tests is an important role for public health nurses. In addition, if patients are willing to make lifestyle changes or health decisions, the appropriate psychosocial support and education can be provided to clients and their families. Nurses play an important role in answering questions and assisting in challenges these clients and families face with making decisions when there is any suspicion of increased risk for genetically based diseases. To make things more confusing, companies market their tests and advertise directly to the public. This type of marketing has implications for nurses and other health care providers who need to provide the appropriate counseling about the implications and indica- tions for such testing. For example, marketing on the Internet complicates client decision making since it can provide con- sumers with easy access to genetic tests without involving a health care professional in the testing process. Even the clini- cally available genetic tests, which may provide legitimate test results, are difficult to interpret without genetic counseling. Currently, the Centers for Disease Control and Prevention (CDC), the Centers for Medicare Services (CMS), and the
Autism (strong genetic basis) Multiple sclerosis Neural tube disorders Asthma Cleft lip, palette Allergies Congenital heart disease Autoimmune disorders Coronary artery disease Bipolar disorder Type I diabetes Schizophrenia Type II diabetes Kidney stones Breast cancer Gallstones Colon cancer Obesity Lung cancer Peptic ulcer disease Rheumatic heart disease Gout Alcoholism
BOX 11-1 Examples of Multifactorial Disorders
248 PART 3 Conceptual and Scientific Frameworks
limits disclosure of such information, and (5) prohibits retali- ation against employees who complain about genetic discrimi- nation (USDHHS, 2009).
In accordance with GINA, genetic information is defined as information about the following: • An individual’s genetic tests (including genetic tests done as
part of a research study) • Genetic tests of an individual’s family members (defined
as dependents and up to and including fourth-degree relatives)
• Genetic tests of any fetus of an individual or family member who is a pregnant woman, and genetic tests of any embryo legally held by an individual or family member using assisted reproductive technology
• The manifestation of a disease or disorder in an individual’s family members (family history)
• Any request for, or receipt of, genetic services or participa- tion in clinical research that includes genetic services (genetic testing, counseling, or education) by an individual or an individual’s family members (USDHHS, 2010).
PERSONALIZED HEALTH CARE The importance of genetic developments to public health nursing practice is underscored by initiatives between the private sector and the public sector to improve population health through the use of genetic and genomic information. These included the initial goals for the Personalized Health Care Initiative instituted by the U.S. Department of Health and Human Services. Now policy makers and scientists agree that there are many factors involved in bringing new genomic tech- nologies into the marketplace, and consideration of these factors is influencing the direction of DHHS. Ensuring that new technologies are accessible is of particular concern. Policies and practices for large genomic databases still need to be developed (National Cancer Institute, 2014). See the box on Quality and Safety Education for Nurses.
Despite the need for ongoing policy and practice develop- ment, however, continual integration of genetics into public health remains the objective for Healthy People 2020. Screening and genetic testing for specific groups of individuals remain as the standard of practice while other routine screenings or tests are questioned for their impact on morbidity and mortality. Women with certain high-risk family health history patterns for breast and ovarian cancer, for example, could benefit from receiving genetic counseling to learn about genetic testing for BRCA1 and BRCA2 mutations. Surgery for women with these gene mutations could reduce the risk of breast and ovarian cancer by 85% or more.
The Evaluation of Genomic Applications in Practice and Prevention Working Group (EGAPP) supports the develop- ment of a systematic process for assessing the available evidence regarding the validity and utility of rapidly emerging genetic tests for clinical practice. This independent, multidisciplinary panel prioritizes and selects tests, reviews CDC-commissioned evidence reports and other contextual factors, highlights critical knowledge gaps, and provides guidance on appropriate use of
practice presents both potential benefits and concerns and raises medical, ethical, legal, and social issues that are emerging in policy and procedure and have an impact on society and individuals (CDC, 2010).
Ethical and Legal Considerations Discoveries in genetics, including those associated with the HGP, present complicated ethical issues for consumers, provid- ers, and health care policy makers. All humans have a right to be concerned about genetic science and its effect on their well- being. Therefore, in the face of this biotechnological revolution, nurses need to carefully review the ethical and legal implica- tions of genetic science.
The Code of Ethics developed by both the International Council of Nurses and the American Nurses Association emphasize the responsibility of nurses to work with other health care professionals to meet the social and health care needs of the public. They include in this mandate the right that people have to seek and receive genomic health care that is nondis- criminatory, confidential, and private and that enables patients to make informed decisions (ICN, 2012; ANA, 2001). Similarly, the International Society of Nurses in Genetics (ISONG, 1998) advocates for nurses at both the basic and advanced practice levels to be able to deliver genetic nursing care. ISONG further postulates that the genetic nurse at the basic level of preparation identifies genetic risk factors, provides nursing interventions, makes referrals, and proves health promotion education.
Logan Karns, a certified genetics counselor working in the prenatal genetics department at the University of Virginia Health System, describes many ethical dilemmas as medical science moves forward: “Our technological advances have always outpaced our ethical thinking about the consequences of what we’re doing. We need to have a measured thoughtful- ness about everything.” She describes genetic knowledge as unique: “a window from the past and a glimpse into the future” (Karns, 2010).
With the advancement of technology and science, the use of personal genetic information has been a source of controversy. In the past, private health information and genetic data had been available for agencies and resulted in genetic discrimina- tion and a denial of health insurance coverage for individuals and families.
On November 21, 2009, the Genetic Information Nondis- crimination Act (GINA) took effect through an act of the U.S. Congress. It was designed to prohibit the improper use of genetic information in health insurance and employment. This act prevents group health plans and health insurers from denying coverage to a healthy individual or charging higher premiums based solely on genetic predisposition to disease. This legislation also prohibits employers from using individu- als’ genetic information when making hiring, firing, job place- ment, or promotion decisions.
GINA does the following: (1) prohibits employers from dis- criminating against an employee based on genetic information, (2) places broad restrictions on an employer’s deliberate acqui- sition of genetic information, (3) mandates confidentiality for genetic information that employers lawfully collect, (4) strictly
249CHAPTER 11 Genomics in Public Health Nursing
HEALTHY PEOPLE 2020
The objectives for Healthy People 2020 include two new objectives that relate to genomics: • G-2: (Developmental) Increase the proportion of persons with newly diag-
nosed colorectal cancer who receive genetic testing to identify Lynch syn- drome (or familial colorectal cancer syndromes).
• G-1: Increase the proportion of women with a family history of breast and/ or ovarian cancer who receive genetic counseling.
genetic tests in specific clinical scenarios. Currently, EGAPP finds sufficient evidence to recommend offering genetic testing for Lynch syndrome, sometimes referred to as Hereditary Nonpolyposis Colorectal Cancer, or HNPCC, to individuals with newly diagnosed colorectal cancer to reduce morbidity and mortality in relatives (EGAPP, 2013).
GENOMIC COMPETENCIES FOR THE PUBLIC HEALTH WORKFORCE Public health professionals should know about genetics and how to apply current information to the health of individuals, families, and communities. Several significant health care pro- fessional groups have developed competencies for members of their workforces that include knowledge of genetics and genom- ics. The development of such competencies has grown consid- erably since the mapping of all human genes in the HGP. The CDC (2001) developed “Genomic Competencies for the Public Health Workforce” in 2001. See www.cdc.gov/genomics/ translation/competencies. The CDC’s contention is that all public health workers need to be aware of the advances in the science of genomics and incorporate the appropriate compe- tencies into their work. They developed seven sets of competen- cies that related to the work of the individual public health worker. The competencies discussed here are those designed for all public health professionals and are to be used in educational and training programs for public health professionals. Accord- ing to the CDC (2010), a public health worker should be able to perform the following: • Demonstrate basic knowledge of the role genomics plays in
the development of disease • Identify limits of his or her genomic expertise • Make appropriate referrals to those with more genomic
expertise The CDC goes on to list eight specific competencies for
public health professionals. They are not listed here because they are consistent with more recently developed competen- cies that are specific to nursing. The public health competen- cies can be found online at http://www.cdc.gov/genomics/ public.
Similar to the set of competencies developed by the CDC are those developed by the National Coalition of Health Profes- sional Education in Genetics (NCHPEG) to be included in all health professional education (NCHPEG, 2007). These compe- tencies, entitled “Core Competencies in Genetics for Health Professionals,” recommend that at a minimum health care pro- fessionals should be able to do the following: 1. Examine their competence of practice regularly to identify
areas of strength and areas where professional development related to genetics and genomics would be helpful.
2. Understand that health-related genetic information can have social and psychological implications for individuals and families.
3. Know how and when to make a referral to a genetics professional. NCHPEG goes on to group their competencies into the fol-
lowing areas: knowledge, skills, and attitudes. Their competen- cies are congruent with those developed by the CDC and the ones that will be discussed in more depth in the following section that pertain specifically to nursing. NCHPEG has also developed core principles in genetics related to (1) biological variation, (2) cell biology, (3) classical (Mendelian) genetics, (4) molecular genetics, (5) development, and (6) new genetic tech- nology (NCHPEG, 2009).
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Client-Centered Care Recognize the client or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the client’s preferences, values, and needs.
Important aspects of client-centered care include: • Knowledge: Describe strategies to empower patients or families in all
aspects of the health care process • Skills: Assess level of patient’s decisional conflict and provide access to
resources • Attitudes: Appreciate shared decision making with empowered patients
and families, even when conflicts occur
Client-Centered Care Question As the study of genomics becomes more integrated in health care through the rapid growth of personalized medicine, public health nurses may be required to provide the rationale behind the value of population-based health initia- tives. The following client-centered scenario speaks to this tension.
You are providing home care to a healthy newborn baby and mother. The baby is three weeks old and this is your first visit. Part of your education for the mother is to review the newborn’s vaccination schedule. Upon review of the baby’s next needed vaccinations, the mother states that she is interested in the baby’s care being based on the baby’s genetics, that she wants her baby to receive personalized medicine. The mother states that she has read an article about individualized approaches to vaccines. “What is recom- mended for the whole population might not be good for my baby.” • What probing questions might you ask to further understand this mother’s
position? • How do you address this mother’s concern about the lack of individual
consideration in population-based vaccination recommendations? • What information about personalized medicine will be helpful to this
mother? • What information about vaccines and vaccination schedules will be helpful
to this mother? • What Internet resources do you share with her, to address her questions
and concerns? • What conversation will you be ready to have in your second home visit
with this mother?
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver, College of Nursing.
250 PART 3 Conceptual and Scientific Frameworks
workforce. Their work led to the development of the genomic competences discussed later in this section (Jenkins and Calzone, 2007).
An advisory group developed a set of competencies in 2006 that were revised in 2008 to incorporate outcome indicators (Consensus Panel on Genetic/Genomic Nursing Competencies, 2009). These essential competencies apply to all registered nurses.
Professional Practice Domain: Nursing Assessment: Applying/Integrating Genetic and Genomic Knowledge The registered nurse: • Demonstrates an understanding of the relationship of genet-
ics and genomics to health, prevention, screening, diagnos- tics, prognostics, selection of treatment, and monitoring of treatment effectiveness
• Demonstrates ability to elicit a minimum of three-generation family health history
• Constructs a pedigree from collected family history informa- tion using standardized symbols and terminology
• Collects personal, health, and developmental histories that consider genetic, environmental, and genomic influences and risks
• Critically analyzes the history and physical assessment find- ings for genetic, environmental, and genomic influences and risk factors
• Assesses clients’ knowledge, perceptions, and responses to genetic and genomic information
• Develops a plan of care that incorporates genetic and genomic assessment information
Identification The registered nurse: • Identifies clients who may benefit from specific genetic
and genomic information and/or services based on assess- ment data
• Identifies credible, accurate, appropriate, and current genetic and genomic information, resources, services, and/or tech- nologies specific to given clients
• Identifies ethical, ethnic/ancestral, cultural, religious, legal, fiscal, and societal issues related to genetic and genomic information and technologies
• Defines issues that undermine the rights of all clients for autonomous, informed genetic- and genomic-related deci- sion making and voluntary action
Referral The registered nurse: • Facilitates referral for specialized genetic and genomic ser-
vices for clients as needed.
Provision of Education, Care, and Support The registered nurse: • Provides clients with interpretation of selective genetic and
genomic information or services
It is well established that new health technologies driven by the knowledge of human genetics can improve the safety, quality, and effectiveness of health care for every client in the United States (USDHHS, 2007) (myhealthcare.com). This per- spective on health care is proactive, focused on wellness by managing gene-based information to understand each indi- vidual’s requirements for the maintenance of his or her health, prevention of disease, and therapy tailored to each individual’s genetic uniqueness. An approach to health care that is inclusive of a genetic profile of each individual enables nurses and other health care professionals to design care highly customized to match individual needs. A continuing approach to health care, built on the knowledge of continual scientific discovery of the health applications from genetics and genomics can help improve health outcomes for individuals and families. An incorporated knowledge of environment, health-related behav- iors, culture, values, and the impact of social conditions such as poverty will provide additional arms of assessment when caring for patients. Genetic science emphasizes a fundamental public health nursing issue: the importance of understanding both biological predisposition to disease and the impact of behavior and social conditions on overall community health and well-being.
INCORPORATING GENOMICS AND GENETICS INTO PUBLIC HEALTH NURSING PRACTICE Public health nursing has long been concerned with environ- mental or social determinants of health and disease and has only recently become engaged in genomic variations within populations. The advances brought about by genomics, however, are dynamically changing our perceptions, as advancing knowl- edge enables health promotion and disease prevention pro- grams to be specifically directed at susceptible individuals and families, or at subgroups of the population, based on their unique genomic risk profile. Personalized health care based on a broad cultural and social context, a core value of public health nursing, will continue to be more predictive and preventive in nature. The public is beginning to expect that all nurses will use emerging genetic information and technology in their practice, in research, and in all forms of health education.
Nurses began applying genetic concepts to their practice in the 1970s. Some of these early nurses worked as genetic clinical coordinators and provided genetic counseling to persons with genetic diseases or who had risk factors for such disorders (Williams, 2002). The scope of the work for nurses in the field of genetics changed in the early 1990s when the BRCA1 gene for familial breast cancer was mapped and cloned. This moved the scope of practice from diagnosis and management to that of risk identification (Williams, 2002).
In 2000 the Health Resources and Services Administration (HRSA) convened an expert panel that described the impor- tance of integrating genetics content into nursing curricula. Not much action occurred in this regard for several years. In 2004, the National Human Genome Research Institute (NHGRI) and the National Cancer Institute (NCI) collaborated to develop a genetic and genomic training program for the U.S. nursing
251CHAPTER 11 Genomics in Public Health Nursing
Step Two: Draw a basic outline of the family tree using pedi- gree symbols (see Symbols used in Figure 11-1).
Step Three: Next to each family member’s name, write down everything you know about his or her health and medical history. You can also ask family members if you are uncertain. If a family member is adopted, you can possibly collect infor- mation on either or both the adopted and birth families.
Include the following information: 1) age or date of birth; 2) age or date of death and cause of death for family members who have passed away; 3) medical conditions and how old the person was when diagnosed with the condition; 4) where each side of the family comes from originally and pertinent cultural heritage (e.g., England, Iceland, Mexico, Ashkenazi or Eastern European Jewish) (see Figure 11-2).
• Provides clients with credible, accurate, appropriate, and current genetic and genomic information, resources, ser- vices, and/or technologies that facilitate decision making
• Uses health promotion/disease prevention practices that: • Consider genetic and genomic influences on personal and
environmental risk factors • Incorporate knowledge of genetic and/or genomic risk
factors (e.g., a client with a genetic predisposition for high cholesterol who can benefit from a change in lifestyle that will decrease the likelihood that the genetic risk will be expressed)
• Uses genetic- and genomic-based interventions and infor- mation to improve clients’ outcomes
• Collaborates with health care providers in providing genetic and genomic health care
• Collaborates with insurance providers/payers to facilitate reimbursement for genetic and genomic health care services
• Performs interventions/treatments appropriate to clients’ genetic and genomic health care needs
• Evaluates impact and effectiveness of genetic and genomic technology, information, interventions, and treatments on clients’ outcome (Consensus Panel on Genetic/ Genomic Nursing Competencies, 2009).
HOW TO Help Families Complete a Health History 1. Inform the family that a family health history is a written or
graphic record of diseases or health conditions present in their biological family.
2. Encourage the family to develop a three-generation history of biological relatives, their age of diagnosis of a chronic disease, and the age and cause of death of any deceased family members.
3. Explain to the family that this type of history is a useful tool to help them know about their health risks and to prevent disease in themselves and their close relatives.
4. Tell the family that the health history is not a one-time document, but rather one that should be updated periodically.
5. Suggest that the family consider using the CDC online tool “My Family Health Portrait” to collect and organize their family health history. The tool is available free at https://familyhistory.hhs.gov/ fhh-web/home.action in both English and Spanish.
APPLICATION AND PRACTICE: MAPPING OUT A PEDIGREE A pedigree is a drawing of a family tree used by medical profes- sionals and genetic counselors to assess families and try to spot patterns or indications that may be helpful in diagnosing or managing an individual’s health. The pedigree symbols are used globally (see example from the National Society of Genetic Counselors).
Step One: Talk to the client and/or family and ask questions, and collect all information to include: biological parents, broth- ers and sisters including half-siblings, children, grandparents, aunts and uncles, cousins, nieces and nephews, and include the family giving the history.
LINKING CONTENT TO PRACTICE
In addition to the organizations previously discussed who state that all nurses and public health professionals should have some level of competence in genetics and genomics, there is broader endorsement of this competency in terms of basic public health and public health nursing skills. Specifically, the Quad Council Competencies, which build on those of the Council of Linkages of the Public Health Foundation, state in Domain 36, under Public Health Sci- ences Skills, that nurses define, assess, and utilize the understanding of the health status of populations, determinants of health and illness, factors con- tributing to health promotion and disease prevention, and factors influencing the use of health services. This group also points out in Domain #8, Leadership and Systems Thinking Skills, that nurses should be able to utilize ethical standards of public health nursing practice as the basis of all interactions with organizations, communities, and individuals (Quad Council, 2011). This recom- mended skill would directly pertain to nursing practice that incorporates genetic and genomic competencies.
Although the public health nurse will not always use each of these competencies, the ones used will depend on the nature of the role of the nurse. Nurses work at all three levels (individual, family, and community) in providing care, services, and refer- rals as well as advocating for policy changes and for laws that protect the right to health. Nurses also promote assurance for access to care including genetic screening, privacy of health information, and certainty that no discrimination will be allowed.
The NCHPEG has developed a tool called “genetic red flags” that provides quick tips for risk assessment related to genetics. These tips can serve as a guide to help nurses provide careful and consistent assessments. The “genetic red flags” developed by the National Coalition of Health Professional Education in Genetics provide an excellent tool to determine if an individual or family might be at risk. The group says that the primary red flag for most common diseases is a large number of affected relatives who are closely related. Some of the red flags include the following: 1. Family history of multiple affected family members with the
same or related disorders, which may or may not follow an identifiable pattern in the family
2. Onset at an earlier age than expected. Condition occurrence in the gender that is least expected to have it
3. Disease occurrence in the absence of known risk factors
252 PART 3 Conceptual and Scientific Frameworks
Mexico England and Germany
3 2
P
Grandfather 65
Heart attack
Grandfather 60’s
Colon cancer
Mother 49
High blood pressure
You 15
Sister 18
Club foot
Uncle Adopted
47
Twins Non-identical
20
Half-sister (same mother, different father)
24
Father 50
High cholesterol
Aunt 47
Uncle 62
First cousins 30’s–40’s
First cousin 23
Brother 22
Niece 6 months
Nephew 2
Pregnancy loss
8 weeks
Grandmother 85
Grandmother 70’s
Breast cancer diagnosed 68
FIG 11-2 An example of a family pedigree for four generations. National Society of Genetic Counselors (2014), http://nsgc.org/p/cm/ld/fid=143.
FIG 11-1 Figures to use in a family pedigree. National Society of Genetic Counselors (2014), http://nsgc.org/p/cm/id/fid=193.
5 3
P
8
Male/boy
This line is used to show parents who are divorced/not together
Example: This shows that there are 5 boys and 3 girls
Example: This shows that there are 8 children
Female/girl
Adopted
Diagonal line is used to show that the person has died
Pregnancy loss. Include number of weeks, if known
P stands for current pregnancy, either unknown sex (diamond), boy (square), or girl (circle)
What if there is limited information about family members? • If you do not know names and ages of family members, but do
know the number of boys and the number of girls, you can do this:
• If you do not know the number of boys and the number of girls, use diamond with a number inside it (if total is known) or “?”
253CHAPTER 11 Genomics in Public Health Nursing
effective decisions. Knowing which populations have genetic risk for various diseases will lead nursing science to develop and apply public health interventions that will improve health out- comes and community well-being as well as reduce costs. Nurses will increasingly provide guidance on policy discussions affect- ing health and decisions to ensure confidentiality, provide pro- tection against discrimination based on genetic information, and regulate commercialized genetics products and services.
As the American Academy of Nursing (AAN) has asserted, public health nurses must be well positioned to incorporate evolving knowledge into practice. For people to benefit from widespread genetic and genomic discoveries, nurses must be competent to obtain comprehensive family histories, identify family members at risk for developing a genomic-influenced condition and genomic-influenced drug reactions, help people make informed decisions about and understand the results of their genetic and genomic tests and therapies, and refer at-risk people to appropriate health care professionals and agencies for specialized care (AAN, 2009).
“Nurses have always been ahead of their time in their focus on prevention and health promotion. As we move toward a more balanced health system with more focus and support for health promotion and disease prevention, the role of nurses will be more significant than ever before.”
David Satcher, MD, director, Satcher Health Leadership Institute, Morehouse School of Medicine,
and former U.S. surgeon general
Nurses bring a bio-behavioral perspective that includes an emphasis on prevention and health promotion for individuals, families, and communities. This enables nurses to bring consid- erable expertise to policy-making groups who are working in the area of genetics/genomics (Calzone et al, 2010).
4. Ethnic predisposition to certain genetic disorders 5. Close biological relationship existing between parents
(Genetics in Primary Care, 2014)
THE FUTURE At a time of rapid discoveries in genetics and epigenetics, nurses need to be current with the ongoing discoveries and new litera- ture surrounding these discoveries in order to help clients make
From Clark AE, Adamian M, Taylor JY: An overview of epigenetics in nursing. Nurs Clin of North America 48(4):649–659, 2013.
The term epigenetics refers to heritable changes in gene expression that do not involve changes to the underlying DNA sequence: a change in phenotype without a change in genotype. Epigenetic approaches in research examine complex, multifactorial diseases (e.g., cancer, pain, cardiovascular disease) as well as other health conditions and therapies such as pregnancy, childbirth, and immunotherapy that have an environmental component associated with the condition. Research in epigenetics can also include previous cohorts of populations in order to identify environmental factors affecting disease states and that impact one generation to the next. Epigenetic inheritance is an unconventional finding. It goes against the idea that inheritance happens only through the DNA code that passes from parent to offspring. It proposes that a parent’s experiences, in the form of epigenetic tags, can be passed down to future generations.
Epigenetic changes are regular and natural and can be influenced by several factors including age, the environment/lifestyle, and physical state. Many diseases and conditions that affect a population have a genetic/genomic element that is influenced by these factors. Epigenetic-related diseases have the following characteristics: 1) a heritability that cannot be fully explained by genetic inheritance patterns found in testing; 2) evidence of the influence of imprinting (e.g., maternal diet, or other in utero exposure to toxins, patho- gens, or drugs), which could influence the development of the disease in the offspring even into adulthood; and 3) increase in prevalence of these changes with aging.
Environmental factors on epigenetic changes can be examined using large cohort studies. Epigenetic studies, for example, have examined the impact of famine during the perigestational period to determine the impact on offspring of individuals who have experienced these extreme conditions. One particular study has demonstrated that children born during the period of the Dutch famine from 1944-1945 have increased rates of coronary heart disease and obesity after maternal exposure to famine during early pregnancy compared to those not exposed to famine. In other studies, DNA changes in insulin factors were also found to be associated with exposure to famine (Lumey, Stein & Susser, 2011; Jirtle and Skinner, 2007).
Nurse Use The authors provided an overview of how epigenetic research relates to nursing practice, and they make recommendations and provide online epigen- etic resources that will be useful for future nursing research. They also provide an overview of major epigenetic students in nursing including those specific to childbirth, preeclampsia, metabolic syndrome, immunotherapy cancer, and pain.
EVIDENCE-BASED PRACTICE LEVELS OF PREVENTION
Primary Prevention Since family members share genes, behaviors, lifestyles, and environments with one another that may influence their health, help people complete a family health history.
Secondary Prevention When you review the health history, observe for any diseases that may have a genetic basis; if found, immediately refer the person or family to the appro- priate health care provider. The goal of screening is to detect or define risk in low-risk groups and identify those people who should have diagnostic testing.
Tertiary Prevention If a genetic link to an early or a probable disease is found, guide the family in changing any behaviors in order to minimize the effect of the disease.
Applying the Three Levels of Prevention to Genetics and Genomics
254 PART 3 Conceptual and Scientific Frameworks
P R A C T I C E A P P L I C A T I O N T.S., a 4-year-old with hemophilia B, is attending his Head Start program this fall. His mother brought all of his medical supplies and needles so that staff could start an emergency IV infusion if the need arose. The possibility of needing to start an IV con- cerned the staff who were teachers, not health care workers. The mother was also anxious about her son being away from home and attending preschool for the first time. As the public health nurse who is responsible for providing health care for Head Start programs in your community, how do you manage the health care for this child while also ensuring safety and making sure that adequate plans are in place for this facility? A. Let T.S.’s mother know that she needs a note from T.S.’s physi-
cian before he can bring any medications to the facility.
B. Notify all of the student’s parents/guardians of T.S.’s condi- tion in order to set the guidelines and prevent possible bleeds. The children at the center should be aware of the condition, and the parents also need to educate their chil- dren to ensure extra precaution around T.S.
C. Organize a meeting between staff, educators, and parents of T.S. to educate about hemophilia. The aim is to educate key people to ensure T.S.’s safety while at Head Start. Answers can be found on the Evolve site.
K E Y P O I N T S • Genetics is the study of the function and effect of single
genes that are inherited by children from their parents. Genomics is the study of individual genes in order to under- stand the interplay of genetic, environmental, cultural, and psychosocial factors in disease.
• DNA is a nucleic acid that contains genetic information called genes.
• Genetic mutations can be caused by the environment or can be spontaneous and arise naturally during the process of DNA replication.
• Human disease comes from the collision between genetic variations and environmental factors.
• Genetic testing decisions are personal and complex and can be controversial, leading to challenging situations in families.
• The Genetic Information Nondiscrimination Act (GINA) of 2008 was designed to prohibit the improper use of genetic information in health insurance and employment.
• The use of genomics and how it relates to drug treatment will enable personalized health care and medicine to be tai- lored to each person’s needs; health, therefore, can be predic- tive and preventive in nature.
• According to the International Society of Nurses in Genetics (ISONG), the genetic nurse carries out the responsibility for
identifying genetic risk factors, providing nursing interven- tions, making referrals, and providing health promotion education. The advanced practice nurse can provide genetic counseling or refer to a genetic counselor and act as case manager for a person with or at risk for a disease that arises from a genetic susceptibility.
• Nurses can promote assurance for access to care, including genetic screening, the privacy of health information, and certainty that no discrimination will be allowed in treatment or screening for disease.
• The field of genetics/genomics is growing rapidly and will require nurses to continue to learn and to be aware of advances in research in this area.
• Genomics affects individuals, families, and communities. • Epigenetics is the study of heritable changes in gene activity
that are not caused by changes in the DNA sequence; it also can be used to describe the study of stable, long-term alterations in the transcriptional potential of a cell that are not necessarily heritable. Unlike simple genetics based on changes to the DNA sequence (the genotype), the changes in gene expression or cellular phenotype of epigenetics have other causes.
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Choose a disorder that has a genetic basis. Look at three sites
on the Internet to see what information is available for clients, families, and health professionals. Then evaluate the sites according to the following criteria: • Who wrote the information on the site? Is it written by a
health professional? Is it sponsored by a government organization that is a reliable source of health informa- tion such as the CDC? Is it peer reviewed?
• Is the information written at the literacy level that a client could understand?
• How would you improve the usefulness of these three sites based on the clients, families, and communities with whom you work?
2. Since public health nurses often identify groups within a community who are considered high risk for illness and then provide care to them as individuals, or to their families or in groups, choose a group in your community. Then develop a plan of care including appropriate referrals to other agencies and a comprehensive plan for follow-up.
3. Identify parent support groups in your community and inquire about attending a meeting.
255CHAPTER 11 Genomics in Public Health Nursing
REFERENCES American Academy of Nursing:
Nurses transforming health care using genetics and genomics, revisions submitted to American Academy of Nursing Board of Directors, January 22, 2009. Available at: http://www.aannet.org/ files/public/Genetic_White_Paper _1-22-09.pdf. Accessed June 12, 2014.
American Cancer Society: Breast cancer facts & figures 2013-2014. Atlanta, American Cancer Society, Inc. Available at: http:// www.cancer.org/acs/groups/ content/@research/documents/ document/acspc-042725.pdf. Accessed June 20, 2014.
American Nurses Association: Code of Ethics for Nurses with Interpretive Statements. Kansas City, MO, 2001, ANA. Available at: http:// www.nursingworld.org/ MainMenuCategories/ EthicsStandards/ CodeofEthicsforNurses/Code-of- Ethics.pdf.
Calzone KA, Cashion A, Feetham S, et al: Nurses transforming health care using genetics and genomics. Nurs Outlook 58(1):26–35, 2010. Available at: http:// www.nursingoutlook.org/article/ S0029-6554(09)00073-6/fulltext. Accessed on June 20, 2014.
Centers for Disease Control and Prevention: Genomics Translation: Genomic Workforce Competencies, 2001. Available at: http:// www.cdc.gov/genomics/translation/ competencies/. Accessed on June 20, 2014.
Centers for Disease Control and Prevention: Genetics in the workplace, 2010. http:// www.cdc.gov/niosh/topics/genetics/. Accessed on June, 20, 2014.
Centers for Disease Control and Prevention: Genomic testing, 2013. Retrieved from: http:// www.cdc.gov/genomics/gtesting/. Accessed on June 20, 2014.
Centers for Disease Control and Prevention: Genomics and health, 2014. Retrieved from: http:// www.cdc.gov/genomics/public/. Accessed on June 20, 2014.
Clark A, Adamian M, Taylor J: An overview of epigenetics in nursing. Nursing Clin N Am 48(4):649–659, 2013. Retrieved from: http://
www.sciencedirect.com/science/ article/pii/S0029646513000856. Accessed on June 20, 2014.
Collins FS, Green E, Guttmacher AE, et al: A vision for the future of genomic research. Nature 422:835–847, 2003. Available at: http://www.nature.com/nature/ journal/v422/n6934/full/ nature01626.html. Accessed on June 20, 2014.
Collins FS: An overview of the human genome project, 2006. Available at doi: 10.1111/j.1749-6632.1999. tb08532.x. Accessed June 20, 2014.
Consensus Panel on Genetic/Genomic Nursing Competencies: Essentials of Genetic and Genomic Nursing: Competencies, Curricula Guidelines, and Outcome Indicators, ed 2. Silver Spring, MD, 2009, ANA. Available at: http:// www.nursingworld.org/ MainMenuCategories/ EthicsStandards/ Genetics-1/Essential NursingCompetenciesand CurriculaGuidelinesfor GeneticsandGenomics.pdf. Accessed on June 20, 2014.
European Society of Human Genetics: Quotes from DNA-Day 2012. Quote from L. Haven Figari. Retrieved from: http:// www.dnaday.eu/quotes.htm. on June 20, 2014.
Evaluation of Genomic Applications in Practice and Prevention; EGAPP Working Group Recommendation, 2013. Retrieved from: http:// www.egappreviews.org/ recommendations/lynch.htm. Accessed on June 20, 2014.
Genetics in Primary Care: Genetic red flags, 2014. Available at: http:// www.geneticsinprimarycare.org/ YourPractice/family-Health-History/ Pages/Genetic%20Red%20 Flags.aspx. Accessed June 23, 2014.
International Council of Nurses: The ICN Code of Ethics for Nurses. Geneva, Switzerland, 2012, ICN.
International Society of Nurses in Genetics: Statement on Scope and Standards of Genetics Clinical Nursing Practice. Washington DC, 1998, ANA.
Jenkins J, Calzone KA: Establishing the essential nursing competencies for genetics and genomics.
J Nurs Scholarsh 39(1):10–16, 2007. Available at: http:// www.ncbi.nlm.nih.gov/pmc/articles/ PMC3099038/. Accessed on June 20, 2014.
Jirtle RL, Skinner MK: Environmental epigenomics and disease susceptibility. Nat Rev Genet 8:253–262, 2007. Retrieved from: http://www.nature.com/nrg/journal/ v8/n4/full/nrg2045.html.
Jorde LB, Carey JC, Bamshad MJ, editors: Medical Genetics, ed 4. Philadelphia, 2010, Elsevier.
Karns L, Genetics Counselor UVA Health System (2010). Interview by E. J. Zschaebitz (phone interview). Accessed May 5, 2010.
Lumey LH, Stein AD, Susser A: Prenatal famine and adult health. Ann Rev Pub Health 32:237–262, 2011. Available at: http:// www.annualreviews.org/doi/ pdf/10.1146/annurev- publhealth-031210-101230. Accessed on December 17, 2014.
McKusick VA: History of medical genetics. In Rimoin DL, Connor JM, Pyertiz RE, et al, editors: Emery and Rimoin’s Principles and Practice of Medical Genetics, vol 1, ed 5. London, 2007, Churchill Livingstone, pp 3–32.
National Cancer Institute: Genetics of breast and ovarian cancer, 2014. Available at: http://www .cancer.gov/cancertopics/pdq/ genetics/breast-and-ovarian/ HealthProfessional/page2. Accessed June 20, 2014.
National Center for Biotechnology Information: Anemia, sickle cell, n.d. Available at: http:// www.ncbi.nlm.nih.gov/books/ NBK22238. Accessed June 20, 2014.
National Coalition of Health Professional Education in Genetics: Core competencies for all health professionals, September 2009. Available at: www.nchpeg.org. Accessed June 12, 2014.
National Coalition of Health Professional Education in Genetics: Core principles in genetics, ed 3. September 2007. www.nchpeg .org. Accessed June 12, 2014.
National Institutes of Health: All about the Human Genome Project (HGP). From the National Human
Genome Research Institute, 2014. Retrieved from: http://www .genome.gov/10001772. Accessed June 20, 2014.
National Society of Genetic Counselors: Your genetic health:patient information, 2014. Accessed at: http://nsgc.org/p/cm/ ld/fid=143. Accessed on June 20, 2014.
Perry SE: Genetics, conception and fetal development. In Lowdermilk DL, Perry SE, editors: Maternity Nursing, ed 8. St Louis, 2011, Mosby, pp 135–167.
Quad Council of Public Health Nursing Organizations: Public health nursing competencies. Wheat Ridge, CO, 2011, QCPHNO.
Szoka B: FDA Oversteps on genetic testing: opposing view. USA Today December 16, 2013. Retrieved from http://www.usatoday.com/ story/opinion/2013/12/16/ genetic-tests-23andme-editorials- debates/4045823/?AID=10709313& PID=4003003&SID=m50q5aac4nvt.
U. S. Department of Health and Human Services: Personalized health care, 2007. Available at: http://www.hhs.gov/myhealthcare/. Accessed June 23, 2014.
U.S. Department of Health and Human Services: Guidance on the Genetic Information Nondiscrimination Act: implications for investigators and institutional review boards, 2009. Available at: http://www.hhs.gov/ohrp/policy/ gina.pdf. Accessed June 12, 2014.
U.S. Department of Health and Human Services: Healthy People 2020. Washington, DC, 2010. Accessed at: http://www .healthypeople.gov/2020/ topicsobjectives2020/ overview.aspx?topicid=15U.S. on June 20, 2014.
Wellcome Trust & the Sanger Institute: The first draft of the Book of Humankind has been read, 2012. Quoting Michael Dexter. Retrieved from: http:// www.sanger.ac.uk/about/ press/2000/draft2000/ mainrelease.html. on June 20, 2014.
Williams JK: Education for genetics and nursing practice. AACN Clin Issues 13(4):492–500, 2002.
256
Epidemiology
12
O B J E C T I V E S After reading this chapter, the student should be able to do the following:
1. Define epidemiology and describe its essential elements and approach.
2. Describe current and historical contexts of the development of the field of epidemiology.
3. Identify key elements of the epidemiologic triangle and the ecological model and describe the interactions among these elements in both models.
4. Explain the relationship of the natural history of disease to the three levels of prevention and to the design and implementation of community interventions.
5. Interpret basic epidemiologic measures of morbidity (disease) and mortality (death).
6. Discuss descriptive epidemiologic parameters of person, place, and time.
7. Describe the key features of common epidemiologic study designs.
8. Describe essential characteristics and methods of evaluating a screening program.
9. Identify the most common sources of bias in epidemiologic studies.
10. Evaluate epidemiologic research and apply findings to nursing practice.
11. Discuss the role of the nurse in epidemiologic surveillance and primary, secondary, and tertiary prevention.
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz
• Case Studies • Glossary • Answers to Practice Application
Swann Arp Adams, MS, PhD Dr. Swann Arp Adams has over 17 years of experience in clinical epidemiology. She holds a PhD in epidemiology and an MS in biomedical sciences. Dr. Adams has previous experience in a variety of research fields including physical activity, bone marrow transplantation, diabetes, breast cancer, and cancer disparities. She is the Associate Director of the Cancer Prevention and Control Program and is an associate professor with a joint appoint- ment in the College of Nursing and the Department of Epidemiology and Biostatistics at the University of South Carolina. Her current research work focuses on reducing the burden of cancer disparities experienced by African Americans. Past honors include the Doctoral Achievement Award (2004) and the Gerry Sue Arnold Alumni Award (2008) from the Arnold School of Public Health of the University of South Carolina.
Dr. DeAnne K. Hilfinger Messias is an international community health nurse, educator, and researcher. She spent more than two decades in Brazil, where she directed a primary health care project on the lower Amazon, taught women’s health and community health nursing, and organized women’s health initiatives among poor urban populations. Her research and scholarship focuses on women’s work and health, immigrant women’s health, language access, and community empowerment. She is currently involved in a community-based intervention trial of a promotora-delivered physical activity intervention among low-income Latinas. Dr. Messias was a fellow with the International Center for Health Leadership Development at the School of Public Health, University of Illinois at Chicago (2002–2004) and a Fulbright Senior Scholar in Global/Public Health at the Federal University of Goiás, Brazil (2005). She is a professor and director of the PhD Program in the University of South Carolina College of Nursing, with a joint appoint- ment in the Women’s and Gender Studies Program.
DeAnne K. Hilfinger Messias, PhD, RN, FAAN
The authors would like to acknowledge the contribution of Robert E. McKeown, PhD, FACE, who contributed to this chapter for previous editions.
257CHAPTER 12 Epidemiology
Epidemiology is considered the basic science of public health. Like public health nursing, epidemiology is a complex and con- tinually evolving field with a common focus: the optimal health for all members of all communities, local and global. Nurses use epidemiologic frameworks, methods, and data to better under- stand factors that contribute to health and disease; to develop health promotion and disease prevention interventions and
measures; to identify the presence of infectious agents in indi- viduals and groups; to design, implement, and evaluate com- munity health programs; and to develop and evaluate public health policies. Since nurses care for individuals and families, it is important that they consider the broader context in which these individuals live and the complex interplay of social and environmental factors that affect individual and collective
K E Y T E R M S agent, p. 266 analytic epidemiology, p. 259 attack rate, p. 265 bias, p. 280 case-control design, p. 278 case-control study, p. 278 case fatality rate (CFR), p. 265 cohort study, p. 276 cross-sectional study, p. 278 cumulative incidence rate, p. 263 descriptive epidemiology, p. 258 determinants, p. 258 distribution, p. 258 ecologic fallacy, p. 279 ecologic model, p. 260 ecologic study, p. 279 environment, p. 266 epidemic, p. 259 epidemiologic triangle, p. 266 epidemiology, p. 258 health, p. 258 host, p. 266 incidence proportion, p. 263 incidence rate, p. 263
levels of prevention, p. 268 mortality rates, p. 265 natural history of disease, p. 268 negative predictive value, p. 271 point epidemic, p. 275 popular epidemiology, p. 282 positive predictive value, p. 271 prevalence proportion, p. 263 proportion, p. 262 proportionate mortality ratio (PMR), p. 265 public health, p. 258 rate, p. 262 reliability, p. 271 risk, p. 262 screening, p. 270 secular trends, p. 275 sensitivity, p. 271 social epidemiology, p. 268 specificity, p. 271 surveillance, p. 272 validity, p. 271 web of causality, p. 266 —See Glossary for definitions
C H A P T E R O U T L I N E Definitions of Health and Public Health Definitions and Descriptions of Epidemiology Historical Perspectives Basic Concepts in Epidemiology
Measures of Morbidity and Mortality Epidemiologic Triangle, Web of Causality, and the Ecologic
Model Social Epidemiology Levels of Preventive Interventions
Screening Reliability and Validity
Surveillance Basic Methods in Epidemiology
Sources of Data Rate Adjustment Comparison Groups
Descriptive Epidemiology Person Place Time
Analytic Epidemiology Cohort Studies Case-control Studies Cross-sectional Studies Ecologic Studies
Experimental Studies Clinical Trials Community Trials
Causality Statistical Associations Bias Assessing for Causality
Applications of Epidemiology in Nursing Community-oriented Epidemiology Popular Epidemiology
258 PART 3 Conceptual and Scientific Frameworks
community health services. The IOM report The Future of the Public’s Health in the 21st Century (IOM, 2002) highlights the importance of intersectoral collaborations to accomplish the mission of public health. There is further emphasis on an eco- logical approach to research and practice (discussed later). Interprofessional collaboration between nurses and other health professionals, including epidemiologists, is critical to efforts to create and sustain the conditions necessary for health promo- tion, health maintenance, and overall improvements in public health (Baldwin, 2007).
well-being. Basic knowledge of epidemiology is essential to the practice of nursing across all settings and populations.
DEFINITIONS OF HEALTH AND PUBLIC HEALTH Health is the core concept in nursing and epidemiology. In 1978 the World Health Organization (WHO) affirmed that “health, which is a state of complete physical, mental and social well- being, and not merely the absence of disease or infirmity, is a fundamental human right and the attainment of the highest possible level of health is a most important world-wide social goal” (WHO, 1978, p. 1). As defined by the American Nurses Association (ANA), “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treat- ment of human response, and advocacy in the care of individu- als, families, communities, and populations” (ANA, 2012). This definition reflects the WHO goal and coincides with epidemio- logic principles. A holistic approach to health, including the incorporation of epidemiologic principles, is particularly appropriate for nurses. Nurses incorporate concepts of health into their nursing practice on a daily basis.
Public health has been described as a system and social enterprise; a profession; a collection of methods, knowledge, and techniques; governmental health services, especially medical care for the poor and underserved; and the health status of the public (Turnock, 2011). In the early twentieth century, C.E.A. Winslow defined public health as “the science and art of pre- venting disease, prolonging life and promoting physical health and efficiency through organized community effort.” The Insti- tute of Medicine (IOM) report The Future of Public Health drew upon Winslow’s definition in stating the mission of public health is to fulfill “society’s interest in assuring conditions in which people can be healthy” (IOM, 1988, p. 40). This mission statement clearly indicates a societal interest in the health of all its members. More specifically, the mission of the public health enterprise is to ensure conditions that promote health and well- being. From both public health and nursing perspectives, health encompasses much more than the presence or absence of a physical disease or disability; it involves optimal functioning across a broad range of systems—physiological, somatic, psy- chological, social, and environmental. The authors of the 1988 IOM report caution that this broad view of health and the role of public health professionals and agencies forces “practitioners to make difficult choices about where to focus their energies and raises the possibility that public health could be so broadly defined so as to lose distinctive meaning” (IOM, 1988, p. 40). Nurses are especially well suited to address this concern because of their holistic view of health and broad, interprofessional approach to intervention.
The practice of public health nursing is based on definitions of health and public health that go beyond a narrow biomedical model of individual health. Ensuring the public’s health includes delivery of specific services to individuals, but also includes the establishment and implementation of public policies and pro- grams. Public health and public health nursing activities focus on community prevention, disease control, and personal and
DEFINITIONS AND DESCRIPTIONS OF EPIDEMIOLOGY Epidemiology has been defined as “the study of the occurrence and distribution of health-related states or events in specified populations, including the study of the determinants influenc- ing such states, and the application of this knowledge to control the health problems” (Porta, 2008, p. 81). The word epidemiol- ogy comes from the Greek words epi (upon), demos (people), and logos (thought), and it originally referred to the spread of diseases of infectious origin. In the past century the definition and scope of epidemiology have broadened and now include the examination of the occurrence of chronic diseases, such as cancer and cardiovascular disease; mental health and health- related events, such as accidents, injuries, and violence; occupa- tional and environmental exposures and their effects; and positive health states.
Epidemiologists investigate the distribution or patterns of health events in populations to characterize health outcomes in terms of what, who, where, when, how, and why: What is the outcome? Who is affected? Where are they? When do events occur? This focus is called descriptive epidemiology, because it seeks to describe the occurrence of a disease in terms of person, place, and time (Koepsell and Weiss, 2003). The how and why, or determinants of health events, are those factors, exposures, characteristics, behaviors, and contexts that deter- mine (or influence) the patterns: How does it occur? Why are some affected more than others? Determinants may be indi- vidual, relational or social, communal, or environmental. This
HEALTHY PEOPLE 2020
• AH-2: Increase the percentage of adolescents who participate in extracur- ricular and out-of-school activities.
• AOCBC-4: Reduce the proportion of adults with doctor-diagnosed arthritis who find it “very difficult” to perform specific joint-related activities.
• C-9: Reduce invasive colorectal cancer. • D-16: Increase prevention behaviors in persons at high risk for diabetes
with prediabetes. • FS-5: Increase the proportion of consumers who follow key food safety
practices. • HAI-2: Reduce invasive methicillin-resistant Staphylococcus aureus (MRSA)
infections.
Examples of New Epidemiologic Objectives Included in Healthy People 2020
From U.S. Department of Health and Human Services. Healthy People 2020. Available at www.healthypeople2020. Accessed January 14, 2011.
259CHAPTER 12 Epidemiology
argue the current high rates compared with earlier periods already indicate an epidemic. The rising rates of obesity in the United States have led the Centers for Disease Control and Prevention (CDC) to consider adult obesity as an epidemic (CDC, 2012). Recent epidemiologic data show that 35.7% of U.S. adults 20 years of age and older—more than 78 million people—are obese. Approximately 19% of the population ages 6 to 12 and 17% of those 12 to 19 years old are considered overweight (Ogden et al, 2012). Obesity contributes to increased risk for heart disease, hypertension, diabetes, arthritis-related disabilities, and certain cancers.
Epidemiology builds on and draws from other disciplines and methods, including clinical medicine and laboratory sci- ences, social sciences, quantitative methods (especially biosta- tistics), and public health policy, among others. Epidemiology differs from clinical medicine, which focuses on the diagnosis and treatment of disease in individuals. Epidemiology is the study of populations in order to (1) monitor the health of the population, (2) understand the determinants of health and disease in communities, and (3) investigate and evaluate inter- ventions to prevent disease and maintain health. Effective nursing practice bridges the disciplines of clinical medicine and epidemiology, incorporating a focus on both individual and collective strategies. Nurses working in the community provide clinical services to individuals as they also tend to the broader context in which these individuals live and the complex inter- play of social and environmental factors that affect their well-being. Nurses apply epidemiologic methods in their daily practice, as they note trends in specific illnesses (e.g., sexually transmitted infections) or conditions (e.g., accidents) and in designing, implementing, and evaluating community health programs. The AIDS epidemic was first identified because clini- cians, using basic epidemiology methods, realized that much higher numbers of Pneumocystis jiroveci (carinii pneumonia) were being diagnosed than had ever been seen previously.
HISTORICAL PERSPECTIVES The roots of epidemiology have been traced to ancient Greece (Merrill and Timmreck, 2006). In the fourth century bc, Hip- pocrates maintained that to understand health and disease in a community, one should look to geographic and climatic factors, the seasons of the year, the food and water consumed, and the habits and behaviors of the people. Yet modern epidemiology did not emerge until the nineteenth century and it was only in the twentieth century that the field developed as a discipline with a distinctive identity (Susser, 1985).
Two refinements in research methods in the eighteenth and nineteenth centuries were critical for the formation of epide- miologic methods: (1) use of a comparison group, and (2) the development of quantitative techniques (numerical measure- ments, or counts). One of the most famous studies using a comparison group is the pivotal mid-nineteenth-century inves- tigation of cholera by John Snow, who is often credited with being the “father of epidemiology” (Merrill and Timmreck, 2006). By mapping cases that clustered around a single public water pump in one London cholera outbreak, Snow
focus on investigation of causes and associations is called ana- lytic epidemiology, in reference to the goal of understanding the etiology (or origins and causal factors) of disease; the broad consideration of many levels of potential determinants is called the ecological approach (IOM, 2002). The results of these inves- tigations are used to guide or evaluate policies and programs that improve the health of the community. The differentiation between descriptive and analytic epidemiologic studies is not clear-cut: analytic studies rely on descriptive comparisons, and descriptive comparisons shed light on determinants.
LINKING CONTENT TO PRACTICE
It is important that nurses understand the relationship between population health concepts and clinical practice. Within the field of epidemiology, the definition of population is not necessarily confined to large groups of people, such as the population of the United States. Population health concepts also apply to other types of groups, such as the collective group of clients at one clinical practice site. In this case, the clinical epidemiologic application of population health concepts is evident in questions such as: What are the factors that contribute to the health and illness issues among clients I see in my clinic? Why do some of my clients fare better than others with the same disease conditions? Are there alternative clinical practices that might posi- tively impact the health of my clients? All of these very clinical questions incorporate epidemiologic concepts of describing the burden of disease in a population, identifying and understanding determinants of health, and exam- ining possible root causes of health outcomes. Two important nursing docu- ments recently highlighted ways in which epidemiologic knowledge and skills are essential to nursing practice. The Council on Linkages Between Academia and Public Health Practice (2014) outlined essential analytic/assessment and public health science skills, and The Quad Council of Public Health Nursing Competencies (Swider et al, 2013) provided details and examples of ways to implement these skill sets in nursing practice.
The first step in the epidemiologic process is to answer the “what” question by defining a health outcome. The case defini- tion usually refers to cases of disease, but also may include instances of injuries, accidents, or even wellness (Koepsell and Weiss, 2003). Epidemiology has played an important role in the refinement of the case definition for acquired immunodefi- ciency syndrome (AIDS) and other emerging infectious diseases and in the development of more precise diagnostic criteria for psychiatric disorders. Epidemiologic methods are used to quan- tify the frequency of occurrence and characterize both the case group and the population from which they come. The aim is to describe the distribution (i.e., determine who has the disease and where and when the disease occurs) and to search for factors that explain the pattern or risk of occurrence (i.e., answer the questions of why and how the disease occurs).
An epidemic occurs when the rate of disease, injury, or other condition exceeds the usual (endemic) level of that condition. There is no specific threshold of incidence that indicates the existence of an epidemic. Because of the virtual eradication of smallpox globally, any occurrence of smallpox could be consid- ered an epidemic. In contrast, given the high rates of ischemic heart disease in the United States, an increase of many cases would be needed before an epidemic was noted; some would
260 PART 3 Conceptual and Scientific Frameworks
resulted from large-scale events including the Great Depression and World War II, followed by a rising standard of living for many but continued deep poverty for others. These changes led to increasing longevity and significant shifts in the age distribu- tion of the population, resulting in increases in age-related dis- eases, such as coronary heart disease (CHD), stroke, cancer, and senile dementia (Susser, 1985; IOM, 2002). However, disparities remain among population subgroups in life expectancy and risk of many acute and chronic diseases. Figure 12-1 shows the 10 leading causes of death in the United States in 1900, 1950, and 2010, with the percentage of all deaths attributed to each cause. The top three causes of death have not changed since 1950, whereas the composition of the remaining seven leading causes has changed.
With the increase in chronic disease, epidemiologists realized the necessity of looking beyond single agents (e.g., the infec- tious agent that causes cholera) toward a multifactorial etiology (i.e., many factors or combinations and levels of factors con- tributing to disease, such as the complex set of factors that cause cardiovascular disease), referred to as an ecologic model (IOM, 2002). Researchers and practitioners also recognized the contri- bution of behavioral and environmental causes to some chronic conditions formerly considered to be degenerative diseases of aging. This understanding prompted new thinking about the possibility of preventing or delaying the onset of certain chronic diseases (Susser, 1985). In addition, the development of genetic and molecular techniques (such as genetic markers for increased risk of breast cancer and sophisticated tests for antibodies to infectious agents or for other biological markers of exposures to environmental toxins, such as lead or pesticides) has increased the ability to identify and classify persons in terms of exposures or inherent susceptibility to disease.
demonstrated a connection between water supply and cholera. He later observed that cholera rates were higher among house- holds supplied by water companies whose water intakes were downstream from the city than among households whose water came from further upstream, where it was subject to less con- tamination (Table 12-1). Snow realized that his investigation was an example of what epidemiologists call a natural experi- ment and his findings added credibility to his argument that foul water was the vehicle for transmission of the agent that caused cholera (Gordis, 2013; Koepsell and Weiss, 2003).
Development and application of epidemiologic methods in the twentieth century were stimulated by dramatic changes in society and population dynamics (the combined effects of birth rates, death rates, life expectancy, and patterns of illness and causes of death) (McKeown, 2009). Contributing factors included improved nutrition, new vaccines, better sanitation, the advent of antibiotics and chemotherapies, and declining infant and child mortality and birth rates. Societal changes also
From Snow J: On the mode of communication of cholera. In Snow on Cholera. New York, 1855, The Commonwealth Fund.
Company No. of Houses
Deaths from Cholera
Deaths Per 10,000 Households
Southwark and Vauxhall
40,046 1263 315
Lambeth 26,107 98 37 Rest of London 256,423 1422 59
TABLE 12-1 Household Cholera Death Rates by Source of Water Supply in John Snow’s 1853 Investigation
0
1900
5
Percent
10 15
Diphtheria
Malignant neoplasms
Unintentional injuries
Chronic nephritis and renal sclerosis
Vascular lesions affecting CNS
Symptoms, senility, ill-defined
Heart diseases
Gastritis, enteritis, colitis
Tuberculosis
Pneumonia and influenza
2.3
3.7
4.2
4.7
6.2
6.8
8
8.3
11.3
11.8
A
FIG 12-1 Ten leading causes of death as a percentage of all deaths, United States. A, 1900.
261CHAPTER 12 Epidemiology
0
1950
10 20
Percent
30 40
Diabetes mellitus
Nephritis and renal sclerosis
General arteriosclerosis
Tuberculosis
Influenza and pneumonia
Certain diseases of early infancy
Accidents
CNS vascular lesions
Malignant neoplasms
Disease of the heart
1.7
1.7
2.1
2.3
3.2
4.2
6.3
10.8
14.5
36.9
B
C
0 10
2006
20
Percent
30 40
Septicemia
Nephritis, nephrotic syndrome, nephrosis
Alzheimer’s disease
Influenza and pneumonia
Diabetes mellitus
Accidents
Chronic lower respiratory diseases
Cerebrovascular diseases
Malignant neoplasms
Heart diseases
1.9
1.9
3.0
2.3
3.0
5.0
5.1
5.7
23.1
26.0
B, 1950. C, 2006. (B, Data from Anderson RN: Deaths: leading causes for 2000. Natl Vital Stat Rep 50:16, 2002; Brownson RC, Remington PL, Davis JR: Chronic Disease Epi- demiology and Control, ed 2. Washington, DC, 1998, APHA; U.S. Department of Health, Educa- tion, and Welfare: Vital Statistics of the United States: 1950, vol 1, Washington, DC, 1954, USDHEW, Public Health Service.) C, Heron M. Deaths: Leading causes for 2010. National Vital Statistics Reports 62(6). Hyattsville, MD: National Center for Health Statistics, 2013; Martin JA, Hamilton BE, Sutton PD, et al: Births, final data for 2006. Natl Vital Stat Rep 57:7, 2009.)
FIG 12-1, cont’d
262 PART 3 Conceptual and Scientific Frameworks
from the population being followed those persons who have already experienced the event.
Using the same health event of death from heart disease detailed previously, we can also compute a rate. To calculate the death rate, the denominator will be the number of individuals in the population during the year in which the deaths occurred, rather than total number of deaths. For example, in 2006, the U.S. population estimate was 299,398,484. Since rates are com- monly expressed per 100,000 or per 1000, we will divide this total population figure by 100,000, to get 2993.98484. The resulting calculation of the rate of death from heart disease in the United States in 2006 would be 631,636/2993.98484 = 211 per 100,000.
Risk refers to the probability that an event will occur within a specified time period. A population at risk is the population of persons for whom there is some finite probability (even if small) of that event. For example, although the risk of breast cancer in men is small, a few men do develop breast cancer and therefore could be considered part of the population at risk. There are some outcomes for which certain people would never be at risk (e.g., men cannot be at risk of ovarian cancer, nor can women be at risk of testicular cancer). A high-risk population, on the other hand, would include those persons who, because of exposure, lifestyle, family history, social or environmental context, or other factors, are at greater risk for disease than the population at large. Although anyone may be susceptible to HIV infection, the degree of susceptibility does vary. Everyone in the population is at risk for HIV and AIDS, but persons who have multiple sexual partners without adequate protection or who use intravenous drugs are in the high-risk population for HIV infection. However, others who do not fit these categories may unknowingly be at high risk. An example is women who consider themselves to be in monogamous relationships but are unaware that their partners have sexual relations with other women or men. As proportions, risk estimates have no dimen- sions, but they are a function of the length of time of observa- tion. Given a continuous rate, increasing time will mean that a larger proportion of the population will eventually become ill.
Epidemiologists and other health professionals are interested in measures of morbidity, especially incidence proportions, incidence rates, and prevalence proportions (Gordis, 2013). These measures provide information about the risk of disease, the rate of disease development, and the levels of existing disease in a population, respectively.
BASIC CONCEPTS IN EPIDEMIOLOGY Measures of Morbidity and Mortality Proportions, Rates, and Risk The distribution of health states and events is an important focus of epidemiology. Because people differ in their probability or risk of disease, a primary concern is the identification of how they differ. Today, epidemiologists use tools such as geographic information systems (GISs) to study health-related events to identify disease distribution patterns, similar to John Snow’s mapping of cholera cases in London in the nineteenth century. However, mapping cases is limited in what it can reveal. A higher number of cases may simply be the result of a larger population with more people who are potential cases, or of a longer period of observation. Any description of disease pat- terns should take into account the size of the population at risk for the disease. That is, we should look not only at the numera- tor (the number of cases), but also at the denominator (the number of people in the population at risk) and at the length of time the population was observed. For example, 50 cases of influenza in a month might be viewed as a serious epidemic in a population of 250 but would indicate a low rate in a popula- tion of 250,000. On the other hand, even in a small population, one might observe 50 cases over a period of several years. Using rates and proportions instead of simple counts of cases takes the size of the population at risk into account (Koepsell and Weiss, 2003). How time is considered differs according to the measure being used.
Epidemiologic studies rely on proportions and rates. A pro- portion is a type of ratio in which the denominator includes the numerator. For example, in 2006 there were 2,426,264 deaths recorded in the United States, of which 631,636 were reported as caused by heart disease; so the proportion of deaths attributable to heart disease in 2006 was 631,636/2,426,264 = 0.260, or 26.0%. Because the numerator must be included in the denominator, proportions can range from 0 to 1. Propor- tions are often multiplied by 100 and expressed as a percent, literally meaning per 100. In public health statistics, however, if the proportion is very small, we use a larger multiplier to avoid small fractions; thus the proportion may be expressed as a number per 1000 or per 100,000.
A rate is a measure of the frequency of a health event in “a defined population, usually in a specified period of time” (Porta, 2008, p. 207). A rate is a ratio, but it is not a proportion because the denominator is a function of both the population size and the dimension of time, whereas the numerator is the number of events (Rothman, 2012; Koepsell and Weiss, 2003; Gordis, 2013). Furthermore, depending on the units of time and the frequency of events, a rate may exceed 1. As its name suggests, a rate is a measure of how rapidly something is happening: how rapidly a disease is developing in a population or how rapidly people are dying. Conceptually, a rate is the instantaneous change in a continuous process. Notice the use of the words event and happening. Rates deal with change over time, as indi- viduals move from one state of being to another (e.g., from well to ill, alive to dead, or ill to cured). In observing a population over time to observe such changes in status, we typically exclude
HOW TO Quantify a Health Problem in the Community Planning for resources and personnel often requires quantifying the level of a problem in a community. For example, to know how dif- ferent districts compare in the rates of very-low-birth-weight (VLBW) infants, one would calculate the prevalence of VLBW births in each district: 1. Determine the number of live births in each district from birth
certificate data obtained from the vital records division of the health department.
2. Use the birth weight information from the birth certificate data to determine the number of infants born weighing less than 1500 g in each district.
263CHAPTER 12 Epidemiology
calculate the cumulative incidence rate for each group. The rela- tive risk would then be expressed as the cumulative incidence rate of breast cancer among women taking hormone replace- ment therapy divided by the cumulative incidence rate of breast cancer among those not taking hormone replacement therapy.
Because the relative risk is based upon a ratio, the actual value can range anywhere from >0 to infinity (theoretically). When the cumulative incidence rates are exactly equal, the rela- tive risk is 1.00. This is often termed the “null value,” indicating that the exposure of interest has no effect on the outcome of interest. This is the statistic most often cited in media releases about scientific studies. Using the hormone replacement therapy and breast cancer example, a research study that indicated a relative risk of 1.75 can be interpreted to indicate that the risk of developing breast cancer among those women taking hormone replacement therapy is 75% times the risk of develop- ing breast cancer among women not taking hormone replace- ment therapy. This is also the statistic that the nurses can use to estimate the probability of disease among their patients. This concept will be discussed in more detail later in this chapter in the section on cohort studies.
Measures of Incidence Measures of incidence reflect the number of new cases or events in a population at risk during a specified time. An incidence rate quantifies the rate of development of new cases in a popu- lation at risk, whereas an incidence proportion indicates the proportion of the population at risk who experience the event over some period of time, for example, the proportion of the population who develop influenza during a given year (Rothman, 2012). The population at risk is considered to be persons without the event or outcome of interest but who are at risk of experiencing it. Note that existing (or prevalent) cases are excluded from the population at risk for this definition, since they already have the condition and are no longer at risk of developing it. The incidence proportion is also referred to as the cumulative incidence rate (and erroneously simply as the incidence rate) because it reflects the cumulative effect of the incidence rate over the time period, whether it is a month, a year, or several years. A constant incidence rate operating over a period of time results in an increasing proportion of the population who are affected, that is, the incidence rate may stay constant while the cumulative incidence rate increases with time because the pool of people who have the disease is becom- ing larger. An incidence proportion can be interpreted as an estimate of risk of disease in that population over that period. An example of this might be the incidence proportion for cancer. Using statistics published for a 5-year period of time, one could calculate that 20 of 200 individuals were newly diag- nosed with cancer (hypothetical example). The incidence pro- portion would then be 20/200 = 0.10 or 10%. This could be interpreted that over a 5-year period of time, the risk of cancer in the population was 10%. The risk of disease is a function of both the rate of new disease development and the length of time the population is at risk. The interpretation can be for an indi- vidual (i.e., the probability that the person will become ill) or for a population (i.e., the proportion of a population expected to become ill over the specified period). For further examples of these calculations as it relates to mortality, see Table 12-2.
Another common risk measure used by both the science and general community is relative risk. Essentially, the relative risk compares the incidence of disease in an “exposed” population to the incidence of disease in an “unexposed” population. In this way, the relative risk is based on the calculations that are performed for the cumulative incidence rate. As an example, one could conceptualize the exposure as “taking hormone replacement therapy” and the outcome as breast cancer. In this case, we would identify a group of women who would be of an age to take hormone replacement therapy. Next, we would cat- egorize these women into two groups—those women not taking hormone replacement therapy and those who are taking hormone replacement. Within these two groups, then we would
HOW TO Use Epidemiologic Concepts in Nursing Epidemiologic concepts and data are used in ongoing assessments of both community and individual health problems. An initial com- ponent of a community health assessment is the collection of incidence, morbidity, and mortality rates for specific diseases. Health service data, such as immunization rates, causes of hospi- talization, and emergency department visits, are also obtained. Additional areas for community assessment are outlined in the How To box on page 264. Individual health problems should incor- porate evaluations of health risk based on lifestyle patterns along with the standard history and clinical examinations.
Prevalence Proportion The prevalence proportion is a measure of existing disease in a population at a particular time (i.e., the number of existing cases divided by the current population). We can also calculate the prevalence of a specific risk factor or exposure. When used alone, the term prevalence typically refers to the prevalence pro- portion, although the term is sometimes used to refer to the count of existing cases (i.e., the numerator of the prevalence proportion). For example, consider the following data from a breast cancer screening program that had reached 8000. Among these 8000 women, if 35 had previously been diagnosed with breast cancer and an additional 20 cases of breast cancer were identified as a result of the screening program, the prevalence proportion of current and past breast cancer events in this population would be 55 out of 8000, expressed as a rate of 687.5 per 100,000.
It is important to note that a prevalence proportion is not an estimate of the risk of developing disease. The prevalence proportion is a function of both the rate at which new cases of the disease develop and how long these cases remain in the population. To illustrate this point, consider the prevalence of
3. Calculate the prevalence of VLBW births by district as the number of infants weighing less than 1500 g at birth divided by the total number of live births.
4. If the number of VLBW births in each district is small, use several recent years of data to obtain a more stable estimate.
264 PART 3 Conceptual and Scientific Frameworks
From Heron M. Deaths: Leading causes for 2010. Natl Vital Stat Rep 62(6), Hyattsville, MD, 2013, National Center for Health Statistics; Martin JA, Hamilton BE, Sutton PD, et al: Births: Final data for 2006. Natl Vital Stat Rep 57(7), Hyattsville, MD, 2009, National Center for Health Statistics.
Rate/Ratio Definition and Example
Crude mortality rate Usually an annual rate that represents the proportion of a population who die from any cause during the period, using the midyear population as the denominator
Example: In 2006 there were 2,426,264 deaths in a total population of 299,398,484, or 810.4 per 100,000: 2 426 264
299 398 484 810 4 100 000
, , , ,
. ,= per
Age-specific rate Number of deaths among persons of given age group per midyear population of that age group Example: 2006 age-specific mortality rate for 20- to 24-year-olds:
21 148 21 111 240
100 2 100 000 ,
, , . ,= per
Cause-specific rate Number of deaths from a specific cause per midyear population Example: 2006 cause-specific rate for accidents:
121 599 299 398 484
40 , , ,
. deaths from accidents
midyear population = 66 100 000per ,
Case-fatality rate Number of deaths from a specific disease in a given period divided by number of persons diagnosed with that disease Example: If 87 of every 100 persons diagnosed with lung cancer die within 5 years, the 5-year case fatality rate is 87%. The
5-year survival rate is 13%. Proportionate mortality ratio Number of deaths from a specific disease per total number of deaths in the same period
Example: In 2006 there were 631,636 deaths from diseases of the heart, and 2,426,264 deaths from all causes: 631 636
2 426 264 0 26 26 2006
, , ,
.= or of all deaths in were attributabble to heart disease
Infant mortality rate Number of infant deaths before 1 year of age in a year per number of live births in the same year Example: In 2006 there were 28,527 infant deaths and 4,265,555 live births:
28 527 4 265 555
668 79 100 000 6 69 1000 ,
, , . , .= per live births or per livee births
Neonatal mortality rate Number of infant deaths under 28 days of age in a year per number of live births in the same year Example: In 2006 there were 18,989 neonatal deaths and 4,265,555 live births:
18 989 4 265 555
445 17 100 000 4 45 1000 ,
, , . , .= per or per live births
Postneonatal mortality rate Number of infant deaths from 28 days to 1 year in a year per number of live births in the same year Example: In 2006 there were 9538 postneonatal deaths and 4,265,555 live births:
9538 4 265 555
223 61 100 000 2 24 1000 , ,
. , .= per or per live births
TABLE 12-2 Common Mortality Rates
prostate cancer. The number of people with prostate cancer at any given time reflects both the number of new cases diagnosed at that specific point in time and the number of previously diagnosed men currently living with the diagnosis of prostate cancer. The duration of a specific disease is affected by both case fatality and cure. For example, a disease with a short duration (e.g., an intestinal virus) may not have a high prevalence pro- portion, even if the rate of new cases is high, because cases do not accumulate (see Point Epidemic later in this chapter). A disease with a long course (e.g., Crohn’s disease) will have a higher prevalence proportion than a rapidly fatal disease that has the same rate of new cases.
Comparing Prevalence and Incidence The prevalence proportion measures existing cases of disease and is affected by factors that influence risk (incidence) and by factors that influence survival or recovery (duration). Prevalence proportions are useful in planning health care ser- vices because they indicate the level of disease existing in the
population and therefore the size of the population in need of services. However, prevalence measures are less useful when we are looking for factors related to disease etiology. Because preva- lence proportions reflect duration in addition to the risk of getting the disease, it is difficult to sort out what factors are related to risk and what factors are related to survival or recovery.
For example, the 5-year survival rate for breast cancer is about 85%, but the 5-year survival rate for lung cancer in women is only about 15%. Even if the incidence rates of breast and lung cancer were the same in women (and they are not), the prevalence proportions would differ because, on average, women live longer after a diagnosis of breast cancer than do women diagnosed with lung cancer. In other words, the dura- tion of breast cancer is longer.
The measures of choice in studying disease etiology are inci- dence rates and incidence proportions, because incidence is affected only by factors related to the risk of developing disease and not to survival or cure. At the level of a local health
265CHAPTER 12 Epidemiology
Note that many commonly used mortality rates in Table 12-2 are in fact proportions, not true rates (Rothman, 2012; Gordis, 2013). Because the population changes during the course of a year, we typically take an estimate of the population at midyear as the denominator for annual rates, because the midyear popu- lation approximates the amount of person-time contributed by the population during a given year. Using the approximation noted previously for small rates when the period of observation is a single unit of time, the annual mortality rate is an estimate of the risk of death in a given population for that year. These rates are multiplied by a scaling factor (usually 100,000) to avoid small fractions. The result is then expressed as the number of deaths per 100,000 persons. Although a crude mortality rate is calculated easily and represents the actual death rate for the total population, it has certain limitations. It does not reveal specific causes of death, which change in relative importance over time (see Figure 12-1). Also, it is affected by the age distri- bution of the population because older people are at much greater risk of death than younger people. For example, in 2005 the U.S. crude mortality rate for African Americans was 749.4 per 100,000, compared with a rate of 873.7 per 100,000 for white Americans, even though the mortality rate was higher for African Americans than for whites in every age group up to age 85 (Heron, 2010).
Mortality rates are also calculated for specific groups (e.g., age-, sex-, or race-specific rates). In these instances, the number of deaths occurring in the specified group is divided by the population at risk, now restricted to the number of persons in that group. This rate may be interpreted as the risk of death for persons in the specified group during the period of observation.
The cause-specific mortality rate is an estimate of the risk of death from some specific disease in a population. It is the number of deaths from a specific cause divided by the total population at risk, usually multiplied by 100,000. Two related measures should be distinguished from the cause-specific mor- tality rate. The case fatality rate (CFR) is usually a proportion: the proportion of persons diagnosed with a particular disorder (i.e., cases) that die within a specified period of time. The CFR may be interpreted as an estimate of the risk of death within that period for a person newly diagnosed with the disease (e.g., the proportion of persons with breast cancer who die within 5 years). Because the CFR is the proportion of diagnosed persons who die within the period, 1 minus the CFR yields the survival rate. For example, if the 5-year CFR for lung cancer is 86%, then the 5-year survival rate is only 14% (Remington et al, 2010). Persons diagnosed with a particular disease often want to know the probability of survival. These rates provide an estimate of that probability.
The second measure to be distinguished from the cause- specific mortality rate is the proportionate mortality ratio (PMR)—the proportion of all deaths that are attributable to a specific cause. The denominator is not the population at risk of death but the total number of deaths in the population; there- fore, the PMR is not a rate nor does it estimate the risk of death. The magnitude of the PMR is a function of both the number of deaths from the cause of interest and the number of deaths
department, epidemiologists and nurses would rely on both incidence and prevalence data in planning services focused on the prevention and control of tuberculosis (TB). They would examine the existing level of TB within the community (preva- lence) to plan services and direct prevention and control mea- sures, and they would take into consideration the rate of new TB cases (incidence) to study risk factors and evaluate the effec- tiveness of prevention and control programs.
**For Further Note: This process is very similar to the intake/ assessment process that all nurses are familiar with such as obtaining medical and family history (analogous to #1 and #2 above), identifying health concerns of the patient (analogous to #3 and #5 above), perform clinical exam (analogous to #4 above), and evaluate patient knowledge, beliefs, and personal risk (analogous to #5-#8).
HOW TO Assess Health Problems in a Community 1. Examine local epidemiologic data (e.g., incidence, morbidity, and
mortality rates) to identify major health problems. 2. Examine local health services data to identify major causes of
hospitalizations and emergency department visits. Consult with key community leaders (e.g., political, religious, business, edu- cational, health, and cultural leaders) about their perceptions of identified community health problems.
3. Mobilize community groups to elicit discussions and identify perceived health priorities within the community (e.g., focus groups, neighborhood forums, or community-wide forums).
4. Analyze community environmental health hazards and pollutants (e.g., water, sewage, air, toxic waste).
5. Examine indicators of community knowledge and practices of preventive health behaviors (e.g., use of infant car seats, safe playgrounds, lighted streets, seat belt use, designated driver programs).
6. Identify cultural priorities and beliefs about health among differ- ent social, cultural, racial, or national origin groups.
7. Assess community members’ interpretations of and degrees of trust in federal, state, and local assistance programs.
8. Engage community members in conducting surveys to assess specific health problems.
Attack Rate Another measure of morbidity, often used in infectious disease investigations, is the attack rate. This form of incidence propor- tion is defined as the proportion of persons who are exposed to an agent and develop the disease. Attack rates are often specific to an exposure; food-specific attack rates, for example, are the proportion of persons becoming ill after eating a specific food item.
Mortality Rates Mortality rates are key epidemiologic indicators of interest to nurses (Table 12-2). Although measures of mortality reflect serious health problems and changing patterns of disease, they are limited in their usefulness. Mortality rates are informative only for fatal diseases and do not provide direct information about either the level of existing disease in the population or the risk of contracting any particular disease. Also, it is not uncommon for a person who has one disease (e.g., prostate cancer) to die from a different cause (e.g., stroke).
266 PART 3 Conceptual and Scientific Frameworks
from other causes. If deaths from certain causes decline over time, the PMR for deaths from other causes that remain fairly constant (in absolute numbers) may increase. For example, motor vehicle accidents accounted for 3.3 deaths per 100,000 persons 5 to 14 years of age in the United States in 2006, which is 21.8% of all deaths in this age group (the PMR). By compari- son, motor vehicle accidents caused 22.3 deaths per 100,000 persons 75 to 84 years of age in 2006, which was less than 0.5% of all deaths in this older age group (Heron, 2010). This dem- onstrates that, although the risk of death from a motor vehicle accident was almost 6.8 times greater in the older group (based on the rates), such accidents accounted for a far greater propor- tion of all deaths in the younger group (based on the PMR). The reason is that there is a much greater risk of death from other causes in the older group.
Measures of infant mortality are used around the world as an indicator of overall health and availability of health care services. The most common measure, the infant mortality rate (IMR), is the number of deaths to infants in the first year of life divided by the total number of live births. Because the risk of death declines rather dramatically during the first year of life, neonatal and postneonatal mortality rates are also of interest (see Table 12-2). To effectively plan and evaluate community health interventions, nurses need to be able to understand and interpret these key epidemiologic indicators. One of the benefits of epidemiologic studies is that the results may demonstrate which disease prevention and control interventions are more useful and effective.
Epidemiologic Triangle, Web of Causality, and the Ecologic Model Epidemiologists understand that disease results from complex relationships among causal agents, susceptible persons, and environmental factors. These three elements—agent, host, and environment—are traditionally referred to as the epidemio- logic triangle (Figure 12-2, A). This model was originally devel- oped as a way of identifying causative factors, transmission, and risk related to infectious diseases. Changes in one of the ele- ments of the triangle can influence the occurrence of disease by increasing or decreasing a person’s risk for disease. As illustrated in Figure 12-2, B, specific characteristics of agent and host, as well as the interactions between agent and host, are influenced by the environmental context in which they exist, and may in turn influence the environment. Examples of these three com- ponents are listed in Box 12-1.
Although the interactions of host, environment, and agent are clearly key elements in disease causation, causal relation- ships are often more complex than implied by the concept of the epidemiologic triangle. The concept of a web of causality reflects the more complex interrelationships among the numer- ous factors interacting, sometimes in subtle ways, to increase (or decrease) risk of disease. Furthermore, associations are sometimes mutual, with lines of causality going in both direc- tions. More recently, some epidemiologic researchers have advocated a new paradigm that goes beyond the two-dimensional causal web to consider multiple levels of factors that affect health and disease (Krieger, 1994; Macintyre and Ellaway, 2000).
FIG 12-2 Two models of the agent-host-environment interac- tion (the epidemiologic triangle).
Environment
Agent Host
Environment
Host
Agent
Environment
E nv
ir on
m en
t
E nviro
nm en
t
A
B
Agent Infectious agents (e.g., bacteria, viruses, fungi, parasites) Chemical agents (e.g., heavy metals, toxic chemicals, pesticides) Physical agents (e.g., radiation, heat, cold, machinery)
Host Genetic susceptibility Immutable characteristics (e.g., age, sex) Acquired characteristics (e.g., immunological status) Lifestyle factors (e.g., diet and exercise)
Environment Climate (e.g., temperature, rainfall) Plant and animal life (e.g., agents or reservoirs or habitats for agents) Human population distribution (e.g., crowding, social support) Socioeconomic factors (e.g., education, resources, access to care) Working conditions (e.g., levels of stress, noise, satisfaction)
BOX 12-1 Examples of Agent, Host, and Environmental Factors in the Epidemiologic Triangle
267CHAPTER 12 Epidemiology
settings. However, the model does provide a useful guide for considering the potential relative impact for intervention across various sectors.
Like the web of causality model, the ecologic model recog- nizes multiple determinants of health and treats them as inter- related and acting synergistically (or antagonistically), rather than as a list of discrete factors. The ecologic model spans a broader spectrum of systems and etiological factors than the more traditional web of causality model and it encompasses determinants at many levels: biological, mental, behavioral, social, and environmental factors, including policy, culture, and economic environments. Another way of thinking of this is that the ecologic model moves from a two-dimensional perspective to a multidimensional perspective. Nurses have a significant role in shaping the health of the population and need to be mindful of the many environmental factors that may contribute
Krieger (1994) has suggested that in addition to research on the relationships within the web, we need to look for “the spider”— that is, focus on those larger factors and contexts that influence or create the causal web itself.
With this shift in the scientific thinking, practitioners and researchers are thinking more broadly about the multiple underlying determinants of health. There is increasing recogni- tion of the widespread and profound influence of external factors on the health of individuals, communities, and popula- tions. This is consistent with the ecologic model for population health illustrated in Figure 12-3. This approach expands epide- miologic studies both upward to broader contexts (such as neighborhood characteristics and social context) and down- ward to the genetic and molecular level. Of course the relative impact of the various factors depicted in this figure is not fixed, and would vary across different populations, contexts, and
FIG 12-3 Determinants of population health. This is a guide to thinking about the determinants of population health. (Reprinted with permission from The Future of the Public’s Health in the 21st Century, Copyright 2002 by the National Academy of Sciences, courtesy of the National Academies Press, Washington, DC). a Social conditions include, but are not limited to: economic inequality, urbanization, mobility, cultural values, attitudes and policies related to discrimination and intolerance on the basis of race, gender, and other differences. b Other conditions at the national level might include major sociopolitical shifts, such as recession, war, major environ- mental disasters, and governmental collapse. c The built environment includes transportation, water and sanitation, housing, and other dimensions of urban planning.
Innate individual traits:
age, sex, race, and biological
factors ---
The biology of disease
Liv ing
and working conditions
B ro
a d
so ci
al ,a
ec on
om ic,
cu ltu
ral , he
alth, and environmental conditons b
and
policies at the
g lo
b a l,
n a
tio n a l,
sta te,
a nd
locallevels
So cia
l, f am
ily an d community networksInd
ividual behavior
Over the life span
Living and working conditions may include: • Psychosocial factors • Employment status and
occupational factors • Socioeconomic status
(income, education, occupation)
• The natural and builtc
environments • Public health services • Health care services
268 PART 3 Conceptual and Scientific Frameworks
ondary, and tertiary prevention of communicable and noncom- municable diseases.
Primary Prevention In their daily practice, nurses are often involved in activities related to all three levels of prevention (see Levels of Prevention box). Primary prevention refers to interventions aimed at pre- venting the occurrence of disease, injury, or disability. Interven- tions at this level of prevention are aimed at individuals and groups who are susceptible to disease but have no discernible pathology (i.e., they are in a state of prepathogenesis). This first level of prevention includes broad efforts such as health promo- tion, environmental protection, and specific protection. Health promotion includes nutrition education and counseling and the promotion of physical activity. Environmental protection ranges from basic sanitation and food safety, to home and workplace safety plans, to air quality control. Examples of spe- cific protection against disease or injury include immuniza- tions, proper use of seat belts and infants’ car seats, preconception folic acid supplementation to prevent neural tube defects, fluo- ridation of water supplies to prevent dental caries, and actions taken to reduce human exposure to agents that may cause cancer. Primary prevention occurs in homes, in community settings, and at the primary level of health care (e.g., in public health clinics, physicians’ offices, community health centers, and rural health clinics).
to health behaviors and health outcomes. In addressing health behavior change, nurses often focus on patient education (within the domain of “health behaviors” in Figure 12-3). However, lack of attention to other environmental and social issues (i.e., lack of transportation, lack of adequate childcare arrangements, financial constraints, inadequate housing) may mean that the patient is unable to access or respond appropri- ately to the health education efforts.
Social Epidemiology A renewed interest in social epidemiology is attributed in part to the recognition of persistent social inequalities in health. Social epidemiology is the branch of epidemiology that studies the social distribution and social determinants of health and disease (Berkman and Kawachi, 2000; Krieger, 2000; Kawachi and Berkman, 2003). Social epidemiologists focus on the roles and mechanisms of specific social phenom- ena (e.g., socioeconomic stratification, social networks and support, discrimination, work and employment demands) in the production of health and disease states. Social epidemi- ologists examine social inequalities and data related to neigh- borhoods, communities, employment, and family conditions to analyze health issues and design appropriate and feasible public health interventions. Public health professionals are con- cerned with relationships between social conditions and pat- terns of health and disease in individuals, families, groups, and populations.
The complex factors that influence or lead to social inequali- ties in health are being increasingly examined or “rediscovered” through the lens of epidemiology. Berkman and Kawachi (2000) identified several key concepts within the subfield of social epi- demiology. These include a population perspective (IOM, 2002), the social context of behavior, contextual and multilevel analysis (Sampson et al, 1997; Diez-Roux, 2002), a develop- mental and life-course perspective, and general susceptibility to disease. The aim of social epidemiology is to identify ways in which the structure of society influences the public’s health, through the interactions of social context, environmental factors, biological mechanisms, and the timing and accumula- tion of risk, as represented by the ecologic model and the life- span perspective. Social epidemiologists have called for further research to examine the impact of extra-individual factors (institutions, communities, macroeconomic conditions, and economic and social policy) on exposure to resources (Lynch and Kaplan, 2000).
Levels of Preventive Interventions The goal of epidemiology is to identify and understand the causal factors and mechanisms of disease, disability, and inju- ries so that effective interventions can be implemented to prevent the occurrence of these adverse processes before they begin or before they progress. The natural history of disease is the course of the disease process from onset to resolution (Porta, 2008). The three levels of prevention provide a framework com- monly used in public health practice (see the Levels of Preven- tion box later in the chapter). As practicing epidemiologists, nurses working in the community are involved in primary, sec-
LEVELS OF PREVENTION
Primary Prevention Counsel clients about low-fat diet and regular physical exercise.
Secondary Prevention Implement blood pressure and cholesterol screening; give treadmill stress test.
Tertiary Prevention Provide cardiac rehabilitation, medication, surgery.
Examples Related to Cardiovascular Disease
Examples of nurses’ involvement in primary prevention include health education and promotion programs, such as nutrition education and counseling, sex education, and family planning services. Primary prevention efforts focus on both the general population and on specific vulnerable groups (e.g., the homeless, HIV-positive persons, certain immigrant groups) to improve the general health status and to reduce the incidence of specific diseases such as TB. An example of a primary preven- tion intervention is the provision of health education and train- ing for daycare workers regarding health and hygiene issues, such as proper hand hygiene, diapering, and food preparation and storage. Immunizations are another example of primary prevention. In terms of environmental protection, nurses work proactively to develop and advocate for policies and legislation that lead to prevention of environmental hazards. They can also provide consultation to industries, local governments, and
269CHAPTER 12 Epidemiology
Other examples of secondary prevention interventions include screening tests to detect breast cancer (i.e., mammography), cervical cancer (i.e., Pap tests), colon cancer (i.e., colonoscopy), prenatal screening of pregnant women to detect gestational diabetes, routine tuberculin testing of specific groups (e.g., health care providers, childcare workers), and identification and screening of persons who have had contact with an individual known to have TB. In all these examples, the aim of secondary prevention is to identify the presence of a disease or condition at an early stage and begin necessary treatment early to increase the likelihood of cure or to prevent further complications.
Tertiary Prevention Tertiary prevention includes interventions aimed at disability limitation and rehabilitation from disease, injury, or disability. Tertiary prevention interventions occur most often at second- ary and tertiary levels of care (e.g., specialized clinics, hospitals, rehabilitation centers) but may also occur in community and primary care settings. Medical treatment, physical and occupa- tional therapy, and rehabilitation are interventions character- ized as tertiary prevention. With the emergence of new drug-resistant strains of TB, nurses now face the challenge of designing and implementing programs to increase long-term compliance and provide aftercare for clients in a variety of com- munity settings. An example of tertiary prevention is a public health nurse providing directly observed therapy (DOT) to individuals diagnosed with active TB.
An Intervention Spectrum The standard classification of preventive measures in public health is composed of the primary, secondary, and tertiary levels of prevention. However, this standard classification has been revised and refined for application to diverse settings and health issues. In the field of cancer, this potential for intervention has been conceptualized across the entire continuum of care (Figure 12-4). As cancer is a disease which, for most anatomical sites,
groups of concerned citizens as well as public education for a wide range of preventable environmental health problems.
Secondary Prevention Secondary prevention encompasses interventions designed to increase the probability that a person with a disease will have that condition diagnosed at a stage when treatment is likely to result in cure. Health screenings are the mainstay of secondary prevention. Early and periodic screenings are critical for dis- eases for which there are few specific primary prevention strate- gies, such as breast cancer. (Screening programs are discussed in more detail later in the chapter.) As noted above, primary prevention is a major focus of health education. However, nurses often use health education interventions when caring for individuals with a diagnosed health problem with the aim of preventing further complications or exacerbations. For example, at the individual and family level, teaching the asthmatic child to recognize and avoid exposure to potential asthma triggers and helping the family implement specific protection strategies, such as replacing carpets, keeping air systems clean and free of mold, and avoiding contact with household pets and second- hand smoke could be considered secondary prevention.
Interventions at the secondary level of prevention may occur in community settings as well as within primary and secondary levels of health care services. Oral rehydration therapy (ORT) for infant diarrheal disease is an excellent example of secondary prevention in the community. Particularly in developing coun- tries, when safe water can be made available, ORT is a low-cost and effective way to treat infant diarrheal disease. When mothers identify the early signs of infant dehydration and administer a homemade ORT solution of water, sugar, and salt, they are putting secondary prevention into practice. When taking a health history with clients, nurses can integrate secondary pre- vention into practice by asking about family history of cancer, heart disease, diabetes, and mental illness, and then providing follow-up education about appropriate screening procedures.
FIG 12-4 Multilevel interventions in health care across the cancer care continuum. (Taplin SH, Price RA, Edwards HM, et al: Introduction: Understanding and Influencing Multilevel Factors Across the Cancer Care Continuum. J Natl Cancer Inst Monogr (44): 2–10, 2012. Oxford Univer- sity Press.)
Age Family Hx Exposure Hx Genetics Lifestyle Screening Hx
Risk assessment
Imaging Biopsy Repeat Exams Laboratory Tests Other Appropriate Procedures
Processes of Care Across the Cancer Care Continuum Process of care impacts
Patient & population outcomes
Types of care
Transitions in Care
Diagnosis
Lifestyle counseling Chemo prevention
Primary prevention
Palliative Care Advanced Care Planning Bereavement Support
Efficiency Equity Safety Effectiveness Timeliness Patient-centered
End-of-life care
Excision Surgery Radiation Adjuvant Chemo Palliation
Cancer or precursor treatment
Testing Follow-Up Care Palliation Recurrence Surveillance
Post- treatment
survivorship Improved risk status Biologic outcomes Health related quality of life & well-being Quality of death Financial burden Patient experience
Mortality Morbidity Cost-effectiveness Reduced disparities
Patient
Population
Screening (Asymptomatic) Appropriate Testing (Symptomatic)
Detection
270 PART 3 Conceptual and Scientific Frameworks
procedures. Criteria for evaluating the suitability of screening tests include cost-effectiveness, ease and safety of administra- tion, availability of treatment, ethics of administration or wide- spread implementation, sensitivity, specificity, validity, and reliability (Gordis, 2013; McKeown and Learner, 2009).
Screening procedures exist for a wide range of health condi- tions, including cancer (e.g., breast, cervical, testicular, colon, rectal, and skin), diabetes, hypertension, TB, lead poisoning, hearing loss, and sexually transmitted diseases (e.g., gonorrhea, chlamydia, syphilis). Nurses must keep abreast of recommended screening guidelines, which are regularly reviewed and revised on the basis of epidemiologic research results. For example, the latest U.S. Preventive Services Task Force guidelines (USPSTF, 2008) strongly recommend routine screening for lipid disorders in men 35 years and older and women 45 years and older. Screening for younger adults (men ages 20 to 35 and women ages 20 to 45) is recommended when any of the following risk factors are present: diabetes, family history of cardiovascular disease before age 50 in men or age 60 in women, family history suggestive of familial hyperlipidemia, or multiple coronary heart disease risk factors (e.g., tobacco use, hypertension). The Task Force also noted that all clients, regardless of lipid levels, should be offered counseling about the benefits of a diet low in saturated fat and high in fruits and vegetables, regular physical activity, avoidance of tobacco, and maintenance of healthy weight.
The rationale for the current lipid screening guidelines is as follows. The clearest benefit of lipid screening is identifying individuals whose near-term risk of coronary heart disease is sufficiently high to justify drug therapy or other intensive life- style interventions to lower cholesterol levels. Screening men older than age 35 years and women older than age 45 years will identify nearly all individuals whose risk of coronary heart disease is as high as that of the subjects in the existing primary prevention trials. Younger people typically have a substantially lower risk, unless they have other important risk factors for coronary heart disease or familial hyperlipidemia. The primary goal of screening younger people is to promote lifestyle
has a relatively long period of development, this creates a longer timeline for potential intervention by the researcher or health practitioner. For example, family history of breast cancer is known to be a strong risk factor among specific subgroups of women. Knowing this, the nurse can advocate for genetic testing (first intervention) and also (regardless of the test result) promote healthy lifestyle choices when counseling patients (second intervention). In patients diagnosed with hormone positive breast cancer, the nurse can counsel and facilitate treat- ment adherence for the woman to her hormonal therapy (third intervention point). Other interventions would include facili- tating communication with patients and their families in order to expedite the treatment trajectory from the point of diagnosis to the scheduled surgery (fourth intervention point). Clearly, nurses have critical roles in prevention at all points across the intervention spectrum.
SCREENING Screening, a key component of many secondary prevention interventions, involves the testing of groups of individuals who are at risk for a certain condition but are as yet asymptomatic. The purpose is to classify these individuals with respect to the likelihood of having the disease. From a clinical perspective, the aim of screening is early detection and treatment when these result in a more favorable prognosis. From a public health per- spective, the objective is to sort out efficiently and effectively those who probably have the disease from those who probably do not, again to detect early cases for treatment or begin public health prevention and control programs. A screening test is not a diagnostic test. Effective screening programs must have built-in referral mechanisms for subsequent diagnostic evalua- tion for those who screen positive, to determine if they actually have the disease and need treatment, and there must be effective protocols in place for referral to accessible and appropriate follow-up care and treatment. If there is no effective treatment, or if the individuals or groups targeted for screening experience considerable barriers in accessing appropriate treatment, the justification of the screening program must be assessed ethically as well as epidemiologically (Childress et al, 2002).
As public health advocates, nurses are responsible for plan- ning and implementing screening and prevention programs targeted to the at-risk populations. Nurses working in schools, worksites, primary care facilities, and public health agencies may work together to target at-risk populations on the basis of occupational and environmental risks. Successful screening programs have several characteristics that depend on the tests and on the population screened (Box 12-2). In planning screen- ing programs for a specific population (e.g., school, workplace, community), nurses need to take into consideration various factors. These include the characteristics of the health problem, the screening tests available, and the population (Harkness, 1995). Screening is recommended for health problems that have a high prevalence, are relatively serious, can be detected in early states, and for which effective treatment is available. The popu- lation should be easily identifiable and assessable, amenable to screening, and willing and able to seek treatment or follow-up
1. Valid (accurate): A high probability of correct classification of persons tested
2. Reliable (precise): Results consistent from place to place, time to time, and person to person
3. Capable of large group administration: a. Fast in both the administration of the test and the procurement of results b. Inexpensive in both personnel required and materials and procedures
used 4. Innocuous: Few, if any, side effects; minimally invasive test 5. High yield: Able to detect enough new cases to warrant the effort and
expense (yield defined as the amount of previously unrecognized disease that is diagnosed and treated as a result of screening)
6. Ethical and effective: Meets the desired public health goal with health benefits that outweigh any moral or ethical infringements.
BOX 12-2 Characteristics of a Successful Screening Program
271CHAPTER 12 Epidemiology
Specificity indicates how accurately the test identifies those without the condition or trait—in other words, the proportion of persons whom the test correctly identifies as negative for the disease (true negatives). High specificity is needed when rescreening is impractical and when reduction of false positives is important. The sensitivity and specificity of a test are deter- mined by comparing the results from the screening test with results from a definitive diagnostic procedure (sometimes called the gold standard). For example, the Pap smear is used fre- quently to screen for cervical dysplasia and carcinoma. The definitive diagnosis of cervical cancer requires a biopsy with histologic confirmation of malignant cells.
The ideal for a screening test is 100% sensitivity and 100% specificity. That is, the test is positive for 100% of those who actually have the disease, and it is negative for all those who do not have the disease. In practice, sensitivity and specificity are often inversely related. That is, if the test results are such that one can choose some point beyond which a person is consid- ered positive (a “cutpoint”), as in a blood pressure reading to screen for hypertension or a serum glucose reading to screen for diabetes, then moving that critical point to improve the sensitivity of the test will result in a decrease in specificity. In other words, an improvement in specificity can be made only at the expense of sensitivity. Table 12-3 shows how to calculate sensitivity and specificity. Some authors refer to a false-positive rate, which is 1 minus the specificity, and a false-negative rate, or 1 minus the sensitivity. These “rates” are simply the propor- tions of subjects incorrectly labeled as nondiseased and diseased, respectively.
A third measure associated with sensitivity and specificity is the predictive value of the test. The positive predictive value (also called predictive value positive) is the proportion of persons with a positive test who actually have the disease, inter- preted as the probability that an individual with a positive test has the disease. The negative predictive value (or predictive value negative) is the proportion of persons with a negative test who are actually disease free. Although sensitivity and specific- ity are relatively independent of the prevalence of disease, pre- dictive values are affected by the level of disease in the screened population and by the sensitivity and specificity of the test. When the prevalence is very low, the positive predictive value will be low, even with tests that are sensitive and specific. In
changes, which may provide long-term benefits later in life. The average effect of diet interventions is small, and screening is not needed to advise young adults about the benefits of a healthy diet and regular exercise because this advice is consid- ered useful for all age groups. Although universal screening may detect some clients with familial hyperlipidemia earlier than selective screening, it has yet to be determined if universal screening would lead to significant reductions in coronary events (USPSTF, 2008).
Reliability and Validity Reliability The precision, or reliability, of the measure (i.e., its consistency or repeatability) and its validity or accuracy (i.e., whether it really measures what we think it is measuring, and how exact the measurement is) are important considerations for any mea- surement. For example, suppose you are planning to conduct a blood pressure screening in a community setting. You will prob- ably be taking blood pressure measurements on a large number of people and then following up with repeated measures for individuals identified as having higher levels of blood pressure. If the sphygmomanometer used for the blood pressure screen- ing varies in its measurement so that it does not record a similar reading for the same person twice in a row, it lacks precision (or reliability). The instrument would be unreliable even if the overall mean of repeated measurements was close to the true overall mean for the persons measured. The problem would be that the readings would not be reliable for any indi- vidual, which is what a screening program requires. On the other hand, suppose the readings are reliably reproducible, but, unknown to you, they tend to be about 10 mm Hg too high. This instrument is producing precise readings, but the uncor- rected (or uncalibrated) instrument lacks accuracy (or validity). In short, a measure can be consistent without producing valid results.
Three major sources of error can affect the reliability of measurement: • Variation inherent in the trait being measured (e.g., blood
pressure changes with time of day, activity, level of stress, and other factors)
• Observer variation, which can be divided into intra-observer reliability (the level of consistency by the same observer) and inter-observer reliability (the level of consistency from one observer to another)
• Inconsistency in the instrument, which includes the internal consistency of the instrument (e.g., whether all items in a questionnaire measure the same thing) and the stability (or test-retest reliability) of the instrument over time
Validity: Sensitivity and Specificity Validity in a screening test is measured by sensitivity and speci- ficity. Sensitivity quantifies how accurately the test identifies those with the condition or trait. In other words, sensitivity represents the proportion of persons with the disease whom the test correctly identifies as positive (true positives). High sensi- tivity is needed when early treatment is important and when identification of every case is important.
Result of Screening Test Disease No Disease
Positive True positive (TP) False positive (FP) Negative False negative (FN) True negative (TN)
TABLE 12-3 Classification of Subjects According to True Disease State and Screening Test Results for Calculation of Indices of Validity
Sensitivity = TP/(TP + FN); specificity = TN/(TN + FP); false-negative “rate” = 1 − sensitivity = FN/(FN + TP); false-positive “rate” = 1 − specificity = FP/(TN + FP); positive predictive value = TP/(TP + FP); often multiplied by 100 and expressed as a percentage.
272 PART 3 Conceptual and Scientific Frameworks
where it may not be feasible to maintain a surveillance system across larger geographic areas, sentinel surveillance systems may be instituted. Representative populations may be selected and sentinel providers identified to provide information on specific diseases or conditions. Nurses engage in surveillance activities as they monitor the health status of individuals, fami- lies, and groups in their care. They use surveillance data to assess and prioritize the health needs of populations, design public health and clinical services to address those needs, and evaluate the effectiveness of public health programs.
BASIC METHODS IN EPIDEMIOLOGY Sources of Data One of the first issues to address in any epidemiologic study is how to obtain the data (Koepsell and Weiss, 2003; Gordis, 2013). Three major categories of data sources are commonly used in epidemiologic investigations: 1. Routinely collected data, such as census data, vital records
(birth and death certificates), and surveillance data as carried out by the CDC.
2. Data collected for other purposes but useful for epidemio- logic research, such as medical, health department, and insurance records.
3. Original data collected for specific epidemiologic studies. The first two types of data are often referred to as secondary
data, and the third type is commonly considered primary data.
Routinely Collected Data Vital records are the primary source of birth and mortality statistics. Although registration of births and deaths is man- dated in most countries, thus providing one of the most com- plete sources of health-related data, the quality of specific information varies. For example, on birth certificates, sex and date of birth are fairly reliable, whereas gestational age, level of prenatal care, and smoking habits of the mother during preg- nancy are less reliable. On death certificates, the quality of the cause of death information varies over time and from place to place, depending on diagnostic capabilities and custom. Vital records, readily available in most areas, are inexpensive and convenient and allow study of long-term trends. Mortality data, however, are informative only for fatal diseases or events.
Since 1790, the U.S. Census has been conducted every 10 years. The U.S. Census provides population data, including demographic distribution (e.g., age, race, sex), geographic dis- tribution, and additional information about economic status, housing, and education. Census data are used as denominators for various rates. The American Community Survey is an ongoing survey also conducted by the U.S. Census Bureau. Data from these surveys provide important information on the status of the population and for public health planning and evaluation activities.
Data Collected for Other Purposes Hospital, physician, health department, laboratory, and insur- ance records provide information on morbidity, as do surveil- lance systems, such as cancer registries and health department
addition, lower specificity produces lower positive predictive values because of the increase in the proportion of false-positive results.
In setting cut points, it is necessary to consider the potential human and economic costs of missing true cases by lowering the sensitivity versus the cost of falsely classifying noncases by lowering the specificity. In making such decisions, factors to be considered include the importance of capturing all cases, the likelihood that the population will be rescreened, the interval between screenings relative to the rate of disease development, and the prevalence of the disease. A low prevalence typically requires a test with high specificity; otherwise, the screening will produce too many false positives in the largely nondiseased population. On the other hand, a disease with a high prevalence usually requires high sensitivity; otherwise, too many of the real cases will be missed by the screening (false negatives).
Two or more tests can be combined, in series or in parallel, to enhance sensitivity or specificity. In series testing, the final result is considered positive only if all tests in the series were positive, and it is considered negative if any test was nega- tive. For example, if a blood sample were screened for HIV, a positive enzyme-linked immunosorbent assay (ELISA) might be followed up with a Western blot, and the sample would be considered positive only if both tests were positive. Series testing enhances specificity, producing fewer false positives, but sensitivity will be lower. In series testing, sequence is impor- tant; a very sensitive test is often used first to pick up all cases including false positives, and then a second, very specific test is used to eliminate the false positives. In parallel testing, the final result is considered positive if any test was positive and negative only if all tests were negative. To return to the example of a blood sample being tested for HIV, a blood bank might consider a sample positive if a positive result was found on either the ELISA or the Western blot. Parallel testing enhances sensitivity, leaving fewer false negatives, but specificity will be lower.
SURVEILLANCE Surveillance involves the systematic collection, analysis, and interpretation of data related to the occurrence of disease and the health status of a given population. Surveillance systems are often classified as either active or passive (Teutsch and Churchill, 2010). Passive surveillance is the more common form used by most local and state health departments. Health care providers in the community report cases of notifiable diseases to public health authorities through the use of standardized reports. Passive surveillance is relatively inexpensive but is limited by variability and incompleteness in provider reporting practices. Active surveillance is the purposeful, ongoing search for new cases of disease by public health personnel, through personal or telephone contacts or the review of laboratory reports or hos- pital or clinic records. Because active surveillance is costly, its use is often limited to brief periods for specific purposes as in the emergence of a newly identified disease, a particularly severe disease, or the reemergence of a previously eradicated disease. In situations that do not require ongoing active surveillance, or
273CHAPTER 12 Epidemiology
sources of potentially toxic exposures, and mapping water quality measures in sensitive ecosystems.
Rate Adjustment Rates, which are of central importance in epidemiologic studies, can be misleading when compared across different populations. For example, the risk of death increases rather dramatically after 40 years of age; therefore, a higher crude death rate is expected in a population of older people compared with a pop- ulation of younger people (Rothman, 2012; Koepsell and Weiss, 2003; Gordis, 2013). Because the direct comparison of the overall mortality rate in an area with a large population of older adults to the mortality rate in an area with a much younger population would be misleading, there are methods that adjust for such differences in populations. Age adjustment is based on the assumption that a population’s overall mortality rate is a function of the age distribution of the population and the age- specific mortality rates. Rates for any outcome can be adjusted by the methods described here, but we focus our discussion on age adjustment of death rates because it is most common. As noted previously: as the population ages, the risk of death increases.
Age adjustment can be performed by direct or indirect methods. Both methods require a standard population, which can be an external population, such as the U.S. population for a given year; a combined population of the groups under study; or some other standard chosen for relevance or convenience. A direct age-adjusted rate applies the age-specific death rates from the study population to the age distribution of the standard population. The result is the (hypothetical) death rate of the study population if it had the same age distribution as the standard population.
The indirect method, as the name suggests, is more compli- cated. The age-specific death rates of the standard population applied to the study population’s age distribution produce an index rate that is used with the crude rates of both the study and standard populations to produce the final indirect adjusted rate, which is also hypothetical. The indirect method may be required when the age-specific death rates for the study popula- tion are unknown or unstable (e.g., based on relatively small numbers). Often, instead of an indirect adjusted rate, a stan- dardized mortality ratio (SMR) is calculated. This is the number of observed deaths in the study population divided by the number of deaths expected on the basis of the age-specific rates in the standard population and the age distribution of the study population (Szklo and Nieto, 2012; Gordis, 2013).
Although this discussion has focused on age adjustment, the process can be used to adjust for any factor that might vary from one population to another. For example, to compare infant mortality rates across populations with different birth weight distributions, these methods may be used to produce birth weight–adjusted infant mortality rates. Note that all adjusted rates are fictitious rates. They may resemble crude rates if the distribution of the study sample is similar to the distribu- tion of the standard population. The magnitude of adjusted rates depends on the standard population used. The choice of a different standard would produce a different adjusted
reporting systems, which solicit reports of all cases of a particu- lar disease within a geographic region. Other information, such as occupational exposures, may be available from employer records. School and employment attendance and absenteeism records are another potential source of data that may be used in epidemiologic investigations.
Epidemiologic Data The National Center for Health Statistics sponsors periodic health surveys and examinations in carefully drawn samples of the U.S. population. Examples are the National Health and Nutrition Examination Survey (NHANES), the National Health Interview Survey (NHIS), and several National Health Care Surveys including the National Hospital Discharge Survey (NHDS), the National Ambulatory Medical Care Survey (NAMCS), and the National Nursing Home Survey (NNHS). The CDC also conducts or contracts for surveys such as the Youth Risk Behavior Survey (YRBS), the Pregnancy Risk Assess- ment Monitoring System (PRAMS), and the Behavioral Risk Factor Surveillance System (BRFSS). These surveys provide information on the health status and behaviors of the popula- tion. For many studies, however, the only way to obtain the needed information is to collect the required data in a study specifically designed to investigate a particular question. The design of such studies is discussed later.
With the technological advances available through GIS, the use of cartographic data for epidemiologic studies is becoming more widespread. For example, GIS systems are now an integral component of malaria vector control in Mexico and Central America (Najera-Aguilar et al, 2005). Local health professionals and authorities who survey their communities to identify mos- quito breeding sites now use global positioning system (GPS) and GIS technology to display and analyze their data. The resulting GIS maps are graphic illustrations of their communi- ties, including buildings, streets, rivers, mosquito breeding sites, and dwellings where individuals with malaria live. These maps allow the calculation of preventive treatments for dwellings located inside various radiuses, from 50 to 250 meters, around the houses with malaria cases. The standardization and integra- tion of cartographic data collection in countries with endemic malaria are part of coordinated international efforts to strengthen malaria control. GIS technology has been used to examine other health issues, such as access to prenatal care. McLafferty and Grady (2005) compared levels of geographic access to prenatal clinics among immigrant groups in Brooklyn, New York. They used kernel estimation—a technique to depict the density of points (in this case, prenatal clinics) as a spatially continuous variable that can be represented as a smooth contour map. Then, using birth record data for the year 2000, which included the mother’s country of birth, they compared clinic density levels among different immigrant groups. The authors noted the usefulness of these methods for public health depart- ments in exploring demographic transitions and developing health service networks that are responsive to immigrant popu- lations. GIS technology can be applied in a variety of situations, such as mapping the distribution of health exposures or out- comes, linking data with geo-coded addresses of individuals to
274 PART 3 Conceptual and Scientific Frameworks
related socioeconomic status), and marital status. As noted pre- viously, the most important predictor of overall mortality is age. The mortality curve by age drops sharply during and after the first year of life to a low point in childhood, then it begins to increase through adolescence and young adulthood, and after that it increases sharply (exponentially) through middle and older ages (Gordis, 2013).
There are also substantial differences in mortality and mor- bidity rates by sex. Female infants have a lower mortality rate than comparable male infants, and the survival advantage con- tinues throughout life (Xu, Kochanek, and Tejada-Vera, 2009). However, patterns for specific diseases vary. For example, women have lower rates of CHD until menopause, after which the gap narrows. For rheumatoid arthritis, the prevalence among women is greater than among men (Remington, Brown- son, and Wegner, 2010).
Although the concept of race as a variable for public health research has come under scrutiny (CDC, 1993; Fullilove, 1998), there are clear differences in morbidity and mortality rates by race in the United States (USDHHS, 2000; NCHS, 2009). According to the Office of Minority Health (OMH, 1999), racial and ethnic minority groups are among the fastest-growing populations in the United States, yet they have poorer health and remain chronically underserved by the health care system. Data in the OMH report Elimination of Racial and Ethnic Dis- parities in Health highlighted some of the significant health disparities within the leading categories of death in the United States. For example, in 2007 the overall infant mortality rate (IMR) was 6.8 deaths per 1000 live births, but the IMR among African Americans was 12.9 per 1000 live births (Xu, Kochanek, and Tejada-Vera, 2009), and the gap has been widening in recent years. Racial and ethnic health disparities have been observed in a wide range of diseases and health behaviors, from infant mortality to diabetes, heart disease, cancer, and HIV. Although there has been some progress toward meeting the goal of elimi- nating racial/ethnic disparities, with improvement in rates for most health status indicators across all racial/ethnic groups, the improvements have not been uniform across groups and “sub- stantial differences among racial/ethnic groups persist” (Keppel, Pearcy, and Wagener, 2002). Among Native Americans and Native Alaskans, several health indicators actually worsened from 1990 to 1998. The IMR declined in all groups, but it remains 2.3 times higher for infants born to non-Hispanic African American mothers than for those born to white non- Hispanic mothers. Similarly, the overall age-adjusted mortality rate was 22% higher in the African American population than in the white population in 2006, and it was higher for 10 of the 15 leading causes of death (Heron, 2010). Although individual characteristics such as race, gender, and immigration status are of interest to epidemiologists, there has been increasing focus on social, economic, and cultural contexts and processes under- lying racial and ethnic inequalities in health, such as discrimina- tion (Krieger, 2000; Fuller et al, 2005).
Place When considering the distribution of a disease, geographic pat- terns come to mind: Does the rate of disease differ from place
rate. The change from the 1940 U.S. population to the 2000 U.S. population as the standard for age-adjusted rates from the NCHS demonstrates the difference a change in standard population can make (Anderson and Rosenberg, 1998; Sorlie et al, 1999).
Comparison Groups The use of comparison groups is at the heart of the epidemio- logic approach. Incidence or prevalence measures in groups that differ in some important characteristic must be compared to gain clues about which factors influence the distribution of disease (i.e., disease determinants or risk factors). Observing the rate of disease only among persons exposed to a suspected risk factor will not show clearly that the exposure is associated with increased risk until the rate observed in the exposed group is compared with the rate in a group of comparable unexposed persons. To illustrate, one might investigate the effect of smoking during pregnancy on the rate of birth of low-birth-weight infants by calculating the rate of low-birth-weight infants born to women who smoked during their pregnancy. However, the hypothesis that smoking during pregnancy is a risk factor for low birth weight is supported only when the low-birth-weight rate among smoking women is compared with the (lower) rate of low-birth-weight infants born to nonsmoking women.
The ideal approach would be to compare one group of people who all have a certain characteristic, exposure, or behav- ior, with a group of people exactly like them except that they all lack that characteristic, exposure, or behavior. In the absence of that ideal, researchers either randomize people to exposure or treatment groups in experimental studies, or they select com- parison groups that are comparable in observational studies. Advances in statistical techniques now make it possible to control for differences between groups, but these advanced techniques are effective only in reducing the bias that results from confounding by variables we have measured.
DESCRIPTIVE EPIDEMIOLOGY Descriptive epidemiology describes the distribution of disease, death, and other health outcomes in the population according to person, place, and time, providing a picture of how things are or have been—the who, where, and when of disease pat- terns. Analytic epidemiology, on the other hand, searches for the determinants of the patterns observed—the how and why. That is, epidemiologic concepts and methods are used to iden- tify what factors, characteristics, exposures, or behaviors might account for differences in the observed patterns of disease occurrence. Descriptive and analytic studies are observational, meaning the investigator observes events as they are or have been and does not intervene to change anything or introduce a new factor. Experimental or intervention studies, however, include interventions to test preventive or treatment measures, techniques, materials, policies, or drugs.
Person Personal characteristics of interest in epidemiology include race, ethnicity, sex, age, education, occupation, income (and
275CHAPTER 12 Epidemiology
in recent years although the incidence of breast cancer has increased. Some, although not all, of the increased incidence is a result of improved diagnostic capability. These two trends result in a breast cancer mortality curve that is flatter than the incidence curve (Remington et al, 2010). Mortality data alone do not accurately reflect the true situation. For example, changes in case definition or revisions in the coding of a disease accord- ing to the International Classification of Diseases (ICD) can produce an artificial change in mortality rates.
Point Epidemic One temporal and spatial pattern of disease distribution is the point epidemic. This time-and-space–related pattern is impor- tant in infectious disease investigations and is a significant indicator for toxic exposures in environmental epidemiology. A point epidemic is most clearly seen when the frequency of cases is plotted against time. The sharp peak characteristic of such graphs indicates a concentration of cases in some short interval of time. The peak often indicates the response of the population to a common source of infection or contamination to which they were all simultaneously exposed. Knowledge of the incubation or latency period (the time between exposure and development of signs and symptoms) for the specific disease entity can help to determine the probable time of expo- sure. A common example of a point epidemic is an outbreak of gastrointestinal illness from a foodborne pathogen. Nurses who are alert to a sudden increase in the number of cases of a disease can chart the outbreak, determine the probable time of expo- sure, and, by careful investigation, isolate the probable source of the agent.
Cyclical Patterns In addition to secular trends and point epidemics, there are also cyclical time patterns of disease. One common type of cyclical variation is the seasonal fluctuation seen in a number of infec- tious illnesses. Seasonal changes may be influenced by changes in the agent itself, changes in population densities or behaviors of animal reservoirs or vectors, or changes in human behavior that result in changing exposures (e.g., being outdoors in warmer weather and indoors in colder months). There may also be artificial seasons created by calendar events (e.g., holidays and tax-filing deadlines) that may be associated with patterns of stress-related illness. Patterns of accidents and injuries may also be seasonal, reflecting differing employment and recre- ational patterns. Some disease cycles, such as influenza, have patterns of smaller epidemics every few years, depending on strain, with major pandemics occurring at longer intervals (Heymann, 2014). Workers in public health can prepare to meet increased demands on resources by paying careful attention to these cyclical patterns.
Event-Related Clusters A fourth type of temporal pattern is nonsimultaneous event- related clusters. These are patterns in which time is not mea- sured from fixed dates on the calendar but from the point of some exposure or event, presumably experienced in common by affected persons, although not occurring at the same time.
to place (e.g., with local environment)? If geography had no effect on disease occurrence, random geographic patterns might be seen, but that is often not the case. For example, at high altitudes there is lower oxygen surface tension, which might result in smaller babies. Other diseases reflect distinctive geo- graphic patterns. For example, Lyme disease is transmitted from animal reservoirs to humans by a tick vector. Thus, the disease is more likely to be found in areas where there are animals carrying the disease, a large tick population for transmission to humans, and contact between the human population and the tick vectors (Heymann, 2014).
The influence of place on disease may certainly be related to geographic variations in the chemical, physical, or biological environment. However, variations by place also may result from differences in population densities, or in customary patterns of behavior and lifestyle, or in other personal characteristics. For example, geographic variations might occur because of high concentrations of a religious, cultural, or ethnic group who practice certain health-related behaviors. The high rates of stroke found in the southeastern United States are likely to be the result of a number of social, economic, cultural, and per- sonal factors that have little to do with geographic features per se. Recent epidemiologic research has also focused on neighborhood-level variables, such as unemployment and crime rate, social cohesion, educational levels, racial segrega- tion, and access to important services (Cohen et al, 2000; Caughy, O’Campo, and Patterson, 2001; Bradman et al, 2005; Fuller et al, 2005; McLafferty and Grady, 2005). For example, recent research on adolescent injection drug users (IDUs) found that African American IDUs from neighborhoods with large percentages of minority residents and low adult educational levels were more likely to initiate injection use during adoles- cence than white IDUs from neighborhoods with low percent- ages of minority residents and high adult education levels. Nurses need to pay attention to this wide range of community- level variables as they assess the health of communities.
Time Time is the third component of descriptive epidemiology. In relation to time, epidemiologists ask these questions: Is there an increase or decrease in the frequency of the disease over time? Are other temporal (and spatial) patterns evident? Temporal patterns of interest to epidemiologists include secular trends, point epidemic, cyclical patterns, and event-related clusters.
Secular Trends Long-term patterns of morbidity or mortality rates (i.e., over years or decades) are called secular trends. Secular trends may reflect changes in social behavior or health practices. For example, the increased lung cancer mortality rates among men and women in recent years reflect a delayed effect of increased smoking in prior years. Similarly, the decline in cervical cancer deaths is primarily attributable to widespread screening with the Pap test (Remington, Brownson, and Wegner, 2010). Some secular trends may result from increased diagnostic capability or changes in survival (or case fatality) rather than in incidence. For example, case fatality from breast cancer has decreased
276 PART 3 Conceptual and Scientific Frameworks
and increase or decrease the risk of adverse outcomes). This section deals with analytic study designs and the related mea- sures of association derived from them. Table 12-4 summarizes the advantages and disadvantages of each design.
Cohort Studies The cohort study is the standard for observational epidemio- logic studies, coming closest to the ideal of a natural experiment (Rothman, 2012). In epidemiology, the term cohort is used to describe a group of persons who are born at about the same time. In analytic studies, a cohort refers to a group of persons (generally sharing some characteristic of interest) enrolled in a study and followed over a period of time to observe some health outcome (Porta, 2008). Because they enable us to observe the development of new cases of disease, cohort study designs allow calculation of incidence rates and therefore estimates of disease
An example would be vaccine reactions in an ongoing immu- nization program. If vaccinations are given on a regular basis, one might see nonspecific symptoms (e.g., fever, headaches, and rashes) fairly consistently over perhaps a year, making identifi- cation of a cluster related to the vaccinations difficult. If, however, the time of vaccination is artificially set as zero for each client, and the number of clients with symptoms is plotted against the time since time zero, the reactions are likely to show up as a peak at some period after the immunization.
ANALYTIC EPIDEMIOLOGY Descriptive epidemiology deals with the distribution of health outcomes, whereas analytic epidemiology seeks to discover the determinants of outcomes, or the how and the why (i.e., the factors that influence observed patterns of health and disease
Study Design Advantages Disadvantages
Ecologic Quick, easy, and inexpensive first study Uses readily available existing data May prompt further investigation or suggest other/new
hypotheses May provide information about contextual factors not
accounted for by individual characteristics
Ecologic fallacy: associations observed may not hold true for individuals
Problems in interpreting temporal sequence (cause and effect) More difficult to control for confounding and “mixed” models
(ecological and individual data); more complex statistically
Cross-sectional Gives general description of scope of problem; provides prevalence estimates
Often based on population (or community) sample, not just those who sought care
Useful in health service evaluation and planning Data obtained at once; less expensive and quicker than
cohort because no follow-up Baseline for prospective study or to identify cases and
controls for case-control study
No calculation of risk; prevalence, not incidence Temporal sequence unclear Not good for rare disease or rare exposure unless large sample size
or stratified sampling Selective survival can be major source of selection bias; surviving
subjects may differ from those who are not included (e.g., death, institutionalization)
Selective recall or lack of past exposure information can create bias
Case-control (retrospective, case comparison)
Less expensive than cohort; smaller sample required Quicker than cohort; no follow-up Can investigate more than one exposure Best design for rare diseases If well designed, can be important tool for etiological
investigation Best suited to disease with relatively clear onset (timing of
onset can be established so that incident cases can be included)
Greater susceptibility than cohort studies to various types of bias (selective survival, recall bias, selection bias on choice of both cases and controls)
Information on other risk factors may not be available, resulting in confounding
Antecedent-consequence (temporal sequence) not as certain as in cohort
Not well suited to rare exposures Gives only an indirect estimate of risk Limited to a single outcome because of sampling on disease status
Prospective cohort (concurrent cohort, longitudinal, follow-up)
Best estimate of disease incidence Best estimate of risk Fewer problems with selective survival and selective recall Temporal sequence more clearly established Broader range of options for exposure assessment
Expensive in time and money More difficult organizationally Not good for rare diseases Attrition of participants can bias estimate Latency period may be very long; may miss cases May be difficult to examine several exposures
Retrospective cohort (nonconcurrent cohort)
Combines advantages of both prospective cohort and case-control
Shorter time (even if follow-up into future) than prospective cohort
Less expensive than prospective cohort because reliant on existing data
Temporal sequence may be clearer than case-control
Shares some disadvantages with both prospective cohort and case-control
Subject to attrition (loss to follow-up) Relies on existing records that may result in misclassification of
both exposure and outcome May have to rely on surrogate measure of exposure (e.g., job title)
and vital records information on cause of death
TABLE 12-4 Comparison of Major Epidemiologic Study Designs
277CHAPTER 12 Epidemiology
The incidence proportion of CHD in the active group is a/(a + b), or 48/1000, and the incidence of CHD in the sed- entary group is c/(c + d), or 120/1000. The risk ratio is as follows:
48 1000
120 1000
0 4
÷
= .
Because physical activity is protective for CHD, the risk ratio is less than 1. The interpretation for this hypothetical example is that, over a 5-year period, the risk of CHD in persons who are physically active is about 0.4 as great as the risk among sedentary persons. If the risk was greater for those exposed, the risk ratio would be greater than 1. For example, if the risk ratio of CHD for overweight persons compared with normal weight is 3.5, it would be interpreted to mean that the risk of CHD among overweight persons is 3.5 times the risk of those with normal weight. The null value indicating no association is 1, because the incidence proportion and thus the risk would be equal in the two groups if there were no association. This same statistic can also be expressed (and indeed is more commonly used in the media) as a percentage increase or decrease in risk. For a relative risk of 0.40, it also can be expressed as “a 60% decreased risk (1.0 − 0.4 = 60% reduction from 1.0)”. Likewise, a relative risk of 1.4 could be expressed as a “40% increase in risk.”
Because subjects are enrolled before onset of disease, using the cohort design allows us to study more than one outcome, calculate incidence rates and proportions, estimate risk, and establish the temporal sequence of exposure and outcome with greater clarity and certainty. Use of the cohort design also may avoid many of the problems of the other study designs with selective survival or exposure misclassification (discussed later). On the other hand, large samples are often necessary to ensure that enough cases are observed to provide enough statistical power to detect meaningful differences between groups. This is complicated by the long period required for some diseases to develop (the latency period). In addition, the number of sub- jects required to observe sufficient cases makes longitudinal studies unsuitable for very rare diseases unless they are part of a larger study of a number of outcomes.
Retrospective Cohort Studies Retrospective cohort studies combine some of the advantages and some of the disadvantages of both case-control studies and prospective cohort studies. In these studies, the epidemiologist relies on existing records, such as employment, insurance, or hospital records, to define a cohort, whose members are classi- fied according to exposure status at some time in the past. The cohort is followed over time using the records to determine if the outcome occurred. Retrospective cohort (also called histori- cal cohort) studies may be conducted entirely using past records or may include current assessment or additional follow-up time after study initiation. The obvious advantage of this approach is the time savings, because one does not have to wait for new cases of disease to develop. The disadvantages are largely related to the reliance on existing historical records. Retrospective cohort studies are frequently used in occupational epidemiol-
risk. Cohort studies may be prospective or retrospective (Rothman, 2012; Szklo and Nieto, 2012; Gordis, 2013).
Prospective Cohort Studies In a prospective cohort study (also called a longitudinal or follow-up study), subjects determined to be free of the outcome under investigation are classified on the basis of the exposure of interest at the beginning of the follow-up period. The differ- ent exposure groups constitute the comparison groups for the study. The subjects are then followed for some period of time to determine the occurrence of disease in each group. The ques- tion is the following: “Do persons with the factor (or exposure) of interest develop (or avoid) the outcome more frequently than those without the factor (or exposure)?”
For example, one might recruit a cohort of subjects classified as physically active (“exposed”) or sedentary (“not exposed”). One might further quantify the amount of the “exposure” if there is sufficient information. These subjects would then be followed over time to determine the development of CHD. This study design avoids the problem of selective survival that some- times affects other study designs (Figure 12-5). Because persons initially without the disease are followed over time, this design allows estimation of both incidence rates and incidence propor- tions. The cohort study can also estimate the relative risk of acquiring disease for those who are exposed compared with those who are unexposed (or less exposed). This ratio of inci- dence proportions is called the risk ratio (or relative risk), and a ratio incidence rate is called the rate ratio. For example, if the risk of CHD in smokers is twice as high as the risk among nonsmokers, the risk ratio would be 2. If a factor is unrelated to the risk of a disease, the risk ratio will be close to 1. A value less than 1 may suggest a protective association. For example, the risk of CHD is lower among those who are physically active than among sedentary persons, so the risk ratio for the associa- tion between physical activity and CHD should be less than 1.
Suppose 1000 physically active and 1000 sedentary middle- aged men and women enroll in a prospective cohort study. All are free of CHD at enrollment. Over a 5-year follow-up period, regular examinations detect CHD in 120 of the sedentary men and women, and in 48 of the active men and women. Assuming no other deaths or losses to follow-up, the data could be pre- sented as shown in Figure 12-5.
FIG 12-5 Cohort study.
Physically active
CHD CHD
48 952
120 880
1000
1000
a b
c d
Sedentary
278 PART 3 Conceptual and Scientific Frameworks
This would be interpreted to mean that the odds of a history of substance abuse are about 10 times greater among adolescents who have attempted suicide than among adolescents who have not attempted suicide. Note that, as with the risk ratio, an odds ratio of 1 is indicative of no association (i.e., the odds of expo- sure are similar for cases and controls). An odds ratio less than 1 suggests a protective association (cases are less likely to have been exposed than controls).
Given the way subjects are selected for a case-control study, neither incidence nor prevalence measures can be calculated directly. However, if newly diagnosed cases are enrolled as they are found, and if case ascertainment is fairly complete and the source population well defined, an estimate of incidence may be obtained. In a case-control study, an odds ratio tells how much more or less likely the exposure is to be found among cases than among controls. The odds of exposure among cases (a/c in Figure 12-6) are compared with the odds of exposure among controls (b/d in Figure 12-6). Under certain conditions, the ratio of these two odds provides an estimate of the risk ratio or rate ratio.
Because the number of cases is known or actively sought out, case-control studies do not demand large samples or the long follow-up time that is often required for prospective cohort studies. Thus many of the influential cancer studies are of the case-control design.
Case-control studies are, however, prone to a number of biases (see further discussion under “Bias” later in this chapter). Because these studies begin with existing cases, differential sur- vival can produce biased results. The use of recently diagnosed, or “incident,” cases may reduce this bias. Also, exposure infor- mation is obtained from subject recall or past records, and there may be errors in exposure assessment or misclassification. Because participants are selected precisely because they do or do not have a specific health outcome, case-control studies are limited to a single outcome, although they may investigate a number of potential risk factors.
Cross-sectional Studies The cross-sectional study provides a snapshot, or cross-section, of a population or group (Gordis, 2013). Information is col- lected on current health status, personal characteristics, and potential risk factors or exposures all at once. The cross-sectional study is characterized by the simultaneous collection of infor- mation necessary for the classification of exposure and outcome status, although there may be historical information collected (e.g., on past diet or history of radiation exposure). Surveys are one common type of data collection for cross-sectional studies. They may be administered in person, over the phone, by mail, or, increasingly, on websites or through personal electronic devices. Each form of administration has its advantages and disadvantages, as does the use of surveys for epidemiologic studies, but a complete discussion of survey methodology is beyond the scope of this chapter.
Cross-sectional studies are sometimes called prevalence studies because they provide the frequency of existing cases of a disease in a population. One way cross-sectional studies
ogy where industrial records are available to investigate work- related exposures and health outcomes.
Case-control Studies The case-control design can be viewed against the background of an underlying cohort. The design uses a sample from the cohort rather than following the entire cohort over time. Because it uses only samples of cases and non-cases, it is a more efficient design, although it is subject to certain types of bias (Rothman, 2012). In the case-control study, participants are enrolled because they are known to have the outcome of interest (cases) or they are known not to have the outcome of interest (controls). Case-control status is verified using a clear case defi- nition and some previously determined method or protocol (e.g., by an examination, laboratory test, or medical chart review). Information is then collected on the exposures or char- acteristics of interest, frequently from existing sources, subject interview, or questionnaire (Schlesselman, 1982; Rothman, 2012; Szklo and Nieto, 2012). The question in a case-control study is the following: “Do persons with the outcome of interest (cases) have the exposure characteristic (or a history of the exposure) more frequently than those without the outcome (controls)?”
Suppose a research group wanted to study risk factors for suicide attempts among adolescents. They were able to enroll 100 adolescents who had attempted suicide, and they selected 200 adolescents from the same community with no history of suicide attempt. One of the factors they wanted to investigate is a history of substance abuse. Through a questionnaire and other medical records, they determine that 68 of the 100 ado- lescents who had attempted suicide had a history of substance abuse, whereas 36 of the 200 adolescents with no suicide attempt had such a history. The information could be presented as shown in Figure 12-6. The odds of a positive history of sub- stance abuse among adolescents who attempt suicide is a/c, or 68/32, whereas the odds of substance abuse among controls (no suicide attempts) is b/d, or 36/164. The odds ratio (equivalent to ad/bc) is as follows:
( ) ( )
. 68 164 36 32
9 68 × ×
=
FIG 12-6 Case-control study.
History of substance abuse
Suicide attempt No attempt
68 36
32 164
a b
c d
100 200
No history of substance abuse
279CHAPTER 12 Epidemiology
populations for which the ecological correlations do not account. For that reason, ecologic studies may be suggestive but require confirmation in studies using individual data (Koepsell and Weiss, 2003; Gordis, 2013). However, it has been shown that ecologic data can add important information to analyses even when individual-level data are available (Lynch et al, 1998; Diez-Roux, 2002). Uncertainty concerning the temporal sequence of events is a disadvantage that ecologic studies share with cross-sectional study designs. For example, in the study of unemployment rates and psychiatric disorders, it is unclear whether unemployed persons are at higher risk for psychiatric problems or whether persons with existing psychiatric prob- lems are more likely to be unemployed. Although determining whether one event precedes or succeeds another may seem at first to be a simple matter, in practice it may be difficult to confirm.
EXPERIMENTAL STUDIES The study designs discussed so far are called observational studies because the investigator observes the association between exposures and outcomes as they exist but does not intervene to alter the presence or level of any exposure or behavior. Studies in which the investigator initiates some treatment or interven- tion that may influence the risk or course of disease are called intervention, or experimental, studies. Such studies test whether interventions are effective in preventing disease or improving health. Like observational studies, experimental studies gener- ally use comparison (or control) groups, but unlike observa- tional studies, they are subject to the consequences of randomly allocating persons to a particular intervention group and deter- mining the type or level of the “exposure” (the treatment or intervention). Intervention studies are of two general types: clinical trials and community trials.
Clinical Trials In clinical trials, the research issue is generally the efficacy of a medical treatment for disease, such as a new drug or an exist- ing drug used in a new or different way, a surgical technique, or another treatment. The preferred method of subject alloca- tion in clinical trials is randomization (i.e., assigning treat- ments to clients so that all possible treatment assignments have a predetermined probability but neither subject nor investigator determines the actual assignment of any partici- pant). Randomization avoids the bias that may result if sub- jects self-select into one group or the other or if the investigator or clinician chooses subjects for each group. A second aspect of treatment allocation is the use of masking, or “blinding,” treatment assignments. The optimal design for most situations is the double-blind study in which neither the subject nor the investigator knows who is receiving which treatment. The aim of blinding is to reduce the bias from overestimating therapeutic benefit for the experimental treat- ment when it is known who is receiving it.
Clinical trials are generally thought to provide the best evi- dence of causality because of the assignment of treatment and
evaluate the association of a factor with a health problem is by comparing the prevalence of the disease in those who have the factor (or exposure) with the prevalence in the unexposed. The ratio of the two prevalence proportions indicates an association between the factor and the outcome. If the prevalence of CHD in smokers was twice as high as the prevalence among non- smokers, the prevalence ratio would be 2. If a factor is unrelated to the prevalence of a disease, the prevalence ratio will be close to 1. A value less than 1 may suggest a protective association. For example, the prevalence of CHD is lower among those who are physically active than among sedentary persons, so the prev- alence ratio for the association between physical activity and CHD should be less than 1. Prevalence ratios require caution in interpretation because the prevalence measure is affected by cure, survival, and migration and does not estimate the risk of getting the disease.
Cross-sectional studies are subject to bias resulting from selective survival (i.e., people who have survived to be in the study may be different from people diagnosed about the same time who have died and are not available for inclusion). Suppose that physical activity not only reduced the risk of CHD but also markedly improved survival among those with CHD. Sedentary persons with CHD would then have higher fatality rates than physically active persons who did develop CHD. One might observe higher rates of physical activity in a group of persons surviving with CHD than in a general population without CHD, both because of the survival advantage of those who previously were active and because of increased participation of other survivors in cardiac rehabilitation programs. It could erroneously appear that physical activity was a risk factor for CHD.
Ecologic Studies An epidemiologic study that is a bridge between descriptive epidemiology and analytic epidemiology is the ecologic study. The descriptive component involves examining variations in disease rates by person, place, or time. The analytic component lies in the effort to determine if there is a relationship between disease rates and variations in rates for possible risk (or protec- tive) factors. The identifying characteristic of ecologic studies is that only aggregate data, such as population rates, are used rather than data on individuals’ exposures, characteristics, and outcomes. For example, information on per capita cigarette consumption might be examined in relation to lung cancer mortality rates in several countries, in several groups of people, or in the same population at different times. Other examples include comparisons of rates of breastfeeding and breast cancer, average dietary fat content and rates of CHD, or unemployment rates and levels of psychiatric disorders.
Ecologic studies are attractive because they often make use of existing, readily available rates and are therefore quick and inexpensive to conduct. They are subject, however, to ecologic fallacy (i.e., associations observed at the group level may not hold true for the individuals who make up the groups, or asso- ciations that actually exist may be masked in the grouped data). This may be the result of other factors operating in these
280 PART 3 Conceptual and Scientific Frameworks
at a population level and how these multiple factors are related to each other. This next section will focus on causality within the context of the individual study or series of studies (as with a body of evidence). This is quite different from the web analogy that was used previously because it only focuses on the relationship between a single exposure and outcome measure. It may be useful to think of the web of causation as those factors that play out at the macroscopic level, in contrast to focusing efforts to identify and prove causality at a micro- scopic level.
Statistical Associations One of the first steps in assessing the relationship of some factor with a health outcome is determining whether a statistical asso- ciation exists. If the probability of disease seems unaffected by the presence or level of the factor, no association is apparent. If, on the other hand, the probability of disease does vary according to whether the factor is present, there is a statistical association. The earlier discussion of null values is pertinent at this point. When an observed measure of association (such as a risk ratio) does not differ from the null value, it may not be assumed that there is an association between the factor and the outcome under investigation.
In many studies, a great deal of emphasis is placed on tests of statistical significance. This is a judgment that the observed results are or are not likely to be attributable to chance at some predetermined level of probability (usually 0.05). However, many epidemiologists contend that much more information is provided by an estimate of the association (the ratio or difference in rates or risks) and a confidence interval that indi- cates the precision of the estimate (Rothman, 2012). Note that statistical significance is determined by sample size, the amount of difference between groups, and the variance in the estimates.
Bias Although statistical testing and estimation are critical, it is important to remember that statistical testing and interval esti- mation generally assume that deviations from the true value are the result of chance. However, estimates may appear to be greater or less than they really are because of bias, a systematic error resulting from the study design, execution, or confound- ing. For example, if there were a gumball machine with colors randomly mixed and three red ones in a row came out, that would be a result of chance. If, however, the person loading the gumball machine had poured in a bag of red ones first, then green ones, and then yellow, it would not be surprising to get three red ones in a row because of the way the machine was loaded. In epidemiologic studies, results are sometimes biased because of the way the study was “loaded” (i.e., the way the study was designed, subjects were selected, information was collected, or subjects were classified). Three generally recog- nized categories are selection, classification, and confounding bias (Rothman, 2012).
Bias attributable to the way subjects enter a study is called selection bias. It has to do with selection procedures and the population from which subjects are drawn. It may involve
the greater control over other factors that could influence outcome. Like cohort studies, clinical trials are prospective in direction and provide the clearest evidence of temporal sequence. However, clinical trials are generally conducted in a contrived situation, under controlled conditions, and with select client populations. That means that the treatment may be less effective when it is applied under more realistic clinical or community conditions in a more diverse client population. There are also ethical considerations in experimental studies that go beyond those that apply to observational studies. Also, clinical trials tend to be costly in time, personnel, facilities, and other factors.
Community Trials Community trials are similar to clinical trials in that an inves- tigator determines the exposure or intervention, but in this case the issue is often health promotion and disease prevention rather than treatment of existing disease. The intervention is usually undertaken on a large scale, with the unit of treatment allocation being a community, region, or group rather than individuals. Although a pharmaceutical product may be involved in a community trial (e.g., fluoridation of water or mass immunizations), community trials often involve educa- tional, programmatic, or policy interventions. An example of community intervention is providing exercise programs and facilities and increasing the availability of healthy, fresh foods to study the effect on diabetes rates.
Although community trials provide the best means of testing whether changes in knowledge or behavior, policy, programs, or other mass interventions are effective, they are not without problems. For many interventions, it may take years for the effectiveness of the intervention to be evident. In the meantime, other factors may also influence the outcome, either positively (making the intervention look more effective than it really is) or negatively (making the intervention look less effective than it really is). Comparable community populations without similar interventions for comparative analysis are often difficult to determine. Even when comparable comparison communities are available, especially when the intervention is intended to improve knowledge or change behavior, it is difficult and unethical to prevent the control communities from making use of generally available information. Exposure to this informa- tion, however, may have the effect of making control communi- ties more like the intervention communities. Also, because community trials are often undertaken on a large scale and over long periods, they can be expensive, requiring large staff, com- plicated logistics, and extensive communication resources. Although the randomized trial is often considered the “gold standard” of medical and public health research, because of the limitations noted above, there is clearly a need for other types of research designs to complement randomized control trials (Victoria, Habicht, and Bryce, 2004).
CAUSALITY In a previous section, we introduced the concept of the web of causation. This is a useful analogy in considering causal agents
281CHAPTER 12 Epidemiology
identify, report, treat, and provide follow-up on cases and con- tacts of TB, gonorrhea, and gastroenteritis. School nurses also function as epidemiologists, collecting data on the incidence and prevalence of accidents, injuries, and illnesses in the school population. They are also key players in the detection and control of local epidemics, such as outbreaks of lice. As described earlier in this chapter, nurses across practice settings are actively involved in activities related to primary, secondary, and tertiary prevention (see Levels of Prevention box).
Some nursing job descriptions are specifically based in epi- demiologic practice. These include hospital infection control nurses, nurse epidemiologists, and nurse environmental risk communicators employed by local health departments. Nurses are key members of local fetal and infant mortality review boards, which examine cases of newborn deaths for identifiable risk factors and quality of care measures. Members of these review boards may include public health and maternal child nurses as well as representatives from hospital labor and deliv- ery and neonatal intensive care units.
Nursing documentation on client charts and records is an important source of data for epidemiologic reviews. Client demographics and health histories are often collected or verified by nurses. As nurses collect and document client information, they might not be thinking about the epidemiologic connec- tion. However, the reliability and validity of such data can be a key factor in the quality of future epidemiologic studies. An
self-selection factors as well. For example, are teenagers who agree to complete a questionnaire on alcohol, tobacco, and other drug use representative of the total teenage population?
Bias attributable to misclassification of subjects once they are in the study is information, or classification (or misclassifica- tion), bias. It is related to how information is collected, includ- ing the information that subjects supply or how subjects are classified.
Bias resulting from the relationship of the outcome and study factor with some third factor not accounted for is called confounding. For example, there is a well-known association between maternal smoking during pregnancy and low-birth- weight babies. There is also an association between alcohol con- sumption and smoking that is not attributable to chance nor is it causal (i.e., drinking alcohol does not cause a person to smoke, nor does smoking cause a person to drink alcohol). If one were to investigate the association of alcohol consumption and low birth weight, smoking would be a confounder because it is related to both alcohol consumption and low birth weight. Failure to account for smoking in the analysis would bias the observed association between alcohol use and low birth weight. In practice, one can often identify potentially confounding vari- ables and adjust for them in analysis.
Assessing for Causality The existence of a statistical association does not necessarily mean that there is a causal relationship or that causality is present (Susser, 1973). As noted previously, the observed asso- ciation may be a random event (caused by chance) or may be attributable to bias from confounding or from flaws in the study design or execution. Statistical associations, although necessary to an argument for causality, are not sufficient proof. Some epidemiologists refer to criteria for causality, a term originally established to evaluate the link between an infectious agent and a disease but revised and elaborated to also apply to other out- comes. Although various lists of criteria have been proposed, the seven criteria listed in Box 12-3 are fairly commonly cited (Gordis, 2013; Koepsell and Weiss, 2003). Some have questioned the use of lists of criteria as misleading, especially because only temporal sequence is necessary, and none of the others really is a criterion (Rothman, 2012). Although no single epidemiologic study can satisfy all criteria, public health practitioners rely on the accumulation of evidence and the strength of individual studies to provide a basis for effective public health interven- tions and policies.
APPLICATIONS OF EPIDEMIOLOGY IN NURSING Both knowledge and practical application of epidemiology are essential competencies for nurses (Gebbie and Hwang, 2000). Nurses incorporate epidemiology into their practices and take on a variety of epidemiologic roles. Nurses in diverse settings are involved in the collection, reporting, analysis, interpretation, and communication of epidemiologic data as part of their daily practice. As nurses care for persons with communicable dis- eases, they are implementing epidemiologic practices as they
1. Strength of association: A strong association between a potential risk factor and an outcome supports a causal hypothesis (e.g., a relative risk of 7 provides stronger evidence of a causal association than a relative risk of 1.5).
2. Consistency of findings: Repeated findings of an association with different study designs and in different populations strengthen causal inference.
3. Biological plausibility: Demonstration of a physiological mechanism by which the risk factor acts to cause disease enhances the causal hypothesis. Conversely, an association that does not initially seem biologically defen- sible may later be discovered to be so.
4. Demonstration of correct temporal sequence: For a risk factor to cause an outcome, it must precede the onset of the outcome. (See Prospective Cohort Studies and Table 12-4.)
5. Dose–response relationship: The risk of developing an outcome should increase with increasing exposure (either in duration or in quantity) to the risk factor of interest. For example, studies have shown that the more a woman smokes during pregnancy, the greater the risk of delivering a low- birth-weight infant.
6. Specificity of the association: The presence of a one-to-one relationship between an agent and a disease (i.e., the idea that a disease is caused by only one agent and that agent results in only one disease lends support to a causal hypothesis, but its absence does not rule out causality). This cri- terion is cultivated from the infectious disease model, where it is more often, although not always, satisfied and is less applicable in chronic diseases.
7. Experimental evidence: Experimental designs provide the strongest epide- miologic evidence for causal associations, but they are not feasible or ethical to conduct for many risk factor–disease associations.
BOX 12-3 Criteria for Causality
282 PART 3 Conceptual and Scientific Frameworks
describing her involvement with specific communities, Mood noted that the contact often began with a telephone call of concern about a planned or existing industrial facility or a first- hand observation of illness, expressed in lay terms as “too many cases of cancer,” “several people have had miscarriages,” or “more respiratory problems.” The citizen’s reasoning behind these observations is that “If I am seeing more health problems in my community, I ask what they have in common. The common factor may be where we live. So it must be the air or the water.” This is basic epidemiologic thinking, not irrational fear. Citizens try to make sense of what they are seeing, and they want professional help to unravel the pattern of illness” (Mood, 2000, p 24).
Popular Epidemiology In health departments and hospitals, nurses frequently work with other professionals who have training in epidemiology. However, in the community they may encounter citizens engaged in the practice of popular epidemiology (Brown and Ferguson, 1995; Brown and Masterson-Allen, 1994). Popular epidemiology is a form of epidemiology in which lay people gather scientific data as well as mobilize knowledge and resources of experts to understand the occurrence and distribu- tion of a disease or injury. Popular epidemiology is more than just adding public participation to traditional epidemiology; it also includes an emphasis on social structural factors as a com- ponent of disease etiology, as well as the involvement of social movements, political and judicial approaches to remedies, and challenges to basic assumptions of traditional epidemiology, risk assessment, and public health regulation (Brown and Fer- guson, 1995, p. 149). Popular epidemiology considers the physi- ological, psychological, and social effects of environmental hazards and attempts to show how racial, class, and gender dif- ferences are evident in the health effects of environmental toxic exposure. In contrast, many standard environmental health assessments are not designed to understand local cultures, traditions, or ethnic backgrounds (DiChiro, 1997). This lack of cultural competency can render assessment tools ineffective in terms of the ability to identify potential routes of toxic exposure.
Toxic waste activists are often women living in the commu- nity who have first-hand contact with toxic hazards and there- fore have experiences and access to data that would otherwise be inaccessible to scientists (Brown and Ferguson, 1995). Com- munity toxic waste activists engage in a process of linking tra- ditional scientific practices with more narrative approaches. Their health surveys often make use of sampling techniques, laboratory testing, and mapping of suspected pollutants together with experiential narratives of the effects of toxic pol- lutants on the body and on their local environments (DiChiro, 1997). The information gathered can be used by community activists and health professionals to lobby for health services; advocate for policy development at local, state, and federal levels; establish preventive programs; educate medical profes- sionals about environmental illness; and work with other agencies and community groups to reduce or eliminate toxic exposures.
excellent resource for the application of epidemiologic concepts and methods in practice settings can be found in Brownson and Petitti (2006).
Community-oriented Epidemiology Nurses are often involved in environmental health issues, where they play important roles not only as epidemiologists, but also as community liaisons (Mood, 2000). Nurses serve as important professional contacts and liaisons for people in the community who are actively investigating or concerned about the health and illness issue, such as an increase in the number of cases of cancer, asthma, or traffic accidents. The role of community liaison involves observation, data collection, consultation, and interpretation. By talking and listening to community members around their kitchen tables, at local gath- ering places, or at community meetings, nurses gather informa- tion from the citizens’ perspectives. They can also interpret scientific information for lay persons. The liaison role also involves consultation with public health and environmental professionals and participation in environmental inspections and investigations.
Lillian Mood is a public health nurse with more than 20 years of experience in South Carolina working with communities to detect and explain the causes of illness and disability. In
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Informatics—Use Information and Technology to Communicate, Manage Knowledge, Mitigate Error, and Support Decision Making Important aspects of informatics include: • Knowledge: Identify essential information that must be available in a
common database to support client care. • Skills: Use information management tools to monitor outcomes of care
processes. • Attitudes: Value nurses’ involvement in design, selection, implementation
and evaluation of information technologies to support client care.
Informatics Question: Determine If a Health Problem Exists in the Community Nurses are involved in the surveillance and monitoring of health phenomena. Planning for resources and personnel often requires quantifying the level of a problem in the community. For example, to know how different districts compare in the rates of very-low-birth-weight infants, you would calculate the prevalence of very-low-birth-weight infants in each district: 1. Determine the number of live births in each district from birth certificate
data obtained from the vital records division of the health department. 2. Use the birth weight information from the birth certificate data to deter-
mine the number of infants born weighing less than 1500 grams in each district.
3. Calculate the prevalence of very-low-birth-weight births by district as the number of infants weighing less than 1500 grams at birth divided by the total number of live births.
4. If the number of very-low-birth-weight births in each district is small, use several years of data to obtain a more stable estimate.
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
283CHAPTER 12 Epidemiology
P R A C T I C E A P P L I C A T I O N You are a nurse providing health screenings at a health fair at a local community center. Mr. Greer, a 32-year-old African Ameri- can man, stops by your station and requests that you check his blood pressure. His blood pressure measurement is 135/85 mm Hg. In conducting a brief health history, you learn that Mr. Greer is single, works part time at a convenience store, often eats at fast-food establishments, and has been a smoker since age 17. His father died of a heart attack at age 48; his mother has diabetes. He does not have health insurance at this time. Which of the following would be your best choice in providing Mr. Greer rec- ommendations related to his need for lipid disorder screening, based on the U.S. Preventive Services Task Force guidelines? A. Do not discuss lipid screening with Mr. Greer, because he
is under 35 years of age and routine screening is not recommended.
B. Suggest that Mr. Greer stop smoking and make modifica- tions in his diet to reduce his consumption of saturated fats. Guide him to the information on local community-based resources for tobacco cessation and healthy diet programs at the health fair.
C. Discuss with Mr. Greer his increased risk for heart disease, based on his family history and status as a smoker. Provide a referral for Mr. Greer for a lipid screening, including mea- surement of total cholesterol and high-density lipoprotein cholesterol (HDL-C), being offered by the local hospital at the health fair. Answers can be found on the Evolve site.
K E Y P O I N T S • Epidemiology is the study of the distribution and determi-
nants of health-related events in human populations and the application of this knowledge to improving the health of communities.
• Epidemiology is a multidisciplinary enterprise that recog- nizes the complex interrelationships of factors that influence disease and health at both the individual level and the com- munity level; it provides the basic tools for the study of health and disease in communities.
• Epidemiologic methods are used to describe health and disease phenomena and to investigate the factors that promote health or influence the risk or distribution of disease. This knowledge can be useful in planning and evaluating programs, policies, and services, as well as in clinical decision making.
• Epidemiologic models explain the interrelationships between agent, host, and environment (the epidemiologic triangle) and the interactions of multilevel factors, exposures, and characteristics (causal web) affecting risk of disease.
Queso fresco, a popular Latin American fresh cheese often made from raw milk, has been implicated as a source of Salmonella typhimurium definitive type (DT) 104 in the United States. From 1992 to 1996, the annual incidence of S. typhimurium DT104 infections in Yakima County, Washington, increased from 5.4 to 29.7 cases per 100,000 population, making it one of the highest rates in the country. Between January and May 1997, 89 cases of S. typhimurium were reported in the county, of which 54 were culture-confirmed as DT104, a strain that is resistant to five major antibiotics. The median age of infected persons was 4 years, and 90% of the clients had Spanish surnames. A case-control investigation conducted by the CDC indicated that the most probable source of the outbreak was raw-milk queso fresco. The CDC investigation also indicated that street vendors were the most frequent source (70%) of queso fresco among those who developed the illness.
In response to the outbreak, a multiagency intervention was initiated with the goal of reducing the incidence of S. typhimurium infections resulting from con- sumption of raw-milk queso fresco while maintaining the traditional, nutritious food in the local Hispanic diet. A pasteurized-milk queso fresco recipe developed by a local Hispanic woman was modified by dairy scientists at Washington State University to inhibit undesirable microbial growth, increase shelf life, and improve ease of preparation. The new recipe was tested by local Hispanic persons and adjusted until flavor and texture were satisfactory.
A preintervention survey was conducted to gather background information for use in planning the multipronged intervention, which featured safe-cheese workshops introducing the new pasteurized-milk recipe, a mass media campaign about the risk of raw-milk cheese, and newsletter articles warning dairy farmers about the risks of
selling or giving away raw milk. The safe-cheese workshops were conducted by older Hispanic women (abuelas, or grandmothers), who were recruited from the commu- nity and trained to make the new queso fresco recipe from pasteurized milk. Follow- ing the training, each abuela educator signed a contract indicating her willingness to teach at least 15 additional members of the community how to safely make queso fresco with pasteurized milk. They followed through on their commitment, which included returning surveys completed by the women they taught.
The incidence of S. typhimurium infection in Yakima County decreased rapidly to below pre-1992 levels after the multilevel intervention was initiated. Between June and December 1997, only 16 cases were reported, of which 2 were associ- ated with consumption of queso fresco; in 1998 there were 18 reported cases, none of which were associated with queso fresco. Postintervention surveys of Hispanic area residents who did not participate in the workshops indicated that consumption of queso fresco did not decrease as a result of the intervention (Bell, et al 1999).
Nurse Use The Abuela Project is an example of a successful combination of applied epide- miology and community-based, culturally appropriate public health interven- tions. This activity clearly falls within the scope of good public health nursing. To be successful in seeing correlations, nurses must be vigilant, have inquiring minds, and be able to make associations between events and characteristics (e.g., the associations between how and by whom the cheese was being made, and by whom it was being eaten).
EVIDENCE-BASED PRACTICE The Epidemiologic Basis for Community Health Interventions
From Bell RA, Hillers VN, Thomas TA: The Abuela project: safe cheese workshops to reduce the incidence of Salmonella typhimurium from consumption of raw-milk fresh cheese, Am J Public Health 89:1421-1424, 1999.
284 PART 3 Conceptual and Scientific Frameworks
K E Y P O I N T S — cont’d • A key concept in epidemiology is that of the levels of preven-
tion, based on the stages in the natural history of disease. • Primary prevention involves interventions to reduce the
incidence of disease by promoting health and preventing disease processes from developing.
• Secondary prevention includes programs (such as screening) designed to detect disease in the early stages, before signs and symptoms are clinically evident, to intervene with early diag- nosis and treatment.
• Tertiary prevention provides treatments and other interven- tions directed toward persons with clinically apparent disease, with the aim of lessening the course of disease, reducing disability, or rehabilitating.
• Epidemiologic methods are also used in the planning and design of community health promotion (primary prevention) strategies and screening (secondary prevention) activities, and in the evaluation of the effectiveness of these interventions.
• Basic epidemiologic methods include the use of existing data sources to study health outcomes and related factors and the
use of comparison groups to assess the association between exposures or characteristics and health outcomes.
• Epidemiologists rely on rates and proportions to quantify levels of morbidity and mortality. Prevalence proportions provide a picture of the level of existing cases in a population at a given time. Incidence rates and proportions measure the rate of new case development in a population and provide an estimate of the risk of disease.
• Descriptive epidemiologic studies provide information on the distribution of disease and health states according to personal characteristics, geographic region, and time. This knowledge enables practitioners to target programs and allocate resources more effectively and provides a basis for further study.
• Analytic epidemiologic studies investigate associations between exposures or characteristics and health or disease outcomes, with a goal of understanding the etiology of disease. Analytic studies provide the foundation for understanding disease cau- sality and for developing effective intervention strategies aimed at primary, secondary, and tertiary prevention.
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Interview a local public health nurse or other public health
professional from the local health department. A. Ask about the current public health priorities and how
those priorities were determined. B. Describe the type of epidemiologic data used in deter-
mining local public health priorities. 2. Identify a current health issue in your local community (e.g.,
childhood lead poisoning, diabetes, HIV/AIDS). A. Describe primary, secondary, and tertiary prevention
interventions related to this health issue. B. How could nurses improve the effectiveness of their pre-
vention activities related to this health issue? 3. Look at a recent issue of the Final Mortality Statistics from the
National Center for Health Statistics, or the most recent issue of Health: United States. Examine the trends in cause-specific mortality and choose one or two of the leading causes of death. A. On the basis of current epidemiologic evidence, explain
the factors that have contributed to the following: the observed trend in mortality rates for this disease; the changes in survival; the changes in incidence.
B. Are the changes the result of better (or worse) primary, secondary, or tertiary prevention? Are there modifiable factors, such as health behaviors, that lend themselves to better prevention efforts? What would they be?
4. Identify existing inequalities among the counties in your state, using infant mortality data.
A. Describe the distribution of infant mortality in your state (by county), using rate ratio and population attributable risk data.
B. Compare the infant mortality rates in your state with national and international data.
C. Compare the characteristics of the counties (e.g., urban, rural, racial/ethnic distribution, economic indicators, dis- tribution of health care facilities) with the highest and lowest infant mortality rates.
D. Identify local, state, and national initiatives that are addressing infant mortality.
5. Examine the leading causes of infant death in the United States. A. What differences in intervention approaches are sug-
gested by the various causes of death? B. How would you design an epidemiologic study to examine
risk factors for specific causes of neonatal and postneo- natal death? What types of epidemiologic measures would be useful? What study design(s) would be appropriate?
C. How would you use the information from your study to develop an intervention program and to define the target population for your intervention?
6. Find a report of an epidemiologic study in one of the major public health, nursing, or epidemiology journals. How do the findings of this study, if valid, affect your nursing prac- tice? How do you incorporate the results of epidemiologic research into your nursing practice?
285CHAPTER 12 Epidemiology
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Infectious Disease Prevention and Control
13
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Discuss the current impact and threats of infectious
diseases on society. 2. Explain how the elements of the epidemiologic triangle
interact to cause infectious diseases. 3. Provide examples of infectious disease control
interventions at the three levels of public health prevention.
4. Explain the multisystem approach to control of communicable diseases.
5. Discuss the factors contributing to newly emerging or re-emerging infectious diseases.
6. Define the bloodborne pathogen reduction strategy and universal precautions.
K E Y T E R M S acquired immunity, p. 290 active immunization, p. 290 agent, p. 290 common vehicle, p. 291
communicable diseases, p. 287 communicable period, p. 291 disease, p. 291 elimination, p. 296
A D D I T I O N A L R E S O U R C E S Evolve website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks—Of special note, see the links for these sites:
• Centers for Disease Control and Prevention • Emerging Infectious Diseases, Centers for Disease
Control and Prevention • MMWR Morbidity and Mortality Weekly Report, Centers
for Disease Control and Prevention
• World Health Organization • WER/Weekly Epidemiological Record, World Health
Organization • Quiz • Case Studies • Glossary • Answers to Practice Application
Francisco S. Sy, MD, PhD Dr. Francisco S. Sy is the Director of the Division of Extramural Activities and Scientific Programs at the National Center on Minority Health and Health Disparities (NCMHD) at the National Institutes of Health (NIH) in Bethesda, MD. Before joining NIH, he served as a Senior Health Scientist in the Division of HIV/AIDS Prevention (DHAP), National Center for HIV, STD and TB Prevention (NCHSTP), at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. Dr. Sy was a tenured professor at the University of South Carolina (USC) School of Public Health in Columbia, SC, where he taught infectious disease epidemiology for 15 years. Dr. Sy has written several book chapters and scientific articles on various infectious and tropical diseases, HIV disease epidemiology, prevention, and program evaluation. He is the editor of the AIDS Education and Prevention: An Interprofessional Journal since its inception in 1988. Dr. Sy earned his Doctor of Public Health (DrPH) degree in Immunology and Infectious Diseases from Johns Hopkins University in 1984, Master of Science in Tropical Public Health from Harvard University in 1981 and Doctor of Medicine degree from the University of the Philippines in 1975.
Susan C. Long-Marin developed an interest in infectious disease and public health while serving as a Peace Corps Volunteer in the Philippines in the 1970s. Training in veterinary medicine further increased her respect for the ingeniousness of microbes and the importance of primary prevention. Today she manages the epidemiology program of a county health department in Charlotte, NC, which serves a growing and rapidly changing popula- tion from a variety of racial, ethnic, and national backgrounds. Dr. Long-Marin earned her Doctor of Veterinary Medicine degree from Virginia Tech and her Master of Public Health in Epidemiology degree from the University of South Carolina.
Susan C. Long-Marin, DVM, MPH
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C H A P T E R O U T L I N E Historical and Current Perspectives Transmission of Communicable Diseases
Agent, Host, and Environment Modes of Transmission Disease Development Disease Spectrum
Surveillance of Communicable Diseases Elements of Surveillance Surveillance for Agents of Bioterrorism List of Reportable Diseases
Emerging Infectious Diseases Emergence Factors Examples of Emerging Infectious Diseases
Prevention and Control of Infectious Diseases Planning to Address Infectious Disease Prevention and Control Programs Primary, Secondary, and Tertiary Prevention Role of Nurses in Prevention Multisystem Approach to Control
Agents of Bioterrorism Anthrax Smallpox Plague Tularemia
Vaccine-Preventable Diseases Routine Childhood Immunization Schedule Measles
Rubella Pertussis Influenza
Foodborne and Waterborne Diseases The Role of Safe Food Preparation Salmonellosis Enterohemorrhagic Escherichia coli (EHEC or E. coli
0157:H7) Waterborne Disease Outbreaks and Pathogens Vectorborne Diseases
Lyme Disease Rocky Mountain Spotted Fever Prevention and Control of Tickborne Diseases
Diseases of Travelers Malaria Foodborne and Waterborne Diseases Diarrheal Diseases
Zoonoses Rabies (Hydrophobia)
Parasitic Diseases Intestinal Parasitic Infections Parasitic Opportunistic Infections Control and Prevention of Parasitic Infections
Health Care-Associated Infections Universal Precautions
K E Y T E R M S — cont’d emerging infectious diseases, p. 293 endemic, p. 291 environment, p. 290 epidemic, p. 292 epidemiologic triangle, p. 290 eradication, p. 296 health care–associated infection, p. 314 herd immunity, p. 291 horizontal transmission, p. 291 host, p. 290 incubation period, p. 291
infection, p. 291 infectiousness, p. 291 natural immunity, p. 290 pandemic, p. 292 passive immunization, p. 291 resistance, p. 290 surveillance, p. 292 universal precautions, p. 314 vectors, p. 291 vertical transmission, p. 291 —See Glossary for definitions
The topic of infectious diseases includes the discussion of a wide and complex variety of organisms; the pathology they may cause; and their diagnosis, treatment, prevention, and control. This chapter presents an overview of the communi- cable diseases that nurses encounter most often. Diseases are grouped according to descriptive category (by mode of trans- mission or means of prevention) rather than by individual organism (e.g., Escherichia coli) or taxonomic group (e.g., viral, parasitic). Detailed discussion of sexually transmitted diseases, human immunodeficiency virus (HIV), acquired immunodefi- ciency syndrome (AIDS/HIV stage III), viral hepatitis, and
tuberculosis (TB) is provided in Chapter 14. Although not all infectious diseases are directly communicable from person to person, the terms infectious disease and communicable disease are used interchangeably throughout this chapter.
HISTORICAL AND CURRENT PERSPECTIVES In the United States at the beginning of the twentieth century, infectious diseases were the leading cause of death. By 2000 improvements in nutrition and sanitation, the discovery of antibiotics, and the development of vaccines had put an end to
288 PART 3 Conceptual and Scientific Frameworks
consumption led to the slaughter of thousands of British cattle and a ban on the international sale of British beef. Initially seen only in Europe and Japan as well as Great Britain, the first case of BSE was diagnosed in the United States in 2003. Variant Creutzfeldt-Jakob disease (vCJD), which attacks the brain with fatal results, is the human disease hypothesized but not yet proven to result from eating beef infected with the transmissible agent causing BSE; only three acquired cases of vCJD have been seen in the United States, but these individuals were born outside of and resided in the country for only a short period (CDC, 2013a).
In 1997 vancomycin-resistant Staphylococcus aureus (VRSA) was first reported; previously, vancomycin had been considered the only effective antibiotic against methicillin-resistant S. aureus (MRSA). Although MRSA is still largely a health care– associated infection, community-associated disease is becoming more common with outbreaks frequently associated with school athletic programs and prison populations. Also in 1997, the first reported outbreak of avian flu affecting humans occurred in Hong Kong. Lack of subsequent reports suggested an isolated incident, but in 2004 avian influenza A H5N1 again emerged in Southeast Asia with resulting human cases. This virus has now infected avian populations in Asia, Europe, the Near East, and North Africa, and it continues to cause sporadic human cases, especially in Southeast Asia and Egypt. Human cases are deter- mined to spread largely through direct contact with infected poultry or infected surfaces, with human to human transmis- sion largely ineffective and only a few rare cases thought to have occurred. In 1999 the first Western Hemisphere activity of West Nile virus (WNV), a mosquito-transmitted illness that can affect livestock, birds, and humans, occurred in New York City. By 2002 WNV, thought to be carried by infected birds and pos- sibly mosquitoes in cargo containers, had spread across the United States as far west as California and was reported in Canada and Central America as well.
The viral hemorrhagic fevers (HF) Ebola and Marburg, unknown to most people 30 years ago, have become the premise of movies and novels, and recently the cause of widespread international concern. While earlier reported Ebola virus out- breaks largely occurred in Central Africa and were limited and quickly contained, an outbreak of Ebola virus that began in the spring of 2014 in Guinea, West Africa resisted containment and in spite of international assistance, spread rapidly through neighboring Liberia and Sierra Leone. A small number of cases also occurred in several other West African countries but were contained. An air traveler brought a case to the United States resulting in the infection of two nurses who cared for him. Health care workers returning from work in West Africa were diagnosed, one in the United States and one in Great Britain, and a nurse in Spain was also infected caring for a patient who had been transported from the Ebola-infected region of Africa. By January 2015, this on going epidemic had resulted in over 21,700 reported cases in nine countries (the majority in Guinea, Liberia and Sierra Leone) and almost 8,650 reported deaths. In response to the imported and health care-transmitted cases, infectious disease policies and procedures within hospi- tals were modified, and screening and surveillance tactics were
infectious disease epidemics like diphtheria and typhoid fever that once ravaged entire populations. In 1900 respiratory and diarrheal diseases were major killers. For example, tuberculosis (TB) led to over 11% of all deaths in the United States and was the second leading cause of death; in 2010, 536 deaths or 0.02% were attributed to this once frequently fatal disease (CDC, 2012a). As individuals live longer, chronic diseases— heart disease, cancer, and stroke—have replaced infectious dis- eases as the leading causes of death.
Infectious diseases, however, have not vanished, and they remain a continuing cause for concern. They remain the leading cause of death for children and adolescents worldwide and the second-leading cause overall, killing an estimated 8 million people a year (WHO, 2013). In the United States, the downward trend in mortality from infectious diseases seen since 1900— with the exception of the 1918 influenza pandemic—reversed itself in the 1980s, with the emergence of new entities such as HIV disease and the increasing development of antibiotic resis- tance. Respiratory diseases in the form of pneumonias and influenza remain among the 10 leading causes of death, and new strains such as novel influenza A H1N1 and avian influenza A H5N1 test our disease control abilities and consume resources. Previously unknown causal connections between infectious organisms and chronic diseases have been recognized, such as Helicobacter pylori and peptic ulcer disease, and human papil- lomaviruses (HPVs) and cervical cancer. Also, in the twenty- first century, infectious diseases have become a means of terrorism, as illustrated by the anthrax letters of 2001.
New killers emerge and old familiar diseases take on differ- ent, more virulent characteristics. Consider the following devel- opments from the past 30 years. HIV disease reminds us of plagues from the past and challenges our ability to control and contain infection like no other disease in recent history. Because drugs have been developed to slow the progression but there is still neither vaccine nor cure, this initially infectious disease is now a chronic condition as well. Legionnaires’ disease and toxic shock syndrome, unknown at mid-twentieth century, have become part of the common vocabulary. The identification of infectious agents causing Lyme disease and ehrlichiosis pro- vided two new tickborne diseases to worry about. And, in the summer of 1993 in the southwestern United States, healthy young adults were stricken with a mysterious and unknown but often fatal respiratory disease that is now known as hantavirus pulmonary syndrome. The summer of 1994 brought public attention to a severe, invasive strain of Streptococcus pyogenes group A, referred to by the press as the “flesh-eating” bacteria.
In the 1990s the transmission of infectious disease through the food supply became a newsworthy concern when the con- sumption of improperly cooked hamburgers and unpasteurized apple juice contaminated with a highly toxic strain of E. coli (E. coli 0157:H7) caused illness and death in children across the country. In 1996 multiple states reported outbreaks of diarrheal disease traced to imported fresh berries; the implicated organ- ism in these outbreaks, Cyclosporacayetanensis (a coccidian parasite), was first diagnosed in humans in 1977. Also in 1996, the fear that “mad cow disease” (bovine spongiform encepha- lopathy [BSE]) could be transferred to humans through beef
289CHAPTER 13 Infectious Disease Prevention and Control
Perhaps the most publicized infectious disease event of 2009 was the advent of a new strain of flu, novel influenza A H1N1. First reported from Mexico and rapidly acquired by travelers to that country, H1N1 spread quickly across the world, causing the WHO to declare a pandemic and stimulate the race for a vaccine. While H1N1 did not become the major killer it was feared to, it did disproportionately result in hospitalizations and deaths in younger and middle-aged adults. H1N1 did not disap- pear and has been included in the seasonal vaccine since 2009. During the 2013-2014 flu season in the United States, H1N1 once more became the predominant circulating strain, and once more hit hardest the young and middle-aged.
The year 2012 brought the first reports of another novel coronavirus that, like SARS, results in acute respiratory distress with a high mortality rate. Middle Eastern Respiratory Syn- drome Coronavirus or MERS-CoV has only been seen in indi- viduals living in or who have traveled to countries in the Arabian Peninsula. It seems to spread by close contact and many of the cases have been in health care workers. The reservoir is unknown but there appears to be an association with camels. The first cases of MERS-CoV in the United States were reported in 2014 in individuals who had traveled from Saudi Arabia. Read more about MERS at http://www.cdc.gov/coronavirus/ mers/index.html.
Worldwide, infectious diseases are the leading killer of chil- dren and young adults and are responsible for almost half of all deaths in developing countries. Of these infectious disease deaths, 90% result from six causes: acute respiratory infections, diarrheal diseases, malaria, and measles among children; and TB and HIV infection among adults. TB alone is estimated to kill a million people a year and malaria another 625,000 (WHO, 2013). The CDC in its Ounce of Prevention campaign notes that in the United States as many as 160,000 people die per year with infectious diseases as an underlying cause. The eco- nomic burden of infectious diseases is staggering. Foodborne illnesses alone are estimated to cost $77.7 billion annually in the United States (Scharff, 2012). The CDC estimates the costs to the U.S. health care system of almost 19 million new STD infec- tions each year to be as much as $15.9 billion annually (USDHHS, 2014). In 2013, the annual cost for five of the most significant health care–associated infections was estimated at $9.8 billion (Zimlichman et al, 2013).
Because of the morbidity, mortality, and associated cost of infectious diseases, the national health promotion and disease prevention goals outlined in Healthy People 2020 list a number of objectives for reducing the incidence of these illnesses in a variety of the sections, including Immunization & Infectious disease. Objectives for reducing salmonellosis and other food- borne infections are found in the section on Food Safety, an objective for reducing malaria cases reported in the United States may be seen under Global Health, there is a section on sexually transmitted diseases, and there are objectives related to health care–associated infections (see the Healthy People 2020 box for examples). Although infectious diseases are not cur- rently the leading causes of death in the United States, they continue to present varied, multiple, and complex challenges to all health care providers. Nurses must know about these diseases
introduced at airports around the world for passengers arriving from West Africa (CDC, 2015a).
Although caused by different viruses within the Filoviridae family, Ebola and Marburg hemorrhagic fevers (HF) have similar clinical presentations. The reservoir host of Ebola viruses remains unknown but there is an association with non- human primates, and evidence is also beginning to point toward a bat reservoir (CDC, 2014a). Marburg HF virus had been reported only five times since its recognition in 1967 before a major outbreak in Angola occurred during 2004 and 2005, affecting more than 350 people with a fatality rate of close to 90%. Since then, a much smaller outbreak occurred in Uganda in 2007 among gold miners and another in Uganda in 2012 affecting 15 people. The reservoir host of Marburg virus is the African fruit bat, Rousettusa egyptiacus (CDC, 2014b).
Severe acute respiratory syndrome (SARS) was first recog- nized in China in February 2003 and, as if in a bestselling thriller, this newly emerging infectious disease quickly achieved pandemic proportions. By the summer of 2003, major out- breaks had occurred in Hong Kong, Taiwan, Vietnam, Singa- pore, and Canada. Three months after the first official news of SARS, over 8000 cases with more than 700 deaths had been reported to the World Health Organization (WHO) from 28 countries. Played out on television in pictures of people wearing facemasks for protection, the rapid spread of a previously unknown disease with an initially unknown cause and no defin- itive treatment contributed to the creation of a perception of risk of infection far greater than actually existed. Frightened Americans canceled trips to China and Hong Kong and avoided people who had recently returned from Asia. Then, as suddenly as it began, the pandemic subsided. SARS was found to be caused by a new strain of coronavirus, but since 2003, only a few cases, largely associated with laboratory workers, have been reported. A large number of individuals infected by SARS could be traced back to unrecognized cases in hospitals, suggesting that prompt identification and isolation of symptomatic people is the key to interrupting transmission. No new cases of SARS have been reported since 2004. Global efforts continue to clarify the epidemiology of this disease as well as develop a reliable diagnostic test and vaccine. In 2012, SARS coronavirus was officially declared a select agent—a bacterium, virus, or toxin that has the potential to pose a severe threat to public health and safety. Additional information on SARS can be obtained at the CDC SARS website (http://www.cdc.gov/sars/).
In the first decade of the twenty-first century, foodborne infections again have made headlines as E. coli–infected spinach sickened and killed individuals across the United States. In 2008, tomatoes were blamed for a nationwide outbreak of salmonel- losis but were ruled innocent when the green chilies that accom- panied them in salsa were found to be the actual culprit. Salmonella made the news as contaminated peanut butter forced recalls across the United States, sickened hundreds, and resulted in several deaths, and again in 2012 when contaminated cantaloupes resulted in 261 reported illnesses and 3 deaths across 24 states. Even chocolate chip cookie dough was not safe; a national recall in 2009 followed the discovery that people had been sickened after eating raw dough contaminated by E. coli.
290 PART 3 Conceptual and Scientific Frameworks
States do not normally contract malaria at home, but they may become infected if they change their environment by traveling to a climate where malaria-carrying mosquitoes thrive. As these examples illustrate, the balance among agent, host, and environ- ment is often precarious and may be unintentionally disrupted. At present, the potential results of such disturbance require attention as advances in science and technology, destruction of natural habitats, explosive population growth, political instabil- ity, and a worldwide transportation network combine to alter the balance among the environment, people, and the agents that produce disease.
Agent Factor Four major categories of agents cause most infections and infectious disease: bacteria (e.g., Salmonella and E. coli), fungi (e.g., Aspergillus spp. and Candida spp.), parasites (e.g., hel- minthes and protozoa), and viruses (e.g., hepatitis A and B and HIV). Less commonly seen is the prion, a transmissible agent that causes abnormal folding of normal cellular prion proteins in the brain, resulting in a family of rare progressive neurode- generative disorders that affect both humans and animals. Variant Creutzfeldt-Jakob disease and kuru are examples of prion diseases. The individual agent may be described by its ability to cause disease and by the nature and the severity of the disease. Infectivity, pathogenicity, virulence, toxicity, invasiveness, and antigenicity, terms commonly used to characterize infec- tious agents, are defined in Box 13-1.
Host Factor A human or animal host can harbor an infectious agent. The characteristics of the host that may influence the spread of disease are host resistance, immunity, herd immunity, and infectiousness of the host. Resistance is the ability of the host to withstand infection, and it may involve natural or acquired immunity.
Natural immunity refers to species-determined, innate resistance to an infectious agent. For example, opossums rarely contract rabies. Acquired immunity is the resistance acquired by a host as a result of previous natural exposure to an infec- tious agent. Having measles once protects against future infec- tion. Acquired immunity may be induced by active or passive immunization. Active immunization refers to the immuniza- tion of an individual by administration of an antigen (infec- tious agent or vaccine) and is usually characterized by the presence of an antibody produced by the individual host.
to effectively participate in diagnosis, treatment, prevention, and control.
FIGURE 13-1 The epidemiologic triangle of a disease (Redrawn from Gordis L: Epidemiology, ed 5, Philadelphia, 2005, Saunders.)
Vector
Host
Agent Environment
• Infectivity: The ability to enter and multiply in the host • Pathogenicity: The ability to produce a specific clinical reaction after infec-
tion occurs • Virulence: The ability to produce a severe pathological reaction • Toxicity: The ability to produce a poisonous reaction • Invasiveness: The ability to penetrate and spread throughout a tissue • Antigenicity: The ability to stimulate an immunological response
BOX 13-1 Six Characteristics of an Infectious Agent
TRANSMISSION OF COMMUNICABLE DISEASES Agent, Host, and Environment The transmission of communicable diseases depends on the successful interaction of the infectious agent, the host, and the environment. These three factors make up the epidemiologic triangle (Figure 13-1), as discussed in Chapter 12. Changes in the characteristics of any of the factors may result in disease transmission. Consider the following examples. Antibiotic therapy not only may eliminate a specific pathologic agent, but also alter the balance of normally occurring organisms in the body. As a result, one of these agents overruns another and disease, such as a yeast infection, occurs. HIV performs its deadly work not by directly poisoning the host but by destroy- ing the host’s immune reaction to other disease-producing agents. Individuals living in the temperate climate of the United
HEALTHY PEOPLE 2020
• IID-1: Reduce, eliminate, or maintain elimination of cases of vaccine- preventable diseases.
• IID-12: Increase the percentage of children and adults who are vaccinated against seasonal influenza.
• FS-1: Reduce infections caused by key pathogens transmitted commonly through food.
• HAI-2 Reduce invasive health care–associated methicillin-resistant Staph- ylococcal aureus (MRSA) infections.
Selected Objectives Related to Infectious Diseases
From U.S. Department of Health and Human Services: Healthy People 2020: The Road Ahead. 2009, USDHHS. Available at http://www.healthypeople.gov/HP2020/. Accessed January 26, 2010.
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objects such as toys, clothing, and bedding. Common vehicle refers to transportation of the infectious agent from an infected host to a susceptible host via food, water, milk, blood, serum, saliva, or plasma. Hepatitis A can be transmitted through con- taminated food and water, and hepatitis B through contami- nated blood. Legionellosis and TB are both spread via contaminated droplets in the air. Vectors are arthropods such as ticks and mosquitoes or other invertebrates such as snails that transmit the infectious agent by biting or depositing the infec- tive material near the host. Vectors may be necessary to the life cycle of the organism (e.g., mosquitoes and malaria) or may act as mechanical transmitters (e.g., flies and food).
Disease Development Exposure to an infectious agent does not always lead to an infec- tion. Similarly, infection does not always lead to disease. Infec- tion depends on the infective dose, the infectivity of the infectious agent and the immunocompetence of the host. It is important to differentiate infection and disease, as clearly illus- trated by the HIV disease epidemic. Infection refers to the entry, development, and multiplication of the infectious agent in the susceptible host. Disease is one of the possible outcomes of infection and it may indicate a physiological dysfunction or pathologic reaction. An individual who tests positive for HIV is infected, but if that person shows no clinical signs, the indi- vidual is not diseased. Similarly, if an individual tests positive for HIV and also exhibits clinical signs consistent with AIDS (HIV stage III), that individual is both infected and diseased.
Incubation period and communicable period are not syn- onymous. The incubation period is the time interval between invasion by an infectious agent and the first appearance of signs and symptoms of the disease. The incubation periods of infec- tious diseases vary from between 2 and 4 hours for staphylococ- cal food poisoning to between 10 and 15 years for AIDS (HIV stage III). The communicable period is the interval during which an infectious agent may be transferred directly or indi- rectly from an infected person to another person. The period of communicability for influenza is 3 to 5 days after the clinical onset of symptoms. Hepatitis B–infected persons are infectious many weeks before the onset of the first symptoms and remain infective during the acute phase and chronic carrier state, which may persist for life.
Disease Spectrum Persons with infectious diseases may exhibit a broad spectrum of disease that ranges from subclinical infection to severe and fatal disease. Those with subclinical or inapparent infections are important from the public health point of view because they are a source of infection but may not be receiving care like those with clinical disease. They should be targeted for early diagnosis and treatment. Those with clinical disease may exhibit localized or systemic symptoms and mild to severe illness. The final outcome of a disease may be recovery, death, or something in between, including a carrier state, complications requiring extended hospital stay, or disability requiring rehabilitation.
At the community level, the disease may occur in endemic, epidemic, or pandemic proportion. Endemic refers to the
Vaccinating children against childhood diseases is an example of inducing active immunity. Passive immunization refers to immunization through the transfer of a specific antibody from an immunized individual to a nonimmunized individual, such as the transfer of antibody from mother to infant or by admin- istration of an antibody-containing preparation (immunoglob- ulin or antiserum). Passive immunity from immunoglobulin is almost immediate but short lived. It is often induced as a stopgap measure until active immunity has time to develop after vaccination. Examples of commonly used immunoglobu- lins include those for hepatitis A, rabies, and tetanus.
Herd immunity refers to the immunity of a group or com- munity. It is the resistance of a group of people to invasion and spread of an infectious agent. Herd immunity is based on the resistance of a high proportion of individual members of a group to infection. It is the basis for increasing immunization coverage for vaccine-preventable diseases. Through studies, experts determine what percent coverage (e.g., >90%) of a specified group of people (e.g., children entering school) by a specified vaccine (e.g., one dose of measles vaccine) is necessary to ensure adequate protection for the entire community against a given disease and target immunization campaigns and initia- tives to meet that goal. The higher the immunization coverage, the greater the herd immunity.
Infectiousness is a measure of the potential ability of an infected host to transmit the infection to other hosts. It reflects the relative ease with which the infectious agent is transmitted to others. Individuals with measles are extremely infectious; the virus spreads readily on airborne droplets. A person with Lyme disease cannot spread the disease to other people (although the infected tick can).
Environment Factor The environment refers to everything that is external to the human host, including physical, biological, social, and cultural factors. These environmental factors facilitate the transmission of an infectious agent from an infected host to other susceptible hosts. Reduction in communicable disease risk can be achieved by altering these environmental factors. Using mosquito nets and repellants to avoid bug bites, installing sewage systems to prevent fecal contamination of water supplies, and washing utensils after contact with raw meat to reduce bacterial con- tamination are all examples of altering the environment to prevent disease.
Modes of Transmission Infectious diseases can be transmitted horizontally or vertically. Vertical transmission is the passing of the infection from parent to offspring via sperm, placenta, milk, or contact in the vaginal canal at birth. Examples of vertical transmission are transplacental transmission of HIV and syphilis. Horizontal transmission is the person-to-person spread of infection through one or more of the following four routes: direct/ indirect contact, common vehicle, airborne, or vector borne. Most sexually transmitted infections are spread by direct sexual contact. Enterobiasis, or pinworm infection, can be acquired through direct contact or indirect contact with contaminated
292 PART 3 Conceptual and Scientific Frameworks
occurring one. Health care providers are asked to be alert to (1) temporal or geographic clustering of illnesses (people who attended the same public gathering or visited the same loca- tion), especially those with clinical signs that resemble an infectious disease outbreak—previously healthy people with unexplained fever accompanied by sepsis, pneumonia, rash, or flaccid paralysis, and (2) an unusual age distribution for a common disease (e.g., chickenpox-like disease in adults without a child source case).
Because of the heightened concern about possible bioterrorist attacks, various sorts of syndromic surveillance systems have been developed by public health agencies across the country. These systems incorporate factors such as the previously men- tioned temporal and geographic clustering and unusual age dis- tributions with groups of disease symptoms or syndromes (e.g., flaccid paralysis, respiratory signs, skin rashes, gastrointestinal symptoms) with the goal of detecting early signs of diseases that could result from a bioterrorism-related attack. Syndromic sur- veillance systems may include tracking emergency department visits sorted by syndrome symptoms as well as other indicators of illness including school absenteeism and sales of selected over- the-counter medications. Early on, CDC developed EARS (Early Aberration Reporting System), a surveillance tool available at no charge and used by various public health officials across the country and abroad. Work continues to enhance and strengthen these tools. Although more active infectious disease surveillance is being encouraged because of the potential for bioterrorism, the positive benefit is increased surveillance for other communicable diseases as well. Such heightened surveillance can just as easily warn of a community salmonellosis or influenza outbreak. Although the benefit of syndromic surveillance as a warning system has not been proved, it has been valuable in tracking disease outbreaks such as the 2009 H1N1 pandemic. (For addi- tional information on preparedness surveillance, see the CDC website at http://www.bt.cdc.gov/episurv/.)
Nurses are frequently involved at different levels of the sur- veillance system. They play important roles in collecting data, making diagnoses, investigating and reporting cases, and pro- viding information to the general public. Examples of possible activities include investigating sources and contacts in out- breaks of pertussis in school settings or shigellosis in daycare; performing TB testing and contact tracing; collecting and reporting information pertaining to notifiable communicable diseases; performing infection control in hospitals; and provid- ing morbidity and mortality statistics to those who request them, including the media, the public, service planners, and grant writers.
List of Reportable Diseases “A notifiable disease is one for which regular, frequent, and timely information regarding individual cases is considered necessary for the prevention and control of the disease” (CDC, 2013b). Requirements for disease reporting in the United States are mandated by state rather than federal law and, as such, vary slightly from state to state. State health departments, on a vol- untary basis, report cases of selected diseases to the CDC through the National Notifiable Diseases Surveillance System (NNDSS). State public health officials collaborate with the CDC
constant presence of a disease within a geographic area or a population. Pertussis is endemic in the United States. Epidemic refers to the occurrence of disease in a community or region in excess of normal expectancy. Although people tend to associate large numbers with epidemics, even one case can be termed epidemic if the disease is considered previously eliminated from that area. For example, one case of polio, a disease considered eliminated from the United States, would be considered epi- demic. Pandemic refers to an epidemic occurring worldwide and affecting large populations. HIV disease is both epidemic and pandemic, as the number of cases continues to grow across various regions of the world as well as in the United States. SARS and novel influenza A H1N1 are both emerging infectious diseases and responsible for recent pandemics.
SURVEILLANCE OF COMMUNICABLE DISEASES During the first half of the twentieth century, the weekly pub- lication of national morbidity statistics by the U.S. Surgeon General’s Office was accompanied by the statement, “No health department, state or local, can effectively prevent or control disease without knowledge of when, where, and under what conditions cases are occurring” (CDC, 1996). Surveillance gathers the “who, when, where, and what”; these elements are then used to answer “why.” A good surveillance system system- atically collects, organizes, and analyzes current, accurate, and complete data for a defined disease condition. The resulting information is promptly released to those who need it for effec- tive planning, implementation, and evaluation of disease pre- vention and control programs.
Elements of Surveillance Infectious disease surveillance incorporates and analyzes data from a variety of sources. Box 13-2 lists 10 commonly used data elements.
Surveillance for Agents of Bioterrorism Since September 11, 2001, increased emphasis has been placed on surveillance for any disease that might be associated with the intentional release of a biological agent. The concern is that, because of the interval between exposure and disease, a covert release may go unrecognized and without response for some time if the resulting outbreak closely resembles a naturally
1. Mortality registration 2. Morbidity reporting 3. Epidemic reporting 4. Epidemic field investigation 5. Laboratory reporting 6. Individual case investigation 7. Surveys 8. Utilization of biological agents and drugs 9. Distribution of animal reservoirs and vectors
10. Demographic and environmental data
BOX 13-2 Ten Basic Data Elements of Surveillance
293CHAPTER 13 Infectious Disease Prevention and Control
to determine which diseases should be nationally notifiable. The list of nationally notifiable diseases may be revised as new dis- eases emerge or disease incidence declines. The 69 diseases des- ignated as notifiable at the national level and reported in 2014 are listed in Box 13-3. The NNDSS data are collated and pub- lished weekly in the Morbidity and Mortality Weekly Report (MMWR). Final reports are published annually in the Summary of Notifiable Diseases. (Learn more about the NNDSS at the CDC website at http://wwwn.cdc.gov/nndss/default.aspx. A brief history of the reporting of nationally notifiable infectious diseases in the United States is available at http://wwwn.cdc.gov/ nndss/script/history.aspx.)
EMERGING INFECTIOUS DISEASES Emergence Factors Emerging infectious diseases are those in which the incidence has actually increased in the past several decades or has the potential to increase in the near future. These emerging diseases
may include new or known infectious diseases. Consider the following selected examples. Identified only in 1976 when spo- radic outbreaks occurred in Sudan and Zaire, Ebola virus is a mysterious killer with a frightening mortality rate that some- times reaches 90%, has no known treatment, and has no recog- nized reservoir in nature. It appears to be transmitted through direct contact with bodily secretions and as such can be con- tained once cases are identified. Why outbreaks occur is not understood, although index cases have been associated with the handling of wild primates and evidence is increasing for a bat reservoir. Ebola and its fellow virus Marburg are examples of new viruses that may appear as civilization intrudes farther and farther into previously uninhabited natural environments, changing the landscape and disturbing ecological balances that may have existed unaltered for hundreds of years. (Read more about the viral hemorrhagic viruses Ebola and Marburg at the CDC’s viral special pathogens website: http://www.cdc. gov/ncezid/dhcpp/vspb/index.html.) See also World Health Organization, 2014a.
1. Anthrax 2. Arboviral diseases, neuroinvasive and non-neuroinvasive 3. Babesiosis 4. Botulism 5. Brucellosis 6. Chancroid 7. Chlamydia trachomatis infection 8. Cholera 9. Coccidioidomycosis
10. Congenital syphilis 11. Cryptosporidiosis 12. Cyclosporiasis 13. Dengue virus infections 14. Diphtheria 15. Ehrlichiosis and anaplasmosis 16. Giardiasis 17. Gonorrhea 18. Haemophilus influenzae, invasive disease 19. Hansen’s disease 20. Hantavirus pulmonary syndrome 21. Hemolytic uremic syndrome, post-diarrheal 22. Hepatitis A, acute 23. Hepatitis B, acute 24. Hepatitis B, chronic 25. Hepatitis B, perinatal infection 26. Hepatitis C, acute 27. Hepatitis C, past or present 28. HIV infection (AIDS has been reclassified as HIV Stage III) 29. Influenza-associated pediatric mortality 30. Invasive pneumococcal disease 31. Legionellosis 32. Leptospirosis 33. Listeriosis 34. Lyme disease 35. Malaria
36. Measles 37. Meningococcal disease 38. Mumps 39. Novel influenza A virus infections 40. Pertussis 41. Plague 42. Poliomyelitis, paralytic 43. Poliovirus infection, nonparalytic 44. Psittacosis 45. Q fever 46. Rabies, animal 47. Rabies, human 48. Rubella 49. Rubella, congenital syndrome 50. Salmonellosis 51. Severe acute respiratory syndrome–associated coronavirus disease 52. Shiga toxin–producing Escherichia coli 53. Shigellosis 54. Smallpox 55. Spotted fever rickettsiosis 56. Streptococcal toxic-shock syndrome 57. Syphilis 58. Tetanus 59. Toxic shock syndrome (other than Streptococcal) 60. Trichinellosis 61. Tuberculosis 62. Tularemia 63. Typhoid fever 64. Vancomycin-intermediate Staphylococcus aureus and Vancomycin-resistant
Staphylococcus aureus 65. Varicella 66. Varicella deaths 67. Vibriosis 68. Viral hemorrhagic fever 69. Yellow fever
BOX 13-3 Nationally Notifiable Infectious Conditions—United States 2014
From Centers for Disease Control and Prevention: Nationally Notifible Infectious Conditions United States 2010. 2010, CDC. Available at http://www.cdc.gov/ncphi/disss/nndss/phs/infdis2010.htm. Accessed March 25, 2010. *AIDS has been reclassified as HIV stage III.
294 PART 3 Conceptual and Scientific Frameworks
during its introduction into the United States, between 1999 and 2008, WNV led to almost 30,000 confirmed and probable cases and over 1000 deaths. The number of reported cases varies widely per year. These periodic outbreaks appear to result from a complex interaction of multiple factors, including weather: hot, dry summers followed by rain, which influences mosquito breeding sites and population growth. Because the ecology of WNV is not fully understood, the future pattern and nature of the virus in the United States is uncertain. Until a human vaccine is developed (a vaccine for horses does exist), prevent- ing human infection is dependent on mosquito control and preventing mosquito bites. Rarely, WNV has been transmitted through blood transfusions, in utero exposure, and possibly breastfeeding (CDC, 2010a). (Learn more about WNV and view maps of recent activity at the CDC website: http://www.cdc.gov/ ncidod/dvbid/westnile/index.html.)
Other examples of emerging pathogens newly recognized in the past 30 years include viruses (Australian bat lyssavirus and Hendra or equine morbilli virus); bacteria (Bartonella henselae, Ehrlichiae, and Borrelia burgdorferi); and parasites (Babesia microti and Acanthameoba). B. henselae causes cat scratch fever. Ehrlichiae, B. burgdorferi (causes Lyme disease), and B. microti are all transmitted by ticks.
As shown in Table 13-1 several factors, operating singly or in combination, can influence the emergence of these diseases (Table 13-1) (CDC, 1994). Except for microbial adaptation and changes made by the infectious agent, such as those likely in the emergence of E. coli 0157:H7, most of the emergence factors are consequences of activities and behavior of the human hosts, and of environmental changes such as deforestation,
Hantavirus pulmonary syndrome was first detected in 1993 in the Four Corners area of Arizona and New Mexico, when young, previously healthy Native Americans fell ill with a mys- terious and deadly respiratory disease. The illness was soon discovered to be a variant of, but to exhibit different pathology from, a rodent-borne virus previously known only in Europe and Asia. Transmission is thought to occur through aerosoliza- tion of rodent excrement. One explanation for the outbreak in the Southwest is that an unseasonably mild winter led to an unusual increase in the rodent population; more people than usual were exposed to a virus that had until that point gone unrecognized in this country. Infection in Native Americans first brought attention to hantavirus pulmonary syndrome because of a cluster of cases in a small geographic area, but no evidence suggests that any ethnic group is particularly suscep- tible to this disease. Hantavirus pulmonary syndrome has now been diagnosed in sites across the United States. The best pro- tection against this virus seems to be avoiding rodent-infested environments.
Not only is HIV disease relatively new but the resultant immunocompromise gave rise to previously rare opportunistic infections such as cryptosporidiosis, toxoplasmosis, and Pneumocystis pneumonia (PCP). HIV may have existed in iso- lated parts of sub-Saharan Africa for years and emerged, only recently, into the rest of the world as the result of a combination of factors, including new roads, increased commerce, and prostitution.
Esherichia coli 0157:H7 and other shiga toxin–producing E. coli show a more virulent nature than strains of the past. TB is another familiar face turned newly aggressive. After years of decline, it has resurged as a result of infection resulting from HIV disease and the development of multidrug resistance. New influenza viruses like A H1N1 and A H5N1 challenge scientists to rapidly develop vaccines to protect a world population with little or no immunity.
West Nile Virus (WNV), a mosquito-borne seasonal disease, was first identified in Uganda in 1937 and first detected in the United States in 1999. How WNV arrived in the United States may never be known, but the answer most likely involves infected birds or mosquitoes. Because the virus was new in this country and the outbreak of 2002 caused numerous deaths, WNV garnered a great deal of media attention. However, for the majority of people, infection with WNV results in no clini- cal signs (about 80%) or only mild flu-like symptoms. In a small percentage of individuals, approximately 1 of 150 cases, a more severe, potentially fatal neuroinvasive form may develop, which may leave permanent neurologic deficits for those who survive. The incidence of neuroinvasive disease increases with age, with the highest rates in those 70 years and older. After first appear- ing in New York City in 1999, the virus spent several years quietly spreading up and down the East Coast without remark- able morbidity or mortality. This situation changed abruptly in the summer of 2002 when it began moving across the country, accompanied by significant avian, equine, and human mortal- ity. WNV has now been reported in every state except Hawaii and Alaska and is the most common arbovirus (virus carried by arthropods) disease in the country. The CDC estimates that
From Centers for Disease Control and Prevention: Addressing emerging infectious disease threats: a prevention strategy for the U.S., Atlanta, 1994, CDC.
Categories Specific Examples
Societal events Economic impoverishment, war or civil conflict, population growth and migration, urban decay
Health care New medical devices, organ or tissue transplantation, drugs causing immunosuppression, widespread use of antibiotics
Food production Globalization of food supplies, changes in food processing and packaging
Human behavior Sexual behavior, drug use, travel, diet, outdoor recreation, use of childcare facilities
Environmental Deforestation/reforestation, changes in water ecosystems, flood/drought, famine, global changes (e.g., warming)
Public health Curtailment or reduction in prevention programs, inadequate communicable disease infrastructure surveillance, lack of trained personnel (epidemiologists, laboratory scientists, vector and rodent control specialists)
Microbial adaptation
Changes in virulence and toxin production, development of drug resistance, microbes as co-factors in chronic diseases
TABLE 13-1 Factors that Can Influence the Emergence of New Infectious Diseases
295CHAPTER 13 Infectious Disease Prevention and Control
PREVENTION AND CONTROL OF INFECTIOUS DISEASES Planning to Address Infectious Disease In 2011, the CDC published A CDC Framework for Preventing Infectious Disease: Sustaining the Essentials and Innovating for the Future, a plan for preventing and controlling infectious threats through a “strengthened, adaptable, and multi-purpose U.S. public health system.” Reflecting technological advances of the past decade, the plan places a heavy emphasis on the role of technology in surveillance, detection, and control. Three elements for action are identified: (1) Strengthen public health fundamentals, including infectious disease surveillance, laboratory detection, and epidemiologic investiga- tion; (2) Identify and implement high-impact public health interventions to reduce infectious diseases; and (3) Develop and advance policies to prevent, detect, and control infectious diseases. It also discusses linkages between infectious and chronic disease; lists a timeline of disease threats, emerging pathogens, and unusual health events worldwide from 2000- 2011; and identifies infectious disease issues of special concern: (1) antimicrobial resistance, (2) chronic viral hepatitis, (3) food safety, (4) health care–associated infections, (5) HIV/AIDS,
urbanization, and industrialization. The rise in households with two working parents has increased the number of children in daycare and with this shift has come an increase in diarrheal diseases such as shigellosis. Changing sexual behavior and illegal drug use influence the spread of HIV disease as well as other sexually transmitted infections. Before the use of large air- conditioning systems with cooling towers, legionellosis was vir- tually unknown. Modern transportation systems closely and quickly connect regions of the world that for centuries had little contact. Insects and animals as well as humans may carry disease between continents on ships and planes. Immigrants, both legal and undocumented, as well as travelers, bring with them a variety of known and potentially unknown diseases.
Examples of Emerging Infectious Diseases Selected emerging infectious diseases, including a brief descrip- tion of the diseases and symptoms they cause, their modes of transmission, and causes of emergence, are listed in Table 13-2. Progress in addressing emerging infectious disease as well as current findings and topics can be found in the CDC journal Emerging Infectious Diseases. (The journal is published monthly and is available online at http://www.cdc.gov/ncidod/EID/ about/about.html)(Figure 13-2).
Infectious Agent Diseases/Symptoms Mode of Transmission Causes of Emergence
Borrelia burgdorferi Lyme disease: rash, fever, arthritis, neurologic and cardiac abnormalities
Bite of infective Ixodes tick Increase in deer and human populations in wooded areas
Cryptosporidium Cryptosporidiosis; infection of epithelial cells in gastrointestinal and respiratory tracts
Fecal–oral, person-to-person, waterborne Development near watershed areas; immunosuppression
Ebola-Marburg viruses Fulminant, high mortality, hemorrhagic fever Direct contact with infected blood, organs, secretions, and semen
Unknown, likely human invasion of virus ecological niche
Escherichia coli 0157:H7
Hemorrhagic colitis; thrombocytopenia; hemolytic uremic syndrome
Ingestion of contaminated food, especially undercooked beef and raw milk
Likely caused by a new pathogen
Hantavirus Hemorrhagic fever with renal syndrome; pulmonary syndrome
Inhalation of aerosolized rodent urine and feces
Human invasion of virus ecological niche
Human immunodeficiency virus (HIV-1)
HIV infection; AIDS (HIV stage III); severe immune dysfunction, opportunistic infections
Sexual contact with or exposure to blood or tissues of infected persons; perinatal
Urbanization; lifestyle changes; drug use; international travel; transfusions; transplant
Human papillomavirus (HPV)
Skin and mucous membrane lesions (warts); strongly linked to cancer of the cervix and penis
Direct sexual contact, contact with contaminated surfaces
Newly recognized; changes in sexual lifestyle
Influenza A H1N1 virus (novel, pandemic)
Influenza: fever, cough, headache, myalgia, prostration, possibly GI signs
Person-to-person, airborne (droplet), and contact (direct and indirect)
Antigenic shift
Influenza A H5N1 virus (novel, avian)
Influenza: fever, cough, headache, myalgia, prostration
Direct contact with infected poultry or birds; limited person-to-person transmission
Antigenic shift
Legionella pneumophila Legionnaires’ disease: malaise, myalgia, fever, headache, respiratory illness
Air cooling systems, water supplies Recognition in an epidemic situation
Pneumocystis jiroveci Acute pneumonia Unknown; possibly airborne or reactivation of latent infection
Immunosuppression
SARS Severe and acute pneumonia Person-to-person, airborne (droplet) and direct and indirect contact with respiratory secretions and other bodily fluid
Unknown; newly recognized coronavirus; possible animal transmission into Chinese population
West Nile virus No clinical signs to mild flu-like symptoms to fatal neuroinvasive disease
Bite of infected mosquitoes; infected birds serve as reservoirs
International travel and commerce
TABLE 13-2 Examples of Emerging Infectious Diseases
Based on information from Heymann DL, editor: Control of communicable diseases manual, ed 20, Washington, DC, 2014, American Public Health Association; Fauci AS, Touchette NA, Folkers GK: Emerging infectious diseases: a 10-year perspective from the National Institute of Allergy and Infectious Diseases, Emerg Infect Dis 11(4):519-525, 2005.
296 PART 3 Conceptual and Scientific Frameworks
1988, over 2 billion children around the world have been immu- nized against polio through the cooperation of more than 200 countries and 20 million volunteers, supported by an interna- tional investment of over $3 billion. At the end of 2008, WHO reviewed the progress of the initiative with two independent outside agencies and concluded that the remaining technical and operational challenges to eradication could be overcome in each of the polio-endemic countries by ensuring the political commitment of all polio-affected countries to attain the highest possible coverage and enhancing routine vaccination and sur- veillance (CDC, 2009a).
As a result of the Global Polio Eradication Initiative launch in 1988, the number of polio-endemic countries has decreased from 125 to 3 (Afghanistan, Nigeria, and Pakistan); 4 of the 6 regions of the World Health Organization (WHO) are certified polio free—the Americas, Europe, South East Asia, and the Western Pacific; and the number of worldwide polio cases has fallen from an estimated 350,000 to 407 in 2013, a decrease of more than 99% in reported cases. However, importation of cases resulting from the ease of worldwide travel or breakdowns in coverage in a neighboring country continues to lead to out- breaks in nonendemic countries. Between January and May of 2014, 77 cases of wild polio were reported from 8 countries: Afghanistan, Cameroon, Equatorial Guinea, Ethiopia, Iraq, Nigeria, Pakistan, and Syria. Such outbreaks point to the neces- sity of maintaining mass vaccination campaigns in polio-free countries to protect against cases imported from endemic areas. Challenges to maintaining coverage include political instability and sporadic violence, cultural beliefs about immunization, religious fears, and distrust of immunization. With the potential for eradication so close, in May of 2014, the WHO declared the recent international spread of wild poliovirus a public health emergency of international concern and issued Temporary
(6) respiratory infections, (7) safe water, and (8) zoonotic and vectorborne diseases (CDC, 2011a). (This plan may be viewed at http://www.cdc.gov/oid/docs/ID-Framework.pdf .)
Prevention and Control Programs Infectious disease can be prevented and controlled. The goal of prevention and control programs is to reduce the prevalence of a disease to a level at which it no longer poses a major public health problem. In some cases, diseases may even be eliminated or eradicated. The goal of elimination is to remove a disease from a large geographic area such as a country or region of the world. Eradication is removing a disease worldwide by ending all transmission of infection through the complete extermina- tion of the infectious agent. WHO officially declared the global eradication of smallpox on May 8, 1980 (Evans, 1985). After the successful eradication of smallpox, the eradication of other communicable diseases became a realistic challenge, and in 1987 WHO adopted resolutions for eradication of paralytic poliomyelitis and dracunculiasis (Guinea worm infection) from the world by the year 2000.
These eradication goals were not reached in 2000, but sub- stantial progress has been made. When the resolution was made in 1987 for the eradication of Guinea worm disease, there were an estimated 3.5 million cases a year in 20 countries in Asia and Africa and 120 million people were at risk for the disease. In 2013, only 148 cases were reported worldwide, making the goal of global eradication appear within reach (CDC, 2013c). Read more about Guinea worm disease eradication at http:// www.cdc.gov/parasites/guineaworm/.
With the Global Polio Eradication Initiative, the World Health Organization (WHO) partnered with national govern- ments, Rotary International, the CDC, and UNICEF in what has been called the world’s largest public health initiative. Since
FIGURE 13-2 Examples of recent emerging and reemerging infectious diseases. (Based on Institute of Medicine: Microbial threats to health: emergence, detection, and response. Wash- ington, DC, 2003, National Academy Press.)
Multidrug resistant malaria
Dengue fever
West Nile virus Lyme disease
VCJD
Human MonkeypoxYellow Fever
Cholera
Hantavirus pulmonary syndrome
E. coli 0157:H7
Cyclosporiasis
Cryptosporidiosis
Multidrug resistant tuberculosis
Ebola hemorrhagic fever
Marburg hemorrhagic fever HIV
Rift Valley fever
Diphtheria Pertussis
SARS
Human avian influenza H5N1
Hendra virus
Nipah virus
297CHAPTER 13 Infectious Disease Prevention and Control
Recommendations under the International Health Regulations (2005) to prevent further spread of the disease (CDC, 2014c). (Read more about global polio eradication efforts at http:// www.polioeradication.org/.)
Primary, Secondary, and Tertiary Prevention There are three levels of prevention in public health: primary, secondary, and tertiary. In prevention and control of infectious disease, primary prevention seeks to reduce the incidence of disease by preventing occurrence, and this effort is often assisted by the government. Many interventions at the primary level, such as federally supplied vaccines and “no shots, no school” immunization laws, are population based because of public health mandates. Nurses deliver childhood immunizations in public and community health settings, check immunization records in daycare facilities, and monitor immunization records in schools.
The goal of secondary prevention is to prevent the spread of infection and/or disease once it occurs. Activities center on rapid identification of potential contacts to a reported case. Contacts may be (1) identified as new cases and treated, or (2) determined to be possibly exposed but not diseased and appro- priately treated with prophylaxis. Public health disease control laws also assist in secondary prevention because they require investigation and prevention measures for individuals affected by a communicable disease report or outbreak. These laws can extend to the entire community if the exposure potential is deemed great enough, as could happen with an outbreak of smallpox or epidemic influenza. Nurses perform much of the communicable disease surveillance and control work in this country.
Although many infections are acute, with either recovery or death occurring in the short term, some exhibit chronic courses (AIDS/HIV stage III) or disabling sequelae (leprosy/ Hansen’s disease). Tertiary prevention works to reduce compli- cations and disabilities through treatment and rehabilitation. The Levels of Prevention box has examples of communicable disease prevention and control interventions at the three levels of prevention.
Role of Nurses in Prevention Prevention is at the center of public health, and nurses perform much of this work. Examples include immunizations for vaccine-preventable disease, especially childhood immuniza- tion and the monitoring of immunization status in clinic, daycare, school, and home settings. Nurses work in communi- cable disease surveillance and control, teach and monitor bloodborne pathogen control, and advise on prevention of vector borne diseases. They teach methods for responsible sexual behavior, screen for sexually transmitted infection, and provide HIV disease counseling and testing. They screen for TB, identify TB contacts, and deliver directly observed TB treatment in the community.
Multisystem Approach to Control Communicable diseases represent an imbalance in the harmo- nious relationship between the human host and the
LEVELS OF PREVENTION
Primary Prevention To prevent the occurrence of disease: • Responsible sexual behavior • Malaria chemoprophylaxis • Tetanus boosters, flu shots • Rabies pre-exposure immunization • Safe food-handling practices in the home • Repellants for preventing vector borne disease • Following childhood immunizations recommendations, and “no shots, no
school” laws • Regulated and inspected municipal water supplies • Bloodborne pathogen regulations • Restaurant inspections • Federal regulations protecting American cattle from exposure to bovine
spongiform encephalopathy (BSE)
Secondary Prevention To prevent the spread of disease: • Immunoglobulin after hepatitis A exposure • Immunization and chemoprophylaxis as appropriate in meningococcal
outbreak • Rabies postexposure immunization • Tuberculosis screening for health care workers • Sexually transmitted disease (STD) partner notification • Human immunodeficiency virus (HIV) testing and treatment • Quarantine
Tertiary Prevention To reduce complications and disabilities through treatment and rehabilitation: • Pneumocystis pneumonia (PCP) chemoprophylaxis for people with AIDS/
HIV stage III • Regular inspection of hands and feet as well as protective footwear and
gloves to avoid trauma and infection for leprosy clients who have lost sensation in those areas
Examples of Infectious Disease Interventions
environment. This state of imbalance provides the infectious agent an opportunity to cause illness and death in the human population. Given the many factors that can disrupt the agent- host-environment relationship, a multisystem approach to control of communicable diseases as shown in Table 13-3 must be developed (Wenzel, 1998).
AGENTS OF BIOTERRORISM September 11, 2001, made real the specter of terrorism on American soil. The anthrax attacks that followed further high- lighted the possibilities for the intentional release of a biological agent, or bioterrorism. The CDC suggests that the agents most likely to be used in a bioterrorist attack are those having the potential for both high mortality and easy dissemination— factors most likely to result in major public panic and social disruption. Six infectious agents are considered of highest concern: anthrax (Bacillus anthracis), plague (Yersinia pestis), smallpox (variola major), botulism (Clostridium botulinum), tularemia (Francisella tularensis), and selected hemorrhagic viruses (filoviruses such as Ebola and Marburg; arenaviruses
298 PART 3 Conceptual and Scientific Frameworks
who handle infected animal products such as hair, wool, and bone or bone meal or products made from these materials such as rugs and drums. Products made from infected materials may transmit this disease around the world. Person-to-person trans- mission is rare (Heymann, 2014).
Anthrax disease may manifest in one of three syndromes: cutaneous, gastrointestinal, and respiratory or inhalational. Cutaneous anthrax, the form most commonly seen, occurs when spores come in contact with abraded skin surfaces. Itching is followed in 2 to 6 days by the development of a characteristic black eschar, usually surrounded by some degree of edema and possibly secondary infection. The lesion itself is usually not painful. If untreated, infection may spread to the regional lymph nodes and bloodstream, resulting in septicemia and death. The fatality rate for untreated cutaneous anthrax is between 5% and 20%, but if appropriately treated, death seldom occurs. Before 2001 the last cutaneous case in the United States was reported in 1992. Gastrointestinal anthrax is considered rare and occurs from eating undercooked, contaminated meat. Inhalational anthrax is also considered rare, typically seen in occupations with exposure to hide tanning or bone processing. Before 2001 the last case reported in the United States was in 1976. Initially, symptoms are mild and nonspecific and may include fever, malaise, mild cough, or chest pain. These symp- toms are followed 3 to 5 days later, often after an apparent improvement, by fever and shock, rapid deterioration, and death. Untreated cases of inhalational anthrax are fatal; treated cases may show as high as a 95% fatality rate if treatment is initiated after 48 hours from the onset of symptoms.
Because of factors such as the ability for aerosolization, the resistance to environmental degradation and a high fatality rate, inhalational anthrax has long been considered to have an extremely high potential for being the single greatest biological warfare threat (Cieslak and Eitzen, 1999). An accidental release from a biological research institute in Sverdlovsk, Russia, in 1979 resulted in the documented death of 66 individuals and demonstrated the capacity of this organism as a weapon. Manu- facture and delivery of the spores have been considered a chal- lenge because of a tendency for the spores to clump. During 1998 in the United States, more than two dozen anthrax threats (letters purporting to be carrying anthrax) were made. None of them were real. The events of the fall of 2001, when 11 people were sickened and 5 died from deliberate exposure, have shown that the threat of anthrax as a weapon of bioterror is all too real.
Any threat of anthrax should be reported to the Federal Bureau of Investigation and to local and state health depart- ments. Anthrax is sensitive to a variety of antibiotics including the penicillins, chloramphenicol, doxycycline, and the fluoro- quinolones. In cases of possible bioterrorism activity, individu- als with a credible threat of exposure, with confirmed exposure, or at high risk of exposure are immediately started on antibiotic prophylaxis, preferably fluoroquinolones. Immunization is rec- ommended as well. People who have been exposed are not contagious, so quarantine is not appropriate (Heymann, 2014).
In recent years, although no more deliberate acts of bioter- rorism have been reported, England and the United States have seen rare cases of cutaneous, inhalational, and gastrointestinal
such as Lassa fever, Junin virus, and related viruses). The CDC urges health care providers to be familiar with the epidemiology of these diseases as well as illness patterns possibly indicating an unusual infectious disease outbreak associated with the intentional release of a biological agent. (More information on recognition of illness associated with the intentional release of a biological agent as well as possible agents may be found at the CDC Emergency Preparedness and Response website: http:// www.bt.cdc.gov.)
Anthrax Until the fall of 2001, anthrax was more commonly a concern of veterinarians and military strategists than the general public. After September 11th, the news of deaths caused by letters deliberately contaminated with anthrax and transmitted through the postal service profoundly changed our view of this infectious disease. Anthrax is an acute disease caused by the spore-forming bacterium B. anthracis. It is thought that anthrax may have caused the biblical fifth and sixth plagues of Exodus as well as the Black Bane of Europe in the 1600s. In 1881 anthrax became the first bacterial disease for which immunization was available. More commonly seen in cattle, sheep, and goats, anthrax in modern times has rarely and sporadically affected humans, usually through the handling or consumption of infected animal products (Cieslak and Eitzen, 1999).
Anthrax is a clever organism that perpetuates itself by forming spores. When animals dying from anthrax suffer ter- minal hemorrhage and infected blood comes into contact with the air, the bacillus organism sporulates. These spores are highly resistant to disinfection and environmental destruction and may remain in contaminated soil for many years. In the United States, anthrax zones are said to follow the cattle drive trails of the 1800s. Sometimes referred to as wool handler’s disease, anthrax has commonly posed the greatest risk to people who work directly with dying animals, such as veterinarians, or those
Modified from Wenzel RP: Control of communicable diseases: overview. In Wallace RB, editor: Public health and preventive medicine, ed. 15, 2008, New York.
Goal Example
Improve host resistance to infectious agents and other environmental hazards
Hygiene, nutrition, and physical fitness; increased immunization coverage; provision of drugs for prevention and treatment; stress control and improved mental health
Improve safety of the environment
Sanitation, clean water and air; proper cooking and storage of food; control of vectors and animal reservoir hosts
Improve public health systems
Increased access to health care; appropriate health education; improved surveillance systems
Facilitate social and political change to ensure better health for all people
Individual, organizational, and community action; legislation
TABLE 13-3 A Multisystem Approach to Communicable Disease Control
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anthrax associated with drumming circles using drums covered with imported animal hides. Since December 2009, in the United Kingdom there has been an ongoing outbreak of anthrax among injecting drug users, in some cases resulting in death. The infection is believed to be caused by contaminated heroin. With no new cases after the summer, Scotland declared the outbreak over in December 2010 but concluded the possibility of an ongoing risk of anthrax in heroin users supported by sporadic cases occurring in England. In 2012, 13 cases were reported from Germany, Denmark, France, and the United Kingdom. Ongoing European investigation continues (Grunow et al, 2013).
Smallpox Formerly a disease found worldwide, smallpox has been con- sidered eradicated since 1979. The last known natural case in the United States was in 1949. The last known case of smallpox worldwide occurred in Somalia in 1977. The United States stopped routinely immunizing for smallpox in 1982. The only documented existing virus sources are located in freezers at the CDC in Atlanta and at a research institute in Novosibirsk, Russia. Controversy exists over the destruction of these viral stocks, and despite an earlier call by WHO for destruction in 2002, the date was postponed to allow for additional research needed should clandestine supplies fall into terrorist hands. The World Health Assembly expected to debate this issue in 2014.
Smallpox has been identified as one of the leading candidate agents for bioterrorism. Susceptibility is 100% in the unvacci- nated (those vaccinated before 1982 are not considered pro- tected, although they may have some immunity) and the fatality rate is estimated at 20% to 40% or higher. Immunization with a vaccinia vaccine, the immunizing agent for smallpox, can be protective even after exposure. In 2007 the U.S. Food and Drug Administration (FDA) licensed a new smallpox vaccine, derived from the only other smallpox vaccine licensed by the FDA: Dryvax, approved in 1931 and now in limited supply because it is no longer manufactured. The WHO does not recommend vaccination of the general public because currently the risk of death (1 per 1 million doses) or serious side effects is greater than that of the disease. Those who routinely are exposed to smallpox virus such as laboratory workers should be vaccinated. Because of the potential for bioterrorism and the fact that many health care providers have never seen this disease, it is impor- tant to become familiar with the clinical and epidemiologic features of smallpox and how it is differentiated from chicken- pox (see the How To box). Should a nonvaricella, smallpox-like disease be detected, immediate contact with local and national health authorities is obligatory (Heymann, 2014).
HOW TO Distinguish Chickenpox from Smallpox Despite the availability of a vaccine, chickenpox is still a common disease of childhood and may be seen in susceptible adults as well. Although many health care providers are familiar with chickenpox, most have never seen a case of smallpox. Because of the potential for smallpox to be used as a bioweapon, the CDC suggests that nurses and other practitioners familiarize themselves with the dif- ferences in presentation between the two diseases. The rash
Plague Plague is a vector borne disease transmitted by rodent fleas carrying the bacterium Y. pestis. Portrayed vividly in the Bible and events throughout history, plague is believed responsible for the epidemic of Black Death that killed over a quarter of the population of Europe during the Middle Ages. The disease is endemic in much of South Asia, parts of South America, and the western United States, but the majority of outbreaks and cases today are reported from Africa, especially from the Demo- cratic Republic of the Congo. Plague arrived in the United States as a consequence of a pandemic that began in China during the late 1800s and spread to the West Coast via shipboard rats. Although resulting plague in cities was largely controlled, the disease spread to and became enzootic in wild rodents. The current primary vertebrate reservoirs in the United States are usually ground squirrels rather than rats, rabbits, wild carni- vores, and in some cases cats. Human plague in the western United States occurs infrequently and sporadically with fewer than 20 cases reported a year since 1970. Veterinarians have contracted the disease from infected cats. People with regular
pattern for each disease is distinctive, but in the first 2 to 3 days of development, the two may be indistinguishable. Infectious disease texts and posters provide a pictorial description. If a small- pox infection is suspected, the local health department should be notified immediately.
Chickenpox (Varicella) Smallpox (Historical Variola Major)
Sudden onset with slight fever and mild constitutional symptoms (both may be more severe in adults)
Sudden onset of fever, prostration, severe body aches, and occasional abdominal pain and vomiting, as in influenza
Rash is present at onset Clear-cut prodromal illness, rash follows 2-4 days after fever begins decreasing
Rash progression is maculopapular for a few hours, vesicular for 3-4 days, followed by granular scabs
Progression is macular, papular, vesicular, and pustular, followed by crusted scabs that fall off after 3-4 weeks if client survives
Rash is “centrifugal” with lesions most abundant on the trunk or areas of the body usually covered by clothing
Rash is “centripetal” with lesions most abundant on the face and extremities
Lesions appear in “crops” and can be at various stages in the same area of the body
Lesions are all at same stage in all areas
Vesicles are superficial and collapse on puncture; mild scarring may occur
Vesicles are deep-seated and do not collapse on puncture; pitting and scarring are common
From Heymann DL, editor: Control of communicable diseases manual, ed 19. Washington, DC, 2008, American Public Health Association; Henderson DA: Smallpox: clinical and epidemiologic features. Emerg Infect Dis 5:537–539, 1999.
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outdoor exposure such as hunters, trappers, and those living in rural areas as well as cat owners are at highest risk for natural transmission (Heymann, 2014).
Initial signs and symptoms of plague are nonspecific and include myalgia, malaise, fever, chills, sore throat, and headache. As the disease progresses, lymphadenitis commonly develops in the lymph nodes, draining the area nearest the bite. This swollen node, or bubo, most frequently seen in the inguinal area, gives rise to the name bubonic plague. Whether lymphadenitis is present or not, bubonic plague may progress to septicemic plague and secondary pneumonic plague. Secondary pneu- monic plague can spread through respiratory droplets, resulting in primary pneumonic plague and human-to-human out- breaks. No such transmission has been reported in the United States since 1924, but several cases of primary pneumonic plague have developed from exposure to infected cats.
Untreated cases of primary septicemic and pneumonic plague are most often fatal; the case fatality rate for untreated bubonic plague is 50% to 60%. Streptomycin is the treatment of choice; gentamicin, tetracyclines, and chloramphenicol are alternatives. Immunization may confer some protection against bubonic plague but not pneumonic. Commercial plague vaccine is no longer available in the United States. Naturally acquired plague is usually bubonic. Plague used as a means of a terrorist attack would most likely be aerosolized, resulting in pneumonic disease and human-to-human transmission (Heymann, 2014). Read more about plague at the CDC website: http://www.cdc .gov/plague/.
Tularemia Sometimes referred to as “rabbit fever” or “deer fly fever,” tula- remia is a zoonotic disease caused by the bacterial agent F. tularensis which is carried commonly by wild animals, especially rabbits, as well as muskrats, voles, beavers, some domestic animals, and some ticks, mosquitoes, and flies. Tularemia may be transmitted by the bite of an infected arthropod; contact of eyes, skin, or mucous membranes with infected tissues, blood, or water; ingestion of inadequately cooked infected meat or contaminated water; inhalation of contaminated dust; and han- dling of contaminated pelts and paws. Hunters handling rabbit and rodent carcasses, lawn care workers, and those working outside in rural areas may be at higher risk. Tularemia has also occurred from running over an infected rabbit with a lawn mower and by handling sick pets including dogs, cats, hamsters, and prairie dogs. Tularemia is not transmitted from person to person (Heymann, 2014).
How tularemia presents varies depending on how the infec- tion was acquired and the virulence of the infecting agent. There are two subspecies of F. tularensis—one causing few deaths even without treatment and one resulting in a 5% to 15% fatality rate without treatment, primarily from respiratory disease. Commonly the onset of tularemia is sudden and may resemble influenza with high fever, myalgia, headache, nausea, and chills. Frequently an ulcerative lesion appears at the point of inoculation accompanied by swelling of associated lymph nodes. However, lymphadenitis can occur without a primary lesion. In either case, the presence of these buboes can cause
confusion with plague. Inoculation, or introduction of the organism, into the eye results in a purulent conjunctivitis accompanied by regional lymphadenitis. Ingestion of infected tissue or contaminated water produces a sore throat, abdominal pain, diarrhea, and vomiting. Infection by inhalation may cause respiratory involvement and possible sepsis. Pneumonia is a potential complication with all forms and requires prompt treatment to prevent potentially fatal complications. Aminogly- cosides or ciprofloxacin are the treatment drugs of choice. There is no vaccination for tularemia currently in widespread use in the United States, although live attenuated vaccine applied intradermally by scarification is available to high-risk workers (Heymann, 2014).
Tularemia has been reported from every state except Hawaii but is not a particularly common disease, with an average of 130 cases per year reported from 2003 through 2012. The only two reported outbreaks of pneumonic tularemia in the United States have come from Martha’s Vineyard, where the disease is endemic and cases are frequently reported in lawn care workers (Feldman et al, 2003). Because of the low incidence of naturally occurring disease, tularemia was removed from the nationally notifiable disease list in 1994 but reinstated in 2000 with the growing concern over bioterrorism. Aerosolized tularemia with resulting pneumonic disease is considered the most likely sce- nario for use as an agent of bioterrorism (CDC, 2009b). (Read more about tularemia at the CDC website: http://www.cdc.gov/ tularemia/index.html.)
VACCINE-PREVENTABLE DISEASES Vaccines are one of the most effective methods of preventing and controlling communicable diseases. The smallpox vaccine, which left distinctive scars on so many shoulders, is no longer in general use because the smallpox virus has been declared eradicated from the world’s population. Despite threats of bio- terrorism, there are no plans to reintroduce universal smallpox immunization because of potential side effects. Diseases such as polio, diphtheria, pertussis, and measles, which previously occurred in epidemic proportions, are now controlled by routine childhood immunization. They have not, however, been eradicated, so children need to be immunized against them. In the United States, “no shots, no school” legislation has resulted in the immunization of most children by the time they enter school. However, many infants and toddlers, the group most vulnerable to these potentially severe diseases, do not receive scheduled immunizations despite the availability of free vac- cines. And infants less than six months of age who are not yet fully immunized may be susceptible to infections in unimmu- nized individuals around them (see the Evidence-Based Practice box). Surveys show inner-city children from minority and ethnic groups are particularly at risk for incomplete immuniza- tion, and children from religious communities whose beliefs prohibit immunization and children with parents who have philosophical objections to immunization may receive no pro- tection at all. Studies also show low levels of vaccination against pneumonia in senior citizens and lower levels of influenza cov- erage in adults from minority and ethnic groups. Healthy People
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Haemophilus influenzae type B meningitis, Varicella (chicken- pox), Streptococcus pneumoniae–related illnesses, rotavirus, hepatitis A, influenza, HPV, and meningococcal disease (CDC, 2014d). The vaccine schedule is a rather complex and frequently changing document that makes continuing adjustments for the latest research and recommendations and is issued annually by the Advisory Committee on Immunization Practices (ACIP). More recent additions to the schedule include hepatitis A, rota- virus, seasonal influenza for all children ages 6 months through 18 years, and Tdap (the tetanus, reduced-strength diphtheria, and acellular pertussis vaccine licensed for older children, ado- lescents, and adults). Because many of these vaccines require three to four doses, the schedule begins at birth with succeeding staggered vaccinations designed to achieve recommended immunization levels by 2 years of age. Additional doses may be required before a child enters school and at adolescence or on entering college. The ACIP, the American Academy of Pediatrics and the American Academy of Family Physicians regularly update recommended immunization schedules. The ACIP also issues a recommended adult immunization schedule for those over 18 years old, by age group and immune status. The 2014 schedule includes, as appropriate, HPV, varicella, measles, mumps and rubella, pneumococcus, zoster to prevent shingles, and tetanus every 10 years with one dose given as Tdap. Other immunizations available in special circumstances include, but are not limited to, rabies, yellow fever, typhoid, smallpox, and anthrax. (Recommended vaccine schedules may be viewed at http://www.cdc.gov/vaccines/schedules/index.html.)
Measles Measles is an acute, highly contagious disease that, although considered a childhood illness, may be seen in the United States in adolescents and young adults. Symptoms include fever, sneezing and coughing, conjunctivitis, small white spots on the inside of the cheek (Koplik’s spots), and a red, blotchy rash beginning several days after the respiratory signs. Measles is caused by the rubeola virus and is transmitted by inhalation of infected aerosol droplets or by direct contact with infected nasal or throat secretions or with articles freshly contaminated with the same nasal or throat secretions. A very contagious nature, combined with the fact that people are most contagious before they are aware they are infected, makes measles a disease that can spread rapidly through the population. Infection with measles confers lifelong immunity (Heymann, 2014).
Measles and malnutrition form a deadly combination for many children in the developing world. Despite the introduc- tion in 1963 of a live attenuated measles vaccine that is safe, effective, and widely available, measles is still endemic in many countries. The WHO estimates 20 million people are affected each year with over 100,000 deaths—mostly children under the age of five. Much of this mortality is preventable by immunizing all infants. The good news is that with the launch of the Measles and Rubella Initiative in 2001, global measles deaths have decreased by 78 percent worldwide in recent years—from 562,400 deaths in 2000 to 122,000 in 2012 (WHO, 2014b).
Immunization has dramatically decreased measles cases in the United States to the point that, in March 2000, a panel of
2020 includes several objectives about obtaining and maintain- ing appropriate levels of immunization in all age groups. (Addi- tional information on vaccine-preventable diseases may be found at the CDC website: http://www.cdc.gov/vaccines/.)
Because they are too young to be fully immunized, infants under six months of age are at greatest risk for complications and death from pertussis. New mothers, fathers, caretakers, and close contacts to the infant are frequently the source of infection, leading to the concept of cocooning the infant against pertussis through immunizing individuals who have close contact with the baby. In examining ways to increase Tdap (tetanus, reduced diphtheria, acel- lular pertussis) uptake in new mothers, researchers looked at two hospitals with zero postpartum Tdap immunization rates. One followed standard proce- dures and the other instituted a standing order for new mothers to receive Tdap before discharge. Implementing the standing orders raised the zero starting rate to 69%. At the hospital that followed standard procedures, the rate for postpartum Tdap immunization remained at zero. Since this study, the Advisory Committee on Immunization Practices has updated its recommenda- tion to say women should receive Tdap, if they have not already, toward the end of their second trimester or during their third trimester of pregnancy. However, even with this new recommendation, studies find only a small percentage of unimmunized pregnant women receive a Tdap vaccination (LABioMed, 2014).
Nurse Use The adult public has been slow to embrace Tdap. One reason may be lack of awareness of the availability of the vaccine and/or of the importance it plays in keeping infants safe. There are a variety of ways to approach this issue, starting with consumer awareness and provider education and advocacy. This study shows how a change in standard practice within an institution had a dramatic effect on Tdap immunization in postpartum mothers. Whether Tdap or other issues that require attention, nurses manage clinics and take leader- ship roles in hospitals, physicians’ offices, health departments, and safety-net health services, which puts them in a position to both assess where there are opportunities for intervention and to change practice to address important public health concerns.
EVIDENCE-BASED PRACTICE
Because many children receive their immunizations at public health departments, nurses play a major role in increasing immunization coverage of infants and toddlers. Nurses track children known to be at risk for underimmunization and call or send reminders to their parents. They help avoid missed immunization opportunities by checking the immunization status of every young child encountered, whether or not the clinic or home visit is related to immunization. In addition, they organize immunization outreach activities in the community; provide answers to parents’ questions and concerns about immunization; and educate parents about why immunizations are needed, inappropriate contraindications to immunization, and the importance of completing the immunization schedule on time.
Routine Childhood Immunization Schedule The 2014 recommended immunization schedule for children and adolescents in the United States includes routine immunization against the following 16 diseases: hepatitis B, diphtheria, pertussis, tetanus, measles, mumps, rubella, polio,
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measles morbidity, especially in communities with many unvac- cinated residents (CDC, 2015b; CDC, 2014e).
Healthy People 2020 calls for the reduction, elimination or maintained elimination of vaccine-preventable diseases includ- ing the reduction of indigenous measles cases. Efforts to meet this goal will require (1) rapid detection of cases and imple- mentation of appropriate outbreak control measures, (2) achievement and maintenance of high levels of vaccination cov- erage among preschool-age children in all geographic regions, (3) continued implementation and enforcement of the two- dose schedule among young adults, (4) the determination of the source of all outbreaks and sporadic infections, and (5) cooperation among countries in measles control efforts. Nurses receive reports of cases, investigate them, and initiate control measures for outbreaks. They use every opportunity to immu- nize adolescents and young adults who lack documentation of two doses of measles vaccine. Nurses who work in regions where undocumented residents are common, where groups obtain exemption from immunization on religious grounds or who choose not to vaccinate for philosophical reasons, where preschool coverage is low and/or where international visitors are frequent need to be especially alert for measles cases and the necessity of prompt outbreak control among particularly sus- ceptible populations.
Rubella The rubella (German measles) virus causes a mild febrile disease with enlarged lymph nodes and a fine, pink rash that is often difficult to distinguish from measles or scarlet fever. In contrast to measles, rubella is only a moderately contagious illness. Transmission is through inhalation of or direct contact with infected droplets from the respiratory secretions of infected persons. Children may show few or no constitutional symp- toms, whereas adults usually experience several days of low- grade fever, headache, malaise, runny nose, and conjunctivitis before the rash appears. Many infections occur without a rash (Heymann, 2014).
For many years, because it caused only a mild illness, rubella was considered to be of minor importance. Then, in 1941 the link between maternal rubella and poor pregnancy outcomes was recognized and the disease suddenly assumed major public health significance. Rubella infection, in addition to causing intrauterine death and spontaneous abortion, may result in anomalies referred to as congenital rubella syndrome (CRS), affecting single or multiple organ systems. Defects include cata- racts, congenital glaucoma, deafness, microcephaly, mental retardation, cardiac abnormalities, and diabetes mellitus. CRS occurs in up to 90% of infants born to women who are infected with rubella during the first trimester of pregnancy (Heymann, 2014). During the 1962 to 1965 rubella pandemic, an estimated 12.5 million cases of rubella occurred in the United States, resulting in 2000 cases of encephalitis, 11,250 fetal deaths, 2100 neonatal deaths, and 20,000 infants born with CRS. The eco- nomic impact of this epidemic was estimated at $1.5 billion (CDC, 2005).
The United States has established and achieved the goal of eliminating indigenous rubella transmission and CRS. Rubella
experts declared measles no longer endemic in the United States. Before introduction of the vaccine in 1963, 200,000 to 500,000 cases of measles were reported yearly, but by 1983 reported cases had fallen to an all-time low of less than 1500. In the late 1980s, the incidence of measles began to climb again, with more than 55,000 cases reported between 1989 and 1991. This increase resulted from low immunization rates among pre- school children and was countered with efforts to increase immunization rates and the routine use of two doses of measles vaccine for all children. Except for outbreaks in 1994 that occurred predominantly among high school and college-age persons, many of whom had not received two doses of measles vaccine, reported measles cases dropped continuously from 1991 to 2004 when only 37 confirmed cases were reported to the CDC—the lowest number since measles became a nation- ally reportable disease in 1912.
Since measles elimination was documented in the United States in 2000, annual reported cases have ranged from the low of 37 in 2004 to a high of 644 in 2014. Years with high numbers of reports are driven by outbreaks. In 2008, 140 cases were reported with 3 outbreaks. This increase was attributed to spread in communities with groups of unvaccinated people. The 220 cases in 2011 largely resulted from cases imported from a large outbreak in France. The United States experienced 11 outbreaks in 2013, three of which had more than 20 cases and in 2014 saw 23 outbreaks and 644 cases, many of which were associated with a large, ongoing measles outbreak in the Philippines. The first three weeks of January 2015 saw 68 cases from 11 states, most of which were linked with a large outbreak in a California amusement park (CDC, 2015b).
These recent outbreaks in the United States highlight the ongoing risk of measles importation from other countries by people who travel. With first-dose vaccine coverage of preschool children at greater than 90% and schools in 49 states requiring two doses of vaccine, the pattern of infection has shifted from under immunization of infants and school-age children to disease acquired from other countries. Because imported cases had not previously resulted in large outbreaks, it appeared that vaccination efforts had been successful in increasing herd immunity against measles, but groups who remain at greatest risk for infection are those who do not routinely accept immu- nization, such as people with religious or philosophical objec- tions, students in schools that do not require two doses of vaccine, and infants in areas where immunization coverage is low. The exposure of these groups to an imported case can result in a major outbreak and, indeed, beginning with the 2008 outbreaks, most increases have not been the result of a greater number of imported cases but of greater viral transmission after importation into the United States, leading to a larger number of importation-associated cases. These importation-associated cases largely occur among the unvaccinated, frequently among school-aged children who are eligible for vaccination but whose parents choose not to have them vaccinated and infants who are too young for vaccination. States vary in the ease of obtain- ing philosophical exemptions from immunization and require- ments for vaccination of home-schooled children. The increase in importation-associated cases may result in an increase in
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Before the development of a whole-cell vaccine—DTP (diphtheria, tetanus, pertussis)—in the 1940s, pertussis led to hundreds of thousands of cases and thousands of deaths per year, the majority in children younger than 5 years. After vaccine licensure and the introduction of universal vaccination, reported cases in the United States steadily declined, hitting a record low of just over 1000 in 1976. However, beginning in the early 1980s, pertussis cases began to show cyclical increases peaking every 3 to 5 years with the peaks getting higher and reported cases going up. In 2012, over 48,000 cases were reported, the highest number since 1955 (CDC, 2014f ).
In the mid 2000s the epidemiology of pertussis appears to have changed. While infants less than 6 months were still the most likely to be infected as they are not old enough to be fully vaccinated, incidence began increasing in children 7 to 10 years old, many of whom had been fully vaccinated, suggesting that the acellular vaccine DTaP, introduced in 1997 for the entire childhood series in response to concerns over serious side effects in some children after DTP, may not offer the duration of pro- tection seen with the whole-cell vaccine. Tdap (tetanus, reduced strength diphtheria, acellular pertussis) was licensed in 2005 as a booster for adults in place of their next tetanus vaccination and adolescents, with routine recommendation for immuniza- tion at 11 to 12 years. The reduction in rates in preteens 11 to 12 years old demonstrates immediate protection from Tdap, but increasing incidence in 13- to 14-year-olds suggests waning immunity with no durable protection. But while waning immu- nity may not be completely protective, evidence suggests that when infected, people who have been boostered will experience milder disease. While positive for those thus protected, this lack of symptoms may have the unintended consequence of making them excellent inapparent carriers. Nonetheless, vaccination with DTaP and Tdap continues to be recommended as the single most effective strategy in reducing illness and death from per- tussis. Pregnant women and close contacts to their babies are especially encouraged to be vaccinated in an effort to prevent disease in infants, the group most likely to experience severe complications and death. In addition to maintaining high rates of immunization, prevention efforts also included publicizing Tdap, increasing awareness of pertussis in adolescents and adults among providers, and promptly implementing treatment and control in the face of outbreaks (CDC, 2012b).
Because pertussis does have a cyclical pattern (there are peri- odic outbreaks such as those seen in California in 2010 and in Washington state as well as numerous other states across the country in 2012), it is important for nurses to work with the community to maintain the highest possible levels of immuni- zation coverage to minimize these occurrences. Because of the contagious nature of pertussis, nurses play a major role in limit- ing transmission during outbreaks by ensuring appropriate treatment of family members and close contacts. The Quality and Safety in Nursing Education box describes safety factors related to pertussis.
Influenza Influenza is a viral respiratory tract infection often indistin- guishable from the common cold or other respiratory diseases.
elimination is defined as the absence of continuous endemic transmission lasting ≥12 months. With the introduction of a vaccine in 1969, cases of rubella in the United States fell pre- cipitously from 57,686 to less than 10 cases per year 2003 and 2004 with a large percentage of the cases imported or import linked. By the beginning of 2005, at the 39th National Immu- nization Conference, the director of the CDC announced that rubella was no longer endemic in the United States. From 2005 through 2011, 67 rubella cases were reported as well as two rubella outbreaks involving three cases and four cases of CRS. Of these 67 cases, 28 cases (42%) were known importations. Elimination of endemic rubella was once again documented and verified in the United States in December 2011 (CDC, 2013d).
Rubella remains endemic in parts of the world, however, and because of international travel and countries without routine rubella vaccination, imported cases of rubella and CRS cases are possible. In 2012, WHO estimated 110,000 cases of CRS worldwide, many of them in Asia and Africa where vaccination coverage is lowest. WHO also reports that intensive and widespread rubella vaccination efforts have largely eliminated rubella and CRS in many developed and in some developing countries. The WHO Region of the Americas has had no endemic (naturally transmitted) cases of rubella infec- tion since 2009.
Unimmunized immigrants do not necessarily import disease, but their unimmunized status may leave them vulnerable to infection once they arrive. In addition to a focus on identifying and vaccinating foreign-born adults, the continued elimination of rubella and CRS in the United States will require (1) main- taining high immunization rates among children, (2) ensuring vaccination among women of child-bearing age, especially those who are foreign-born, (3) continuing aggressive surveil- lance, and (4) responding rapidly to any outbreak.
Pertussis Pertussis (whooping cough) begins as a mild upper respiratory tract infection progressing to an irritating cough that within 1 to 2 weeks may become paroxysmal (a series of repeated violent coughs). The repeated coughs occur without intervening breaths and can be followed by a characteristic inspiratory “whoop.” Pertussis is caused by the bacterium Bordetella pertus- sis and is transmitted via an airborne route through contact with infected droplets. It is highly contagious and considered endemic in the United States. Vaccination against pertussis, delivered in combination with diphtheria and tetanus, is a part of the routine childhood immunization schedule. Treatment of infected individuals with antibiotics such as erythromycin may shorten the period of communicability but does not relieve symptoms unless given early in the course of the infection. Prophylactic treatment with antibiotics is recommended for family members and close contacts of infected individuals, regardless of immunization status and age, if there is a child in the house under the age of 1 year or a woman in the last 3 weeks of pregnancy or to prevent ongoing transmission within the family. Infection with pertussis does not offer permanent immunity (Heymann, 2014).
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will be most prevalent that year. Because of the changing nature of the virus, yearly immunization is necessary and in the United States is given in early fall before the flu season begins. In recent history, if vaccine were available, immunization for seasonal flu was particularly recommended for children ages 6 months up to 19 years, pregnant women, people 50 years of age and older, people of any age with certain chronic medical conditions, people who live in nursing homes and other long-term care facilities, and people who live with or care for those at risk for complications from flu. During the 2009-2010 influenza season, pandemic novel influenza A H1N1 replaced other seasonal flu viruses as the predominantly circulating virus, and the recom- mended priority groups shifted from seniors to the young; high school students and pregnant women seemed particularly hard hit, whereas those over 65 appeared to perhaps have some degree of protection. For the 2010-2011 flu season, novel influ- enza A H1N1 was included in the vaccine and the ACIP recom- mended universal coverage for everyone ages 6 months and older (CDC, 2010b).
Flu immunizations, when matched appropriately with circu- lating virus strains, are estimated to provide 70% to 90% pro- tection against infection in healthy young adults; although they do not always prevent infection, they do result in milder disease symptoms. There are now a variety of vaccines available includ- ing one that is not grown in eggs for those with egg sensitivity and one that is administered nasally as a mist. Although influ- enza is often self-limiting in the healthy population, serious complications, particularly viral and bacterial pneumonias, can be deadly to older adults, children under 2 years of age, and those debilitated by chronic disease. When appropriate, it is important to couple influenza immunization of this population with immunization against pneumococcal pneumonia.
The use of influenza antiviral drugs should be considered in the nonimmunized or groups at high risk for complications. New evidence also suggests that antivirals can decrease the number of deaths in hospitalized influenza patients. The neur- aminidase inhibitors (oseltamivir, zanamivir) have activity against influenza A and B viruses, whereas the adamantanes (amantadine, rimantadine) have activity only against influenza A viruses. Since January 2006, the neuraminidase inhibitors have been the only recommended influenza antiviral drugs because of widespread resistance to the adamantanes among influenza A (H3N2) virus strains. There have been incidences, worldwide and in the United States, of H1N1 virus resistance to oseltamivir. Current guidelines indicate antiviral treatment should be guided by surveillance data on circulating viruses and confirmatory testing of viral subgroups. CDC annually pub- lishes Recommendations for Influenza Antiviral Medications (CDC, 2014g). (Read more about influenza at http://www.cdc .gov/flu/index.html.)
Healthy People 2020 targets increasing the proportion of the population vaccinated annually against influenza and pneumo- coccal disease. Nurses often spearhead influenza immunization campaigns that target older adults. Examples include conduct- ing flu clinics at polling places during elections or at commu- nity centers and churches during “senior vaccination Sundays.” Inhabitants of residences and nursing homes for older adults
Transmission is airborne and through direct contact with infected droplets. Unlike many viruses that do not survive long in the environment, the flu virus is thought to exist for many hours in dried mucus. Outbreaks are common in the winter and early spring in areas where people gather indoors such as in schools and nursing homes. Gastrointestinal and respiratory symptoms are common. Because symptoms do not always follow a characteristic pattern, many viral diseases that are not influenza are often called flu. The most important factors to note about influenza are its epidemic nature and the mortality that may result from pulmonary complications, espe- cially in older adults and children less than 2 years of age (Heymann, 2014).
There are three types of influenza viruses: A, B, and C. Type A is usually responsible for large epidemics, whereas outbreaks from type B are more regionalized; type C epidemics are spo- radic, less common, and usually result in only mild illness. Influenza viruses often change in the nature of their surface appearance or their antigenic makeup. Types B and C are fairly stable viruses, but type A changes constantly. Minor antigenic changes are referred to as antigenic drift, and they result in yearly epidemics and regional outbreaks. Major changes such as the emergence of new subtypes are called antigenic shift; these occur only with type A viruses. Antigenic shift and drift lead to epidemic outbreaks every few years and pandemic outbreaks every 10 to 40 years as seen with novel influenza A H1N1 in 2009. Mortality rates associated with epidemics may or may not be higher than those in nonepidemic situations.
The preparation of influenza vaccine each year is based on the best possible prediction of what type and variant of virus
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency-Safety Minimizes risk for harm to clients and providers through both system effective- ness and individual performance. Important aspects of safety include the following: • Knowledge: Discuss potential and actual impact of national client safety
resources, initiatives, and regulations. • Skills: Use national client safety resources for own professional develop-
ment and to focus attention on safety in care settings. • Attitudes: Value the relationship between national safety campaigns and
implementation to local practices and practice settings.
Safety Question: Pertussis With the focus of pertussis in the news how is it impacting your community?
Look into local statistics around pertussis occurrence. Has there been an increased occurrence of pertussis over the past 5 years?
How do your local statistics compare to national statistics for pertussis from the Centers for Disease Control and Prevention?
What might be some system approaches to educating your community about the risk of pertussis?
What might be some system approaches to providing pertussis vaccinations to the appropriate populations?
What data points will you want to track to assess whether your interventions have been effective?
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virus did not appear to prove overall any more frightening than seasonal flu and more vaccine came on the market, the available supply was more than enough for anyone who wished to be immunized. The delivery of the vaccine, in addition to seasonal flu vaccine, proved a planning and logistical challenge to the public health system, demanded considerable resources, and provided a valuable exercise in implementation of preparedness strategies. Nurses were at the forefront of this expansive opera- tion by planning for, scheduling, and immunizing—in a variety of community settings, schools, and clinics—a large portion of the population, including two doses to children. During the summer of 2009, novel H1N1 outbreaks extended the normal flu season far beyond the usual period and dominated reported circulating flu viruses from the Southern Hemisphere as well. Activity peaked at the end of October in the United States, but novel H1N1 continued into 2010 as the dominant circulating strain. Resistance to antiviral neuraminidase inhibitors was reported but remained low, and the vast majority of 2009 H1N1 viruses tested did not appear to change significantly, remaining related to the A/California/7/2009 H1N1 reference virus selected by WHO as the 2009 H1N1 vaccine virus. An H1N1 component was included in the 2010 seasonal vaccine (CDC, 2010c). H1N1 returned as the predominant strain seen during the 2013-2014 flu season.
Avian Influenza A (H5N1) In 1997 in Hong Kong, the first known cases of human illness associated with an avian influenza type A virus H5N1 were reported. Referred to in the press as Hong Kong bird flu, this virus appeared to have been transmitted to people through contact with infected poultry. As a result of this association, Hong Kong officials ordered the slaughter of all chickens in and around Hong Kong with a resulting halt in the spread of disease. No cases were reported outside Hong Kong and, despite recurring outbreaks of avian flu in poultry, no further H5N1 virus activity in humans was reported (CDC, 1998). This situation changed dramatically in late 2003 and early 2004 when H5N1 outbreaks occurred among poultry, people, and, in some cases, other animals in nine Asian countries. And unlike the earlier situation in Hong Kong, these outbreaks have not disappeared but only subsided to again reappear. As of the beginning of 2014, human infections with H5N1 have been reported from 16 different countries with some fatality rates as high as 70%. The largest numbers have been reported from Indonesia (195), Egypt (173), and Vietnam (125). Canada has reported one case. To date, there have not been any reports of highly pathogenic avian influenza H5N1 virus infections among wild birds, poultry, or other animals or humans in the United States.
An unanswered question is whether there are actually many more human cases than are identified because symptoms are not severe enough to recognize. Most of the reported cases have resulted from contact with infected poultry, but it is believed that a few cases of human-to-human transmission have occurred. So far, the documented spread from human to human has been rare and not sustained, but because influenza viruses have the ability to change, concern exists among scientists that
are at risk, since influenza can spread rapidly with severe con- sequences through such living arrangements. As with children, nurses should check immunization history and encourage immunization for every older adult encountered in a clinic or home visit.
But while children, the elderly, and those with health condi- tions that put them at high risk for complications have tradi- tionally been targets for immunizations, new strains of influenza such as H1N1 have more seriously affected young adults, leading to the recommendation that everyone over 6 months of age receive flu immunization. Nurses not only can promote this message, they can provide an example by choosing immuniza- tion as well. The CDC estimates that in the early flu season of 2013, 64% of health care providers were immunized against flu, and while this is higher than the general population (who were at closer to 40%), it is far from the Healthy People 2020 goal of 90%. When nurses get immunized against influenza, they are protecting not only themselves but their patients (CDC, 2014h).
Pandemic Novel Influenza A (H1N1) Novel influenza A H1N1, a new flu virus that quickly reached pandemic proportions, was first recognized in Mexico and the United States in the spring of 2009. Originally called swine flu, the virus is of swine origins but does not spread from swine to people. Instead, it is transmitted rapidly and easily from person to person and in some cases is suspected to have spread from humans to swine as well as other animals such as dogs, cats, and ferrets. Because the virus was new, the population lacked immu- nity and visitors to Mexico quickly became infected and carried it to people around the globe. By June of 2009 more than 70 countries had reported cases of novel H1N1 infection, and ongoing community-level outbreaks of novel H1N1 occurred in multiple parts of the world, prompting the WHO to declare a global pandemic. This action was a reflection of the spread of the new H1N1 virus, not the severity of illness caused by the virus.
Although novel H1N1 appeared to spread in the same manner as seasonal influenza viruses, the groups most affected were children, young adults (especially those with underlying chronic disease), and pregnant women, as opposed to seniors who are the usual targets of seasonal flu but were thought in this case to perhaps have some degree of immunity. Initial reports made it appear that the virus inflicted a high case fatality rate, but as surveillance strengthened and expanded, this did not prove to be the case; however, by the end of the year, pedi- atric deaths were higher than in previous years and pediatric hospitalizations higher than other age groups. The majority of 2009 novel H1N1 deaths occurred in people between the ages of 50 and 64 years of age, 80% of whom have had an underlying health condition (CDC, 2010c).
With the identification of the virus, the scramble was on for a vaccine, which became available in the fall of 2009 in limited doses and was initially targeted to priority groups, including those 6 months to 24 years of age, caretakers, infants less than 6 months of age, pregnant women, adults 25 to 64 years of age with chronic conditions, health care providers, and first responders. Initial demand for vaccine was high, but since the
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outbreaks were reported from all 50 states, Puerto Rico, and the District of Columbia. These outbreaks resulted in 29,444 cases of illness, 1,184 hospitalizations, and 23 deaths. Among the 790 outbreaks with a single laboratory-confirmed etiologic agent, norovirus was the most commonly reported, accounting for 42% of outbreaks, and Salmonella was second, accounting for 30% of outbreaks. Of the 653 outbreaks where a food source was identified, 299 were determined to originate from only one ingredient with the most outbreaks attributed to beef, fish, dairy, and poultry. The most illnesses were associated with eggs, followed by beef and poultry. Of organisms paired with food sources, the most outbreaks were from Campylobacter in unpas- teurized dairy, Salmonella in eggs, STEC O157 in beef, cigua- toxin in fish, and scombroid toxin (histamine fish poisoning) in fish, and the most outbreak-related illnesses by far resulted from Salmonella in eggs (2,231 illnesses) followed by Salmonella in sprouts (493) and Salmonella in vine-stalk vegetables such as tomatoes (422). The combinations responsible for the most hospitalizations were Salmonella in vine-stalk vegetables, STEC O157 in beef, and Salmonella in sprouts; those that caused the most deaths were STEC O157 in beef (three deaths), Salmonella in pork, and Listeria in dairy (two each). Thirty-eight multistate outbreaks were reported; twenty-one were caused by Salmonella (CDC, 2013e). (Learn more about the Foodborne Disease Outbreak Surveillance System at http://www.cdc.gov/foodborne burden/surveillance-systems.html.)
The ability to identify multistate outbreaks has been greatly enhanced through technology now routinely used in public health laboratories (serotyping and pulsed-field gel electropho- resis) and the rapid sharing of this information among public health officials through PulseNet, the national molecular sub- typing network for foodborne disease surveillance. Since 1996, this DNA fingerprinting has allowed the detection of thousands of individual and multistate outbreaks including people sick- ened from eating Salmonella contaminated peanut butter, tomatoes and cantaloupes, E. coli in leafy vegetables, and Vibrio parahaemolyticus in oysters. (Learn more about PulseNet at http://www.cdc.gov/pulsenet/index.html.)
The CDC recommends three goals in achieving food safety: (1) control or eliminate pathogens in domestic and imported food, (2) reduce or prevent contamination during growing, harvesting, and processing, and (3) continue the education of restaurant workers and consumers about risks and prevention measures. Also noted is the need for continued efforts to understand how contamination of fresh produce and pro- cessed foods occurs and to develop and implement measures that reduce it.
Foodborne illness, or “food poisoning,” as it is erroneously but commonly called, is often categorized as either food infec- tion or food intoxication. Food infection results from bacterial, viral, or parasitic infection of food by pathogens such as Salmo- nella, Campylobacter, hepatitis A, Toxoplasma, and Trichinella. Food intoxication is caused by toxins produced by bacterial growth, chemical contaminants (heavy metals), and a variety of disease-producing substances found naturally in certain foods such as mushrooms and some seafood. Examples of food intoxications are botulism, mercury poisoning, and paralytic
H5N1 may modify to the point where people could easily infect each other; also, because H5N1 does not usually infect humans, they would have little immune protection. Such a change could give rise to pandemic influenza with a virus that appears to exact a high toll in human lives. Given this possibility, surveil- lance becomes of utmost importance and close attention is paid to H5N1 virus activity among poultry and humans in Asia, Europe, and North Africa. Vaccine development efforts are underway and, although licensed in some countries, are not yet generally available (CDC, 2014i).
FOODBORNE AND WATERBORNE DISEASES In recent years attention has focused on stories related to food- borne illness associated with peanut butter, cookie dough, spinach, lettuce, tomatoes, chili peppers, strawberries, raspber- ries, oysters, uncooked eggs, poultry and hamburger, raw milk, unpasteurized apple cider, and so forth. Cans of beef stew sus- pected to be contaminated with botulism have been pulled off grocery store shelves and the term mad cow disease has entered the popular vocabulary. Recalls of food products have become a common occurrence. Highly centralized food production and processing systems that use food produced in far-reaching areas and distribute it through widespread distribution networks increase the potential for any contamination to result in large- scale, multistate outbreaks. One incident of contamination may affect hundreds of people across the country and result in numerous deaths. Anyone can acquire foodborne illness, regardless of socioeconomic status, race, sex, age, occupation, education or area of residence, but the very young, old, and debilitated are most susceptible and bear the highest burden of morbidity and mortality.
In 2010, the CDC developed new lower than previously esti- mated but more precise estimates for foodborne illness suggest- ing that in the United States, as many as 1 in 6 Americans (or 48 million people) gets sick, 128,000 are hospitalized, and 3,000 die from foodborne illnesses each year, most the result of unidentified agents (CDC, 2010d). Known pathogens cause an estimated 9.4 million foodborne illnesses annually in the United States (Scallan et al, 2011). Because their presentations are often not clinically distinctive and frequently self-limiting, single cases of foodborne illness may be difficult to identify. Affected individuals in single cases or in outbreak situations may not see a physician or are treated presumptively and not tested. In either case, the illness goes unreported, resulting in statistics that underestimate the true magnitude of the problem.
FoodNet is a CDC sentinel surveillance system targeting 10 sites across the country and collecting information from labo- ratories on disease caused by enteric pathogens transmitted commonly through food. It is a collaborative effort among CDC, the U.S. Department of Agriculture (USDA), and the FDA. In 2011 FoodNet reported 18,964 laboratory-diagnosed cases of infection, the majority caused by Salmonella, Campy- lobacter, and Shigella (CDC, 2012c).
Confirmed foodborne outbreaks are reported by states to the CDC through the Foodborne Disease Outbreak Surveillance System. During 2009-2010, a total of 1,527 foodborne disease
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Causal Agent Incubation Period Duration Clinical Presentation Associated Food
Staphylococcus aureus 30 min to 7 hr 1-2 days Sudden onset of nausea, cramps, vomiting, and prostration, often accompanied by diarrhea; rarely fatal
All foods, especially those likely to come into contact with food-handlers’ hands that may be contaminated from infections of the eyes and skin
Clostridium perfringens (strain A)
6-24 hr 1 day or less Sudden onset of colic and diarrhea, maybe nausea; vomiting and fever unusual; rarely fatal
Inadequately heated meats or stews; food contaminated by soil or feces becomes infective when improper storage or reheating allows multiplication of organism
Vibrio parahaemolyticus 4-96 hr 1-7 days Watery diarrhea and abdominal cramps; sometimes nausea, vomiting, fever, headache; rarely fatal
Raw or inadequately cooked seafood; period of time at room temperature usually required for multiplication of organism
Clostridium botulinum 12-36 hr, sometimes days Slow recovery, maybe months
Central nervous system signs; blurred vision, difficulty in swallowing and dry mouth, followed by descending symmetrical flaccid paralysis in an alert person; “floppy baby” in infant; fatality <15% with antitoxin and respiratory support
Home-canned fruits and vegetables that have not been preserved with adequate heating; infants have become infected from ingesting honey
TABLE 13-4 Commonly Encountered Food Intoxications
Based on information from Heymann DL, editor: Control of communicable diseases manual, ed 20, Washington, DC, 2014, American Public Health Association.
shellfish poisoning. Table 13-4 presents some of the most common agents of food intoxication and their incubation period, source, symptoms, and pathology. Although it is not a hard-and-fast rule, food infections are associated with incuba- tion periods of 12 hours to several days after ingestion of the infected food, whereas intoxications become obvious within minutes to hours after ingestion. Botulism is a clear exception to this rule, with an incubation period up to several days or more in adults. Possessing a potent preformed toxin, capable of producing severe intoxication resulting in flaccid paralysis and death if not identified and treated early, C. botulinum is one of the organisms considered a strong candidate for a weapon of bioterrorism (Heymann, 2014).
The Role of Safe Food Preparation Protecting the nation’s food supply from contamination by virulent microbes is a multifaceted issue that is and will con- tinue to be incredibly costly, controversial, and time-consuming to address. The specter of terrorist threats to the food supply adds an additional layer of complexity. However, much food- borne illness, regardless of causal organism, can easily be pre- vented through simple changes in food preparation, handling, and storage. Common errors include (1) cross-contamination of food during preparation, (2) insufficient cooking or reheat- ing temperatures, (3) holding cooked food or storing food at temperatures that promote growth of pathogens and/or forma- tion of toxins, and (4) poor personal hygiene. Because these measures are so important in preventing foodborne disease, Healthy People 2020 has continued to include an objective directed toward them. WHO estimates that 2.2 million people, 1.9 million of them children, die annually from foodborne and waterborne diarrheal diseases in less-developed countries. In 2001 WHO released a new campaign entitled Five Keys to Safer Food, which reduces the former Ten Golden Rules for Food
Preparation developed in the early 1990s to five even simpler and easier to remember principles (presented in Box 13-4). A poster explaining the Five Keys is available in 25 languages and is accompanied by a training manual titled Bring Food Safety Home (Heymann, 2014). (Read more about the Five Keys at the WHO website: http://www.who.int/foodsafety/consumer/5keys/ en/index.html.)
Salmonellosis Salmonellosis is a bacterial disease characterized by sudden onset of headache, abdominal pain, diarrhea, nausea, some- times vomiting, and almost always fever. Onset is typically within 48 hours of ingestion, but the clinical signs are impos- sible to distinguish from other causes of gastrointestinal dis- tress. Diarrhea and lack of appetite may persist for several days, and dehydration may be severe. Although morbidity can be significant, death is uncommon except among infants, older adults, and the debilitated. The rate of infection is highest among infants and small children. It is estimated that only a small proportion of cases are recognized clinically and that only 1% of clinical cases are reported. The number of
1. Keep food clean. 2. Separate raw and cooked food. 3. Cook thoroughly. 4. Keep food at safe temperatures. 5. Use safe water and raw materials.
BOX 13-4 WHO Five Keys to Safer Food
From the World Health Organization: Five Keys to Safer Food campaign. 2009b, WHO. Available at http://www.who.int/foodsafety/ consumer/5keys/en. Accessed March 25, 2010; Heymann DL, editor: Control of communicable diseases manual, ed 19. Washington, DC, 2008, American Public Health Association.
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all bacteria. Tracking the contamination is complicated by the fact that hamburger is often made of meat ground from several sources. The best protection against this pathogen, as with most foodborne agents, is to thoroughly cook food before eating it.
WATERBORNE DISEASE OUTBREAKS AND PATHOGENS Waterborne pathogens usually enter water supplies through animal or human fecal contamination and frequently cause enteric disease. They include viruses, bacteria, and protozoans. Hepatitis A virus is probably the most publicized waterborne viral agent, although other viruses may also be transmitted by this route (enteroviruses, rotaviruses, and paramyxoviruses). The most important waterborne bacterial diseases are cholera, typhoid fever, and bacillary dysentery. However, other Salmo- nella spp. as well as Shigella, Vibrio, and Campylobacter species and various coliform bacteria including E. coli 0157:H7 may be transmitted in the same manner. Recently, since added to sur- veillance in 2001, Legionella spp. have frequently been impli- cated in waterborne disease outbreaks (WBDOs) in the United States. In the past, the most important waterborne protozoans have been Entamoeba histolytica (amebic dysentery) and Giardia lamblia, but major outbreaks of cryptosporidiosis in municipal water, as seen in the diarrheal outbreak that crippled the city of Milwaukee in 1993, have pushed Cryptosporidium into the debate over how to best safeguard municipal water supplies. Protozoans do not respond to traditional chlorine treatment as do enteric and coliform bacteria, and their small size requires special filtration.
The CDC defines a WBDO as an incident in which two or more persons experience similar illness after consuming water that epidemiologic evidence implicates as the source of that illness. Recreational water and other water not intended for drinking as well as drinking water may be involved in water- borne outbreaks. Facilities with inadequate chlorination and pools allowing diapered children pose particular risk for infec- tion, as does drinking water without adequate disinfection while hiking and camping in the backcountry.
Since 1971, the CDC, the U.S. Environmental Protection Agency (EPA), and the Council of State and Territorial Epide- miologists have maintained a collaborative Waterborne Disease and Outbreaks Surveillance System for collecting and reporting data related to occurrences and causes of waterborne disease and outbreaks. This surveillance system is the primary source of data concerning the scope and effects of WBDOs in the United States. The CDC and the EPA, to improve timeliness and completeness of reporting, are collaborating with public health jurisdictions to implement electronic reporting through the National Outbreak Reporting System (NORS) (CDC, 2013f ).
VECTORBORNE DISEASES Vectorborne diseases refer to illnesses for which the infectious agent is transmitted by a carrier, or vector, which is usually an arthropod (mosquito, tick, fly), either biologically or mechani- cally. With biological transmission, the vector is necessary for
Salmonella infections yearly may actually be in the millions (Heymann, 2014).
Outbreaks occur commonly in restaurants, hospitals, nursing homes, and institutions for children. The transmission route is eating food derived from an infected animal or contaminated by feces of an infected animal or person. Unchlorinated munici- pal water supplies have also been implicated in Salmonella out- breaks. Raw or undercooked meat and meat products, raw or undercooked poultry, uncooked eggs, unpasteurized milk and dairy products, and contaminated produce are the foods most often associated with salmonellosis. Recent large outbreaks have been linked with eating tomatoes, jalapeño peppers, and peanut butter. Meat and poultry may be contaminated during prepara- tion or cross-contaminate food being prepared with them. Improper food preparation temperatures (cooking and holding) and cross-contamination appear to be the biggest risk factors for food-associated outbreaks. Animals are the common reser- voir for the various Salmonella serotypes, although infected humans may also fill this role. Animals are more likely to be chronic carriers. Reptiles such as iguanas have been implicated as Salmonella carriers along with pet turtles, poultry, cattle, swine, rodents, dogs, and cats. People have also been infected by handling Salmonella-contaminated dry dog food and treats. Person-to-person transmission is an important consideration in daycare and institutional settings (Heymann, 2014).
Enterohemorrhagic Escherichia coli (EHEC or E. coli 0157:H7) Escherichia coli 0157:H7 belongs to the enterohemorrhagic cat- egory of E. coli serotypes producing a strong cytotoxin called a Shiga toxin and are collectively known as Shiga toxin–producing E. coli (STEC). E. coli serotypes in this group can cause a poten- tially fatal hemorrhagic colitis. This pathogen was first widely described in humans in 1992 following the investigation of two outbreaks of illness associated with consumption of hamburger from a fast-food restaurant chain. Transmission is through ingestion of food contaminated by infected feces. Ruminants, particularly cattle, are the most important reservoir, although humans may also serve as a source for person-to-person trans- mission. Undercooked hamburger has been implicated in several outbreaks, as have roast beef, alfalfa sprouts, melons, lettuce, uncooked spinach, unpasteurized milk and apple cider, municipal water, and person-to-person transmission in daycare centers, homes, and institutions. Recent large outbreaks have been associated with uncooked spinach and petting zoos. Infec- tion with E. coli 0157:H7 causes bloody diarrhea, abdominal cramps, and, infrequently, fever. Children and older adults are at highest risk for clinical disease and complications. Hemolytic uremic syndrome (HUS) is seen in approximately 15% of cases among children and a smaller number of adults and may result in acute renal failure. The case fatality rate for infection that results in HUS can be as great as 5% (Heymann, 2014).
Hamburger often appears to be involved in outbreaks because the grinding process exposes pathogens on the surface of the whole meat to the interior of the ground meat, effectively mixing the once-exterior bacteria thoroughly throughout the hamburger so that searing the surface no longer suffices to kill
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or preceded by fever, fatigue, malaise, headache, muscle pains, and a stiff neck, as well as tender and enlarged lymph nodes and migratory joint pain. Most clients diagnosed in this early stage respond well to 10 to 14 days of oral tetracycline or penicillin.
If not treated during this first stage, Lyme disease can prog- ress to stage II, which may include additional skin lesions, head- ache, and neurologic and cardiac abnormalities. Clients who progress to stage III have recurrent attacks of arthritis and arthralgia, especially in the knees, which may begin months to years after the initial lesion. The clinical diagnosis of classic Lyme disease with the distinctive skin lesion is straightforward. Illness without the lesion is more difficult to diagnose, because serologic tests are more accurate in stages II and III than in stage I (Heymann, 2014).
Rocky Mountain Spotted Fever Contrary to its name, Rocky Mountain spotted fever (RMSF) is seldom seen in the Rocky Mountains and most commonly occurs in the southeast, Oklahoma, Kansas, and Missouri. The infectious agent is R. rickettsii. The tick vector varies according to geographic region. The dog tick, Dermacentor variabilis, is the vector in the eastern and southern United States. RMSF is not transmitted from person to person. It is thought that one attack confers lifelong immunity.
Clinical signs include sudden onset of moderate to high fever, severe headache, chills, deep muscle pain, and malaise. About 50% of cases experience a rash on the extremities that spreads to most of the body. Many cases of what has been referred to as “spotless” RMSF may actually be caused by recently identified forms of human ehrlichiosis, another tick- borne infection. RMSF responds readily to treatment with tet- racycline. Definitive diagnosis can be made with paired serum titers. Because early treatment is important in decreasing mor- bidity and mortality, treatment should be started in response to clinical and epidemiologic considerations rather than waiting for laboratory confirmation (Heymann, 2014).
Prevention and Control of Tickborne Diseases In Healthy People 2020, the HP2010 objective for reducing Lyme disease has been archived because of lack of proven interven- tions to prevent transmission. A vaccine for Lyme disease, rec- ommended for use by persons living in high-risk areas, was licensed in 1998; however, in 2002 the manufacturer withdrew it from the commercial market because of low demand and sales. Measures for preventing exposure to ticks include reduc- ing tick populations, avoiding tick-infested areas, wearing pro- tective clothing when outdoors (long sleeves and long pants tucked into socks), using repellants, and immediately inspecting for and removing ticks when returning indoors. The CDC reports that landscaping modifications such as removing brush and leaf litter or creating a buffer zone of wood chips or gravel between yard and forest may reduce exposure to ticks as well as appropriate pesticide application to lawns. Ticks require a pro- longed period of attachment (6 to 48 hours) before they start blood-feeding on the host; prompt tick discovery and removal can help prevent transmission of disease. Ticks should be removed with steady, gentle traction on tweezers applied to the
the developmental stage of the infectious agent. Examples include the mosquitoes that carry WNV and the fleas that trans- mit plague. Mechanical transmission occurs when an insect simply contacts the infectious agent with its legs or mouth parts and carries it to the host. For example, flies and cockroaches may contaminate food or cooking utensils. Most vector borne diseases involve zoonotic cycles requiring some sort of animal host or reservoir.
Vectorborne diseases commonly encountered in the United States are those associated with ticks, such as Lyme disease (Borrelia burgdorferi), Rocky Mountain spotted fever (Rickettsia rickettsii), ehrlichiosis (Ehrlichiae), and anaplasmosis (Ana- plasma phagocytophilum), formerly known as human granulo- cytic ehrlichiosis. Nurses who work with large immigrant populations or with international travelers may encounter malaria and dengue fever, both carried by mosquitoes. More recently in the news, WNV is an example of endemic mosquito- borne viruses that include St. Louis, LaCrosse, and western and eastern equine encephalitis. Plague (Y. pestis) is carried by fleas of wild rodents. Other more rarely seen tick-associated diseases include babesiosis (Babesia microti), tularemia (F. tularensis), and Q fever (Coxiella burnetii). Southern tick-associated rash illness (STARI) is a newly described illness for which the caus- ative organism has not been determined. STARI resembles Lyme disease in appearance but does not result in the neuro- logic, arthritic, and other chronic conditions seen with Lyme disease. It is mainly found in the southeast and is associated with the bite of the Lonestar tick (Amblyomma americanum) (CDC, 2011b) and ticks (CDC, 2014j).
Lyme Disease Parents in Lyme, CT, concerned about the unusual incidence of juvenile rheumatoid arthritis in their children, were the first to bring attention to this tick borne infection that now bears their town’s name. First described in 1975, Lyme disease became a nationally notifiable disease in 1991 and is now the most common vector borne disease in the United States, with over 30,000 confirmed cases and probable cases reported to CDC in 2012. However, new studies suggest that the actual number of diagnosed cases may be as many as 10 times that number, making Lyme disease a major public health problem and with an urgent need for improved prevention (Kuehn, 2013). The causative agent, the spirochete B. burgdorferi, was identified in 1982. Lyme disease is transmitted by ixodid ticks that are associ- ated with white-tailed deer (Odocoileus virginianus) and the white-footed mouse (Peromyscus leucopus). Lyme disease usually occurs in summer during tick season and it has been reported throughout the United States, with 95% of cases concentrated in rural and suburban areas of the northeast, mid-Atlantic and north-central states, particularly Wisconsin and Minnesota.
The clinical spectrum of Lyme disease can be divided into three stages. Stage I is characterized by erythema chronicum- migrans, a distinctive skin lesion often called a bull’s-eye lesion because it begins as a red area at the site of the tick attachment that spreads outward in a ring-like fashion as the center clears. About 50% to 70% of infected persons develop this lesion 3 to 30 days after a tick bite. The skin lesion may be accompanied
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the mosquitoes breed. Malaria is an old disease that appears in recorded history in 2700 bc China. Although no longer endemic in most temperate countries, malaria is the most prev- alent vector borne disease worldwide, occurring in over 100 countries and territories. Half of the world’s population is con- sidered at risk; 90% of cases occur in Africa. Malaria is the fifth-leading cause of infectious disease death worldwide and the second-leading cause of infectious disease death (after HIV disease) in Africa. There is no vaccine available to protect against this disease, which in 2012 resulted in an estimated 207 million cases and 627,000 deaths, most in the Africa Region. The WHO reports malaria mortality rates have fallen by 42% globally since 2000, and by 49% in the WHO African Region. This move in a positive direction is attributed to international funding for bed net campaigns and increased access to treat- ment (WHO, 2014c).
Malaria prevention depends on protection against mosqui- toes and appropriate chemoprophylaxis. Drug resistance is an increasing problem in combating malaria. Of the four Plasmo- dium species causing human malaria, P. ovale and P. vivax result in disease that can progress to relapsing malaria and P. vivax is increasingly drug resistant. P. falciparum causes the most serious malarial infection and is highly drug resistant. Thus decisions about antimalarial drugs must be tailored individually on the basis of the type of malaria in the specific area of the country to be visited, the purpose of the trip, and the length of the visit. The CDC and the WHO publish guides on the status of malaria and recommendations for prophylaxis on a country-by- country basis. At this time, there is no one drug or drug com- bination known to be safe and efficacious in preventing all types of malaria. Antimalarials are generally started a week to several weeks before leaving the country and are continued for 4 to 6 weeks after returning.
Despite appropriate prophylaxis, malaria may still be con- tracted. Travelers should be advised of this fact and urged to seek immediate medical care if they exhibit symptoms of cycli- cal fever and chills up to 1 year after returning home. Immi- grants and visitors from areas where malaria is endemic may become clinically ill after entering the United States. Approxi- mately 1500 cases of malaria in travelers and immigrants are reported in the United States every year. Also, although malaria is eliminated from the United States, the mosquito vectors are not, so local cases still can occur if these vector mosquitoes bite people infected outside the country. From 1957 to 2011, 63 outbreaks of locally transmitted mosquito-borne malaria have been reported in the United States. In these outbreaks, local mosquitoes become infected by biting persons carrying malaria parasites (acquired in endemic areas) and then transmit malaria to local residents. From 1963 to 2011, 97 individuals have acquired malaria through blood transfusions (CDC, 2014k). (For more information about malaria in the United States as well as worldwide, visit the malaria homepage at the CDC website: http://www.cdc.gov/malaria/.)
Foodborne and Waterborne Diseases As in the United States, much foodborne disease abroad can be avoided if the traveler eats thoroughly cooked foods prepared
head parts of the tick. The tick’s body should not be squeezed during the removal process to avoid infection that could be transmitted from resultant tick feces and tissue juices (Heymann, 2014). When outdoors, permethrin sprayed on clothing and tick repellents on bare skin containing 20% to 30% diethyl- toluamide (DEET) can offer effective protection; use of DEET should be avoided on children less than 2 years of age because of reports of significant toxicity, including skin irritation, ana- phylaxis, and seizures. Read more about tick-associated diseases at the CDC website (http://www.cdc.gov/ticks/index.html) and the prevention of tick-associated diseases on the Lyme Disease Resources CDC website, which includes handouts that can be ordered and the Handbook on Tick Management produced by the state of Connecticut (http://www.cdc.gov/ncidod/dvbid/ Lyme/ld_resources.htm) (CDC, 2014j).
DISEASES OF TRAVELERS Individuals traveling outside the United States need to be aware of and take precautions against potential diseases to which they may be exposed. Which diseases and what precautions to take depend on the individual’s health status, the destination, the reason for travel, and the length of travel. Persons who plan to travel in remote regions for an extended period may need to consider rare diseases and take special precautions that would not apply to the average traveler. Consultation with public health officials can provide specific health information and rec- ommendations for a given situation. Nurses often staff public health travel clinics and provide this information based on CDC recommendations. The CDC offers information for both medical professionals and travelers at their Travelers’ Health webpage including the Yellow Book, CDC Health Information for International Travel, which in addition to being available online, can be ordered in hardcopy or accessed from mobile devices. (To read more about Travelers’ Health and the Yellow Book, see http://wwwnc.cdc.gov/travel/page/yellowbook-home -2014.)
On return from visiting exotic places, travelers may bring back with them an unplanned souvenir in the form of disease. Therefore, in a presenting client, it is important to ask about a history of travel. Even the apparently healthy returned traveler, especially one who was in a tropical country for some time, should undergo routine screening to rule out acquired infec- tions. Likewise, refugees and immigrants may arrive with infec- tious disease problems ranging from helminthic infections to diseases of major public health significance, such as TB, malaria, cholera, HIV disease, and hepatitis. Nurses may find themselves dealing with these diseases, since refugees and immigrants, especially the undocumented, are often treated through the public health system.
Malaria Caused by the bloodborne parasite Plasmodium, malaria is a potentially fatal disease characterized by regular cycles of fever and chills. Transmission is through the bite of an infected Anopheles mosquito. The word malaria is based on an associa- tion between the illness and the “bad air” of the marshes where
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rabies (family Rhabdoviridae, genus Lyssavirus). Many of the emerging infectious diseases such as avian influenza A H5N1, WNV, monkey pox, hantavirus pulmonary syndrome, and variant Creutzfeldt-Jakob disease are examples of zoonoses. Also, among the diseases considered best candidates for weapons of bioterrorism, anthrax, plague, tularemia, and some of the hemorrhagic fever viruses (e.g., Lassa) are all zoonoses. The CDC estimates that 75% of recently emerging infectious dis- eases affecting humans are diseases of animal origin and that approximately 60% of all human pathogens are zoonotic.
Rabies (Hydrophobia) One of the most feared of human diseases, rabies has the highest case fatality rate of any known human infection, essen- tially 100%. Despite the availability of intensive medical care, only six individuals have been known to recover after the onset of rabies, three in the United States, and only one survivor who did not receive pre-exposure or postexposure prophylaxis (PEP) has been reported (CDC, 2012d). A significant public health problem worldwide with as many as 50,000 deaths a year, mostly in developing countries, rabies in humans in the United States is a rare event because of the widespread vaccina- tion of dogs begun in the 1950s. Today, the major carriers of rabies in the United States are not dogs but wild animals— raccoons, skunks, foxes, coyotes, and bats. Small rodents, rabbits and hares, and opossums rarely carry rabies. Epidemio- logic information should be consulted for information on the potential carriers for a given geographic region. When the virus spreads from wild to domestic animals, cats are often involved. Of the 31 human cases of rabies reported in the United States from 2003 through June 2013, 36% were acquired outside the continental United States. Domestically acquired cases were largely associated with insectivorous bats (85%) and raccoons (15%). However, five of these domestic cases occurred not through direct contact but as the result of organ trans- plant. Cases contracted outside the United States most com- monly resulted from the bites of infected dogs (82%), with one fox and one bat exposure (Dyer et al, 2013). Rabies is transmit- ted to humans by introducing virus-carrying saliva into the body, usually via an animal bite or scratch. Transmission may also occur if infected saliva comes into contact with a fresh cut or intact mucous membranes. Rabies is found in neural tissue and is not transmitted via blood, urine, or feces. Airborne transmission has been documented in caves with infected bat colonies. Transmission from human to human is theoretically possible but has not been documented except through trans- plant organs harvested from individuals who died of undiag- nosed rabies. Guidelines for organ donation exist to minimize this possibility (Heymann, 2014).
The best protection against rabies remains vaccinating domestic animals—dogs, cats, cattle, and horses. If a person is bitten, the bite wound should be thoroughly cleaned with soap and water and a physician consulted immediately. Be suspicious of bites from a wild animal or an unprovoked attack from a domestic animal. Even when there is no suspicion of rabies, contact a physician because tetanus or antibiotic prophylaxis may be needed. An estimated 23,000 people per year require
with reasonable hygiene; eating foods from street vendors may not be a good idea. Trichinosis, tapeworms, and fluke infections, as well as bacterial infections, result from eating raw or under- cooked meats. Raw vegetables may act as a source of bacterial, viral, helminthic, or protozoal infection if they have been grown with or washed in contaminated water. Fruits that can be peeled immediately before eating, such as bananas, are less likely to be a source of infection. Dairy products should be pasteurized and appropriately refrigerated.
Water in many areas of the world is not potable (safe to drink), and drinking this water can lead to infection with a variety of protozoal, viral, and bacterial agents including amoebae, Giardia, Cryptosporidium, hepatitis, cholera, and various coliform bacteria. Unless traveling in an area where the piped water is known to be safe, only boiled water (boiled for 1 minute), bottled water, or water purified with iodine or chlo- rine compounds should be consumed (CDC, 2013g). Ice should be avoided because freezing does not inactivate these agents. If the water is questionable, choose coffee or tea made with boiled water, carbonated beverages without ice, beer, wine, or canned fruit juices.
Diarrheal Diseases Travelers often suffer from diarrhea, so much so that colorful names, such as Montezuma’s revenge, turista, and Colorado quickstep, exist in our vocabulary to describe these bouts of intestinal upset. Some of these diarrheas do not have infectious causes; they result from stress, fatigue, schedule changes, and eating unfamiliar foods. Acute infectious diarrheas are usually of viral or bacterial origin. E. coli probably causes more cases of traveler’s diarrhea than all other infective agents combined. Protozoan-induced diarrheas such as those resulting from Ent- amoeba and Giardia are less likely to be acute, and they more commonly present once the traveler returns home. Travelers need to pay special attention to what they eat and drink. (Read more about travelers’ health at the CDC website: http:// www.cdc.gov/travel/.)
ZOONOSES A zoonosis is an infection transmitted from a vertebrate animal to a human under natural conditions. The agents that cause zoonoses do not need humans to maintain their life cycles; infected humans have simply managed somehow to get in their way. Means of transmission include animal bites (bats and rabies), inhalation (rodent excrement and hantavirus), inges- tion (milk and listeriosis), direct contact (rabbit carcasses and tularemia), and arthropod intermediates. This last trans- mission route means that many vector borne diseases are also zoonoses. For example, white-tailed deer harbor ticks that can carry Lyme disease, and rats and ground squirrels may be infested with fleas capable of transmitting plague. Other than vector borne diseases, some of the more common zoonoses in the United States include toxoplasmosis (Toxoplasma gondii), cat-scratch disease (Bartonella henselae), brucellosis (Brucella species), leptospirosis (Leptospira interrogans), listeriosis (Liste- ria monocytogenes), salmonellosis (Salmonella serotypes), and
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factors are tropical climate and inadequate prevention and control measures. Poor sanitation, a lack of cheap and effective drugs, and a scarcity of funding lead to high reinfection rates even when control programs are attempted. Parasitic organisms result in a wide spectrum of diseases including leading causes of death and disability in Africa, Asia, Central America, and South America. Examples include malaria, guinea worm disease, river blindness (onchocerciasis), leishmaniasis, amoebiasis, African sleeping sickness, Chagas’ disease, schistosomiasis, and lymphatic filariasis. These parasitic diseases not only cause major mortality in endemic regions but also tremendous mor- bidity. Debilitation from infection may result in an inability to attend school or work as well as growth retardation, develop- mental disabilities, and cognitive impairment in young chil- dren, all of which contribute to significant economic burden for the countries affected.
Parasitic infections also affect persons living in developed countries. In the United States parasitic organisms frequently cause foodborne and waterborne diarrheal illness (Giardia, Entamoeba, Cryptosporidia) and sexually transmitted infections (Trichomonas), and they pose a particular problem for immuno- deficient individuals (Cryptosporidia, Toxoplasma, Cyclospora). Trichomoniasis is a common, easily treated with antibiotics, sexually transmitted disease caused by the protozoan parasite Trichomonas vaginalis. An estimated 3.7 million people are estimated to be infected but only 30% may show symptoms (CDC, 2012e). Giardiasis is a diarrheal illness caused by the
PEP after being in contact with potentially rabid animals (Christian et al, 2009).
No successful treatment exists for rabies once symptoms appear, but if given promptly and as directed, PEP with human rabies immunoglobulin (RIG) and rabies vaccine can prevent the development of the disease. Three products are licensed for use as rabies vaccine in the United States: human diploid cell vaccine (HDCV), purified chick embryo cell culture vaccine (PCECV), and rabies vaccine adsorbed (RVA); only HDCV and PCECV are available for use in the United States (CDC, 2008a). In 2010, the previously recommended series of five 1-mL doses of vaccine injected into the deltoid muscle was changed to four (CDC, 2010e). Reactions to the vaccine are fewer and less serious than with previously used vaccines. Individuals who deal frequently with animals, such as zookeepers, laboratory workers, and veterinarians, may choose to receive the vaccine as pre-exposure prophylaxis. The decision to administer the vaccine to a bite victim depends on the circumstances of the bite and is made on an individual basis.
The Compendium of Animal Rabies Prevention and Control compiled by the National Association of State Public Health Veterinarians, Inc. gives recommendations for prevention of and vaccination for rabies in animals. Recommendations for administering PEP are provided by the Advisory Committee for Recommendations on Immunization Practices and are available through local public health officials or the CDC. In general, cats and dogs that have bitten someone and have verified rabies vaccinations are confined for 10 days for observation. Treat- ment is initiated only if signs of rabies are observed during this period. If the animal is known or suspected to be rabid, treat- ment begins immediately. If the animal is unknown to the victim and escapes, public health officials should be consulted for help in deciding whether treatment is indicated. With wild animal bites, treatment is begun immediately. With bites from livestock, rodents, and rabbits, treatment is considered on an individual basis. Decisions to treat become more complicated for possible nonbite exposure to saliva from known infected animals, and again public health officials are helpful in making these treatment decisions (CDC, 2011c).
PARASITIC DISEASES Parasites are organisms that depend on a host to survive. Endo- parasites, those that live within the body, are classified into four major groups: nematodes (roundworms), cestodes (tape- worms), trematodes (flukes), and protozoa (single-celled animals). Nematodes, cestodes, and trematodes are all referred to as helminths along with acanthocephalins or thorny-headed worms, which are not as commonly involved in human infec- tions. Table 13-5 presents examples of relatively common dis- eases caused by parasites from these groups. Parasites that remain on the surface of a host’s body to feed rather than within it such as ticks, fleas, lice, and mites that attach or burrow into the skin are called ectoparasites. Many parasitic infections are vector borne and/or zoonotic.
Parasitic diseases are more prevalent in rural areas of low- income countries than in the United States. Contributing
Category Parasite Disease
Cestodes Taeniasaginata, Taeniasolium
Beef tapeworm, pork tapeworm
Nematodes Ancylostoma, Necator Ancylostomiasis, necatoriasis (hookworm)
Intestinal Ascaris, Toxocara Ascariasis, toxocariasis (roundworm)
Enterobius vermicularis Enterobiasis (pinworm) Trichuris trichiura Trichuriasis (whipworm)
Blood/Tissue Drancunculiasis medinensis Guinea worm Onchocerca volvulus Onchoserciasis (river
blindness) Wuchereria bancrofti Lymphatic filariasis
(elephantiasis) Trematodes Schistosoma sp. Schistosomiasis (snail
fever) Protozoans Entamoeba histolytica Amebiasis
Giardia lamblia Giardiasis Leishmania spp. Leishmaniasis Plasmodium spp. Malaria Toxoplasma gondii Toxoplasmosis Trichomonas vaginalis Trichomoniasis Trypanosoma spp. African sleeping sickness,
Chagas’ disease
TABLE 13-5 Examples of Diseases Resulting from Endoparasitic Infection by Category
Based on information from Heymann DL, editor: Control of communicable diseases manual, ed 20, Washington, DC, 2014, American Public Health Association.
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Parasitic Opportunistic Infections Opportunistic infections (OIs) are infections that occur more frequently or more severely in individuals immunocompro- mised by HIV infection. Before the introduction of routine prophylactic treatment and potent-combination, highly active antiretroviral therapies (ARTs) in the 1990s, OIs were the leading cause of illness and death in this group. Some of the protozoan parasitic OIs seen in clients with HIV disease and others who are immunocompromised include PCP; cryptospo- ridiosis, microsporidiosis and isosporiasis, all producing diar- rheal disease and transmitted by fecal–oral contact; and toxoplasmosis. With the advent of ARTs, the incidence of OIs in American HIV disease clients has dropped dramatically. Isosporiasis was always rare, but the rates for cryptosporidiosis and microsporidiosis have also declined markedly. Although no longer seen with the frequency of the past, toxoplasmosis and PCP have not disappeared. OIs are more likely to appear in individuals unaware of their HIV disease or without good access to health care. Guidelines for prevention and treatment of OIs are now regularly updated by the Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents representing opinion from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Asso- ciation of the Infectious Diseases Society of America. Because of rapid evolution in HIV management, the Panel makes the most recent information readily available on the AIDS informa- tion website (http://aidsinfo.nih.gov).
Toxoplasma gondii is a coccidial organism harbored by cats infected by eating other infected animals. While rodents, rumi- nants, swine, poultry, and other birds may have infective organ- isms in their muscle tissue, only cats carry this parasite in their intestinal tract, allowing the excretion of infected eggs. People contract the disease through contact with infected cat feces or eating improperly cooked meat. In most healthy people, toxo- plasmosis produces a mild to inapparent infection, but in immunodeficient individuals, the disease may, in addition to rash and skeletal muscle involvement, result in cerebritis, pneu- monia, chorioretinitis, myocarditis, and/or death. Infection early in pregnancy may cause fetal death or deformity. CNS infection is common with HIV disease. Because toxoplasmosis is not a nationally reportable disease, reliable case numbers are not readily available. On their website, CDC estimates there are over a million new Toxoplasma infections and 400 to 4000 cases of congenital toxoplasmosis in the United States each year; an estimated 4,800 people experience ocular involvement as part of infection; and toxoplasmosis is a leading cause of foodborne illnesses deaths, resulting in an estimated 327 deaths and 4,428 hospitalizations per year (CDC, 2014l).
Control and Prevention of Parasitic Infections Correct diagnosis by nurses and other health care workers allows the provision of early and appropriate treatment and client education for preventing and controlling parasitic infec- tions. Diagnosis of parasitic diseases is based on history, includ- ing travel, characteristic clinical signs and symptoms, and the use of appropriate laboratory tests to confirm the clinical
parasite Giardia intestinalis. It is the most common intestinal parasitic infection in the United States and results in 19,000 to 20,000 reported cases annually (CDC, 2012f ). Cryptosporidiosis is also a diarrheal disease caused by the microscopic parasite Cryptosporidium. Because Cryptosporidium possesses an outer shell that allows it to survive outside the body for extended periods of time and tolerate low levels of chlorine disinfection, it is a frequent cause of water-related disease outbreaks in swim- ming pools and splash parks. In the United States “crypto” is a common cause of both foodborne and waterborne disease resulting in an estimated 740,000 cases each year (Scallan et al, 2011).
New technology for recognizing protozoan parasites, the ease of international travel, immigration from developing countries, and diseases that affect the immune system such as HIV disease (thus leaving individuals susceptible to secondary parasitic infections) all contribute to rising reports of and a greater attention to parasitic diseases in the United States. The CDC speaks about the major neglected diseases of poverty in the United States, which it defines as diseases that dispropor- tionately affect people in poverty, infect a significant number of people, and receive limited attention in tracking, prevention, and treatment. Five of the six are parasitic: Chagas’ disease, cysticercosis, toxocariasis, toxoplasmosis, and trichomoniasis. To ensure an accurate diagnosis, nurses and other health profes- sionals need to familiarize themselves with the clinical presenta- tions and risk factors associated with these parasitic diseases.
Intestinal Parasitic Infections Although intestinal parasites are major contributors to morbid- ity and mortality in developing countries, climate, improved sanitary conditions, and effective drug therapy have served to greatly reduce widespread indigenous transmission in the United States, so much so that surveillance for many of these organisms is not widely practiced. A study using 1988-1994 NHANES III data reported that 14% of Americans have anti- bodies to Toxocara, a roundworm carried by dogs and cats that can be passed to humans. While this suggests that tens of mil- lions of Americans have been exposed, it does show how many are actually infected (Won et al, 2008). Although most people show no signs of infection, this parasite can cause systemic illness and blindness. Technological advances have allowed for improved recognition of protozoans, leading to increased reporting of some organisms like Cryptosporidium. Cryptospo- ridiosis became a nationally notifiable disease in 1995 and giar- diasis in 2002. However, many other parasitic infections such as toxocariasis and toxoplasmosis are not reportable.
Enterobiasis (pinworm) is the most common helminthic infection in the United States. Pinworm infection is seen most often among school-aged children and is most prevalent in crowded and institutional settings. Transmission is via con- sumption of infected eggs found in soil contaminated by human feces. Pinworms resemble small pieces of white thread and can be seen with the naked eye. Diagnosis is usually accomplished by pressing cellophane tape to the perianal region early in the morning. Treatment with oral vermicides and concurrent dis- infection is highly effective (CDC, 2013h).
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provides national data on the epidemiology of HAIs in the United Sates. (Read more about preventing health care– associated infections and antibiotic resistance at the CDC HAI website: http://www.cdc.gov/ncidod/dhqp/hai.html.)
Infection control practitioners play a key role in hospital infection surveillance and control programs. Without a quali- fied and well-trained person in this position, the infection control program is ineffective. A great majority of infection control practitioners are nurses. Their common job titles are infection control nurse, infection control coordinator, and nurse epidemiologist.
Universal Precautions In 1985, in response to concerns regarding the transmission of HIV infection during health care procedures, the CDC rec- ommended a universal precautions policy for all health care settings. This strategy requires that blood and body fluids from all clients be handled as if infected with HIV or other bloodborne pathogens. When in a situation where potential contact with blood or other body fluids exists, health care workers must always perform hand hygiene and wear gloves, masks, protective clothing, and other indicated personal pro- tective barriers. Needles and sharp instruments must be used and disposed of properly (CDC, 1989). The CDC also made recommendations for preventing transmission of HIV and hepatitis B during medical, surgical, and dental procedures (CDC, 1991). Updated guidelines and recommendations for preventing HAIs including universal precautions were pub- lished in 2007 (Siegel et al, 2009). Today the Healthcare Infec- tion Control Practices and Advisory Committee is charged with providing guidance on hospital infection control and developing strategies for surveillance, prevention and control of HAIs. The most recent guidance may be found on the Guidelines and Recommendations page of the CDC’s Healthcare Associated Infection web pages at http://www.cdc. gov/hai/prevent/prevent_pubs.html. The following Linking Content to Practice box applies the three public health core functions to infectious diseases.
diagnosis. Knowing what specimens to collect, how and when to collect, and what laboratory techniques to use are all impor- tant in establishing a correct diagnosis. Effective drug treatment is available for most parasitic diseases. The high cost of the drugs, drug resistance, and toxicity are some of the common therapeutic problems. Measures for prevention and control of parasitic diseases include early diagnosis and treatment, improved personal hygiene, safer sex practices, community health education, vector control, and improvements in sanitary control of food, water, and waste disposal.
HEALTH CARE–ASSOCIATED INFECTIONS Previously referred to as nosocomial infections and hospital- acquired infections, health care–associated infections (HAIs) are, as the name implies, those transmitted during hospitalization or developed within a hospital or other health care setting. They may involve clients, health care workers, visitors, or anyone who has contact with a hospital or doctor’s office. Invasive diagnostic and surgical procedures, broad-spectrum antibiotics, and immu- nosuppressive drugs, along with the original underlying illness, leave hospitalized clients particularly vulnerable to exposure to virulent infectious agents from other clients and indigenous hos- pital flora from health care staff. In this setting, the simple act of performing hand hygiene before approaching every client becomes critical. A CDC prevalence survey of U.S. acute care hospitals in 2011 estimated 722,000 HAIs annually, suggesting that on any given day, 1 in 25 hospital patients has at least one health care–associated infection. An estimated 75,000 hospital patients with HAIs died during their hospitalizations. More than half of all HAIs occurred outside of the intensive care unit (Magill et al, 2014). Another recent report estimates total annual costs for five major health care–associated infections (HAIs) at $9.8 billion, with surgical site infections contributing the most to overall costs (Zimlichman et al, 2013). In addition, HAIs have a high likeli- hood of involving and contributing to antibiotic resistance.
The CDC maintains the National Healthcare Safety Network (NHSN), a voluntary, Internet-based surveillance system that
LINKING CONTENT TO PRACTICE
Public health involves the prevention of disease, promotion of health, and pro- tection against hazards that threaten the health of the community as reflected in the public health logo and summed up in the mission “assuring conditions in which people can be healthy.” The three core functions of public health in achieving this mission as defined in 1988 by the Institute of Medicine in Recom- mendations for the Future of Public Health are Assessment, Policy Development, and Assurance. These three have been further divided into the “Ten Essential Services of Public Health” as a means of evaluating the effectiveness of public health efforts.
This chapter presents communicable diseases that commonly challenge the health of a community as well as prevention and control roles for public health nurses. Examples of some of the “Essential Services” under which these roles fall are presented by core function.
Assessment: (1) Monitor health/identify problems and (2) Diagnose and investi- gate health problems. Examples include surveillance, investigation, and identifica- tion of reportable communicable disease cases. Policy Development: (3) Inform, educate, and empower and (4) Mobilize community partnerships. Examples include evaluating immunization status, explaining the reason for immunizations and how to comply with the immunization schedule, organizing community partners to provide immunizations and documentation through a registry, and mounting a community campaign to inform the community of the importance of age-appropriate immuniza- tion. Assurance: (5) Enforce laws and regulations and (6) Link to services and provide care. Examples include assuring compliance with communicable disease control laws through treatment or prophylaxis for exposure to reportable diseases; excluding diseased students from daycare or school; linking individuals without insurance to follow-up care for communicable disease treatment or exposure.
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P R A C T I C E A P P L I C A T I O N The rising numbers of foreign-born residents in communities that did not previously have large immigrant populations pro- vides a challenge to those involved with communicable disease control, especially in outbreak situations. Language barriers, specific cultural practices, and undocumented status all con- tribute to opportunities for infection as well as presenting obstacles to prevention and control. Diseases such as TB, bru- cellosis, measles, hepatitis B, and parasitic infections often origi- nate in other countries and are diagnosed only after the individual arrives in the United States. People coming from countries without, with newly established, or with poorly enforced vaccination programs may be unimmunized. These people are particularly susceptible to infection in outbreak situ- ations. For example, many people coming from Latin America have not been immunized against rubella. Differences in cul- tural practices can lead to outbreaks of foodborne illness. Lis- teriosis outbreaks have been traced to the use of unpasteurized milk in cottage industry cheese production.
In the face of a single infectious disease report or an outbreak situation, when working with communities whose members speak limited English, it is vital (1) to have a means of commu- nication, (2) to be able to provide a culturally appropriate message, and (3) to have an established level of trust. Ideally, these require- ments are addressed before an outbreak occurs, allowing a prompt and efficient response when immediate action is needed. A. What would be a useful first step in building trust with a
largely non–English-speaking immigrant community? 1. Hold a health fair in the community. 2. Provide incentives to use health department services. 3. Identify trusted community leaders such as religious
leaders and ask their help in developing a plan. 4. Distribute a brochure in the target community language.
B. What might best encourage undocumented residents to respond to a request to be immunized during an outbreak situation? 1. Using an already established public health program to
provide interpreter services, making it clear that proof of immigration status is not required for services
2. Printing a request in the newspaper in the language of the targeted individuals
3. Involving trusted community leaders in making the request
4. Emphasizing to the individuals the severity of the conse- quences if immunization does not occur
C. What means of communication would work best when tar- geting largely non–English-speaking communities of recent immigrants? 1. Newspaper articles in target language 2. Radio announcements in target language 3. Fliers in target language posted in the community 4. Announcements from trusted community leaders
D. How would public health officials best undertake the devel- opment of information to effectively reach a largely non– English-speaking community of recent immigrants? 1. Use the services of the local university communications
department. 2. Ask community leaders to work with translators and pre-
vention specialists to develop messages using their own words.
3. Hire a professional to translate an existing well-developed English-language brochure.
4. Use brochures provided by the state health department. Answers can be found on the Evolve site.
K E Y P O I N T S • The burden of infectious diseases is high in both human and
economic terms. Preventing these diseases must be given high priority in our present health care system.
• The successful interaction of the infectious agent, host, and environment is necessary for disease transmission. Knowl- edge of the characteristics of each of these three factors is important in understanding the transmission, prevention, and control of these diseases.
• Effective intervention measures at the individual and com- munity levels must be aimed at breaking the chain linking the agent, host, and environment. An integrated approach focused on all three factors simultaneously is an ideal goal to strive for but may not be feasible for all diseases.
• Health care professionals must constantly be aware of vul- nerability to threats posed by emerging infectious diseases. Most of the factors causing the emergence of these diseases are influenced by human activities and behavior.
• Communicable diseases are preventable. Avoiding infection through primary prevention activities is the most cost- effective public health strategy.
• Health care professionals must always apply infection control principles and procedures in the work environment. They should strictly adhere to universal blood and body fluid pre- cautions to prevent transmission of HIV and other blood- borne pathogens.
• Effective control of communicable diseases requires the use of a multisystem approach focusing on enhancing host resis- tance, improving safety of the environment, improving public health systems, and facilitating social and political changes to ensure health for all people.
• Communicable disease prevention and control programs must move beyond providing drug treatment and vaccines. Health promotion and education aimed at changing indi- vidual and community behavior must be emphasized.
316 PART 3 Conceptual and Scientific Frameworks
K E Y P O I N T S — cont’d • Nurses play a key role in all aspects of prevention and control
of communicable diseases. Close cooperation with other members of the interprofessional health care team must be maintained. Mobilizing community participation is essential to successful implementation of programs.
• The successful global eradication of smallpox proved the feasibility of eradication of selected communicable diseases. As professionals and concerned citizens of the global village, health care workers must support the current global eradica- tion campaigns against poliomyelitis and dracunculiasis.
REFERENCES Centers for Disease Control and
Prevention: Guidelines for prevention of transmission of HIV and hepatitis B virus to health care and public safety workers. MMWR Morb Mortal Wkly Rep 37(S–6):1, 1989.
Centers for Disease Control and Prevention: Recommendations for preventing transmission of HIV and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR Morb Mortal Wkly Rep 40(RR–8):1, 1991.
Centers for Disease Control and Prevention: Addressing emerging infectious disease threats: a prevention strategy for the U.S,
1994. MMWR Morb Mortal Wkly Rep 43(RR–5):1–18, 1994.
Centers for Disease Control and Prevention: Notifiable disease surveillance and notifiable disease statistics—United States, June 1946 and June 1996. MMWR Morb Mortal Wkly Rep 45:530, 1996.
Centers for Disease Control and Prevention: Update: isolation of avian influenza A (H5N1) viruses from humans—Hong Kong, 1997-1998. MMWR Morb Mortal Wkly Rep 46:1245, 1998.
Centers for Disease Control and Prevention: Achievements in public health: elimination of rubella and congenital rubella
syndrome—United States, 1969-2004. MMWR Morb Mortal Wkly Rep 4(11):279–282, 2005.
Centers for Disease Control and Prevention: Human rabies prevention—United States, 2008 recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 57(RR03):1–26, 2008a.
Centers for Disease Control and Prevention: Progress toward interruption of wild poliovirus transmission—worldwide, 2008. MMWR Morb Mortal Wkly Rep 58(12):308–312, 2009a.
Centers for Disease Control and Prevention: Tularemia—Missouri, 2000-2007. MMWR Morb Mortal
Wkly Rep 58(27):744–748, 2009b.
Centers for Disease Control and Prevention: Surveillance for human West Nile virus disease—United States, 1999-2008. MMWR Morb Mortal Wkly Rep 59(2):1–17, 2010a.
Centers for Disease Control and Prevention: Update: influenza activity—United States, August 30, 2009-January 9, 2010. MMWR Morbid Mortal Wkly Rep 59(02):38–43, 2010b.
Centers for Disease Control and Prevention: CDC’s Advisory Committee on Immunization Practices (ACIP) Recommends Universal Annual Influenza
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Accompany a nurse who makes home visits. Discuss living
situations and other risk factors that may contribute to the development of infectious diseases, as well as possible points at which the nurse may intervene to help prevent these dis- eases, such as checking the immunization status of all indi- viduals in the household. What are realistic interventions and how much responsibility should a nurse take in attempt- ing to affect the living situation?
2. To become familiar with the reportable diseases that are a problem in your community, look at how many cases have been reported during the past month, 6 months, and year. Contrast these numbers with national and state statistics. How is your county or city different from or similar to these larger jurisdictions? If different, what environmental, politi- cal, or demographic features may contribute to this difference?
3. Spend time with the persons who are responsible for report- ing and investigating communicable disease in your com- munity. Discuss types of surveillance conducted and outbreak procedures that may accompany the reporting of some of these diseases. If possible, attend an outbreak investigation. Would the existing surveillance systems and outbreak control policies be sufficient in the case of a bioterrorism event?
4. Review the demographic profile of your community includ- ing trends from the past 10 years and projections for the next decade. Pay special attention to growth patterns of particular populations such as racial and ethnic groups or specific age groups (e.g., children under 18, adults 65 and older).
How do changes in these populations affect the delivery of interventions for infectious disease control such as immunization?
5. Visit a clinic that serves a refugee, immigrant, or migrant labor population to observe the infectious diseases com- monly seen in these groups. Compare and contrast this visit with a visit to a clinic that serves an inner-city population and a visit to a clinic that serves a rural population. How are the infectious disease control issues different and/or similar for these varied populations?
6. Sit in a clinic waiting room for immunization services and talk with parents about their concerns and the barriers they may perceive in obtaining immunizations for their children. How can this information be used to better facilitate immu- nization services?
7. Spend time with a school nurse to see what infectious dis- eases are routinely encountered in the educational setting. Discuss risk factors for disease in school-age youths and the strategies used to prevent infectious diseases in this age group. Do school policies support the strategies needed for the prevention of infectious diseases in students?
8. Visit a daycare center. Observe potential situations for the communication of infectious diseases and discuss with the director the steps taken to prevent and control infection, including immunization requirements and procedures for hand hygiene and food preparation. Does the center have specific infection control policies and procedures, and does the staff appear to be following them?
317CHAPTER 13 Infectious Disease Prevention and Control
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Centers for Disease Control and Prevention: Recovery of a patient from clinical rabies—California, 2011. MMWR Morb Mortal Wkly Rep 61(04):61–65, 2012d.
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Centers for Disease Control and Prevention: Giardiasis surveillance—United States, 2009-2010. MMWR Morb Mortal Wkly Rep 61(SS05):13–23, 2012f.
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Centers for Disease Control and Prevention: Summary of notifiable diseases—United States 2011. MMWR Morb Mortal Wkly Rep 60(53):3, 2013b.
Centers for Disease Control and Prevention: Progress toward global eradication of dracunculiasis, January 2012-June 2013. MMWR Morbid Mortal Wkly Rep 62(42):829–833, 2013c.
Centers for Disease Control and Prevention: Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly RepRecomm Rep 62(RR04):1–34, 2013d.
Centers for Disease Control: Surveillance for foodborne disease outbreaks—United States, 2009-2010. MMWR Morbid Mortal Wkly Rep 62(03):41–47, 2013e.
Centers for Disease Control: Surveillance for waterborne disease outbreaks associated with drinking water and other nonrecreational water—United States, 2009-2010. MMWR Morbid Mortal Wkly Rep 6(35):714–720, 2013f.
Centers for Disease Control and Prevention: Water treatment methods. 2013g. Available at: http://wwwnc.cdc.gov/travel/ content/water-treatment .aspx. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Parasites—enterobious, epidemiology and risk factors. 2013h. Available at: http://www .cdc.gov/parasites/pinworm/ epi.html. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Ebola hemorrhagic fever. 2014a. Available at: http:// www.cdc.gov/vhf/ebola/. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Marburg hemorrhagic fever. 2014b. Available at: http:// www.cdc.gov/vhf/marburg/. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Global health—polio. 2014c. Available at: http://www .cdc.gov/polio/updates/. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Recommended immunization schedules for persons aged 0 through 18 years—United States, 2014. MMWR Morb Mortal Wkly Rep 63(05):108–109, 2014d.
Centers for Disease Control and Prevention: Measles cases and outbreaks. 2014e. Available at: http://www.cdc.gov/measles/ cases-outbreaks.html. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Pertussis—surveillance and reporting. 2014f. Available at: http://www.cdc.gov/pertussis/ surv-reporting.html. Accessed May 16, 2014.
Centers for Disease Control and Prevention: CDC recommendations for influenza antiviral medications remain unchanged. 2014g. Available at: http://www.cdc.gov/ media/haveyouheard/stories/ Influenza_antiviral2.html. Accessed May 16, 2014.
Centers for Disease Control and Prevention: 2013-14 Flu season FluVaxView information and coverage, seasonal influenza. 2014h. Available at: http:// www.cdc.gov/flu/fluvaxview/ 1314season.htm. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Highly pathogenic avian influenza A (H5N1) in people, seasonal flu. 2014i. Available at: http://www.cdc.gov/flu/avianflu/ h5n1-people.htm. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Ticks. 2014j. Available at: http://www.cdc.gov/ticks/. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Malaria facts. 2014k. Available at: http://www.cdc.gov/ malaria/about/facts.html. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Neglected parasitic infections in the United States—toxoplasmosis. 2014l. Available at: http://www.cdc .gov/parasites/resources/pdf/ npi_toxoplasmosis.pdf. Accessed May 16, 2014.
Centers for Disease Control and Prevention: Ebola virus disease. 2015a. Available at: http://www .cdc.gov/vhf/ebola/. Accessed January 25, 2015.
Centers for Disease Control and Prevention: Measles cases and outbreaks. 2015b. Available at: http://www.cdc.gov/measles/ cases-outbreaks.html. Accessed January 25, 2015.
Christian KA, Blanton JD, Auslander M, et al: Epidemiology of rabies post-exposure prophylaxis—United States of America 2006-2008. Vaccine 27(51):7156–7161, 2009.
Cieslak TJ, Eitzen EM Jr: Clinical and epidemiologic principles of anthrax. Emerg Infect Dis 5:552–555, 1999.
Dyer JL, Wallace RW, Orciari L, et al: Rabies surveillance in the United States during 2012. JAVMA 243(6):811–812, 2013.
Evans AS: The eradication of communicable diseases: myth or reality? Am J Epidemiol 122:199, 1985.
Fauci AS, Touchette NA, Folkers GK: Emerging infectious diseases: a 10-year perspective from the National Institute of Allergy and Infectious Diseases. Emerg Infect Dis 2005. Available at: http://www .cdc.gov/ncidod/EID/vol11no 04/04-167.htm. Accessed May 16, 2014.
Feldman KA, Stiles-Enos D, Julian K, et al: Tularemia on Martha’s Vineyard: seroprevalence and occupational risk. Emerg Infect Dis 2003. Available at: http:// www.cdc.gov/ncidod/EID/ vol9no3/02-0462.htm. Accessed May 16, 2014.
Grunow R, Klee SR, Beyer W, et al: Anthrax among heroin users in Europe possibly caused by same bacillus anthracis strain since 2000. Eurosurveillance 18(13):1–9, 2013. Available at: http://www.eurosurveillance .org/ViewArticle.aspx? ArticleId=20437. Accessed May 16, 2014.
Heymann DL, editor: Control of Communicable Diseases Manual, ed 20. Washington, DC, 2014, American Public Health Association.
Kuehn BM: CDC estimates 300,000 US cases of Lyme disease annually. JAMA 310(11):1110, 2013.
Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center (LA BioMed): Changes in hospital orders increase pertussis immunization rates. Science Daily 2014. Available at: www .sciencedaily.com/releases/ 2014/03/140305110923 .htm. Accessed May 16, 2014.
Magill SS, Edwards JR, Bamberg W, et al: Multistate point-prevalence survey of health care–associated infections. N Engl J Med 370: 1198–1208, 2014.
Scallan E, Hoekstra RM, Angulo FJ, et al: Foodborne illness acquired in the United States—major pathogens. Emerg Infect Dis 17(1):2011. Available at: http:// dx.doi.org/10.3201/eid1701 .P11101 http://wwwnc.cdc .gov/eid/article/17/1/p1-1101 _article.htm. Accessed May 16, 2014.
Scharff RL: Economic burden from health losses due to foodborne illness in the United States. J Food Prot 75(1):123–131, 2012.
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318 PART 3 Conceptual and Scientific Frameworks
U.S. Department of Health and Human Services: Healthy People 2020. Washington, DC, Office of Disease Prevention and Health Promotion, USDHHS. Available at: http://www.healthypeople .gov/2020/TopicsObjectives 2020/overview.aspx?topicid=37# three. Accessed May 16, 2014.
Wenzel RP: Control of communicable diseases: overview. In Wallace RB, editor: Public Health and Preventive Medicine, ed 14. Stamford, CT, 1998, Appleton & Lange.
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and risk factors for zoonotic toxocara spp. infection. Am J Trop Med Hyg 79(4):552–557, 2008.
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World Health Organization: Ebola Virus Disease, West Africa (Situation as of 15 May 2014), WHO Epidemic & Pandemic Alert and Response (EPR). 2014a, WHO. Available at: http://www.afro.who .int/en/clusters-a-programmes/dpc/ epidemic-a-pandemic-alert-and -response/outbreak-news/4136 -ebola-virus-disease-west-africa -situation-as-of-15-may-2014.html. Accessed May 16, 2014.
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factsheets/fs286/en/. Accessed May 16, 2014.
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Zimlichman E, Henderson D, Tamir O, et al: Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Internal Medicine 173(22):2039–2046, 2013.
319
14
Communicable and Infectious Disease Risks
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Describe the natural history of human immunodeficiency
virus (HIV) infection and appropriate client education at each stage.
2. Explain the clinical signs of selected communicable diseases.
3. Evaluate the trends in incidence of HIV, STDs, hepatitis, and tuberculosis, and identify groups that are at greatest risk.
4. Analyze behaviors that place people at risk of contracting selected communicable diseases.
5. Evaluate nursing activities to prevent and control selected communicable diseases.
6. Explain the various roles of nurses in providing care for those with selected communicable diseases.
K E Y T E R M S acquired immunodeficiency syndrome, p. 321 chlamydia, p. 329 directly observed therapy, p. 338 genital herpes, p. 329 genital warts, p. 330 gonorrhea, p. 328 hepatitis A virus, p. 330 hepatitis B virus, p. 330
hepatitis C virus, p. 332 highly active antiretroviral therapy, p. 321 HIV antibody test, p. 322 HIV infection, p. 321 human immunodeficiency virus, p. 320 human papillomavirus, p. 330 incidence, p. 325 incubation, p. 321
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz • Case Studies
• Glossary • Answers to Practice Application • Resource Tool
• Resource Tool 14.A: Resources on Sexually Transmitted Diseases
Patty J. Hale, RN, FNP, PhD, FAAN Dr. Patty Hale is Professor and Graduate Program Director at James Madison University in Harrisonburg, Virginia. She has practiced public health nursing in Wisconsin and Virginia and has consulted widely with many organizations on community health and infectious diseases, most notably the World Health Organization. Dr. Hale has taught undergraduate and graduate courses in epidemiology, curriculum development and evaluation, com- munity health, and population-focused nursing. Dr. Hale was named a Carnegie U.S. Professor of the Year in 2003, and was the first nurse ever to receive this honor. Dr. Hale holds a bachelor of science from the University of Wisconsin-Milwaukee. She has a master’s in community health nursing and family nurse practitioner from the University of Virginia, and a doctorate in nursing from the University of Maryland at Baltimore.
Erika Metzler Sawin is a second-degree nurse who received her master’s in community health nursing from The University of Texas, Austin, and her doctorate in nursing from the University of Virginia. She is an Assistant Professor in the Department of Nursing at James Madison University in Harrisonburg, Virginia, where she teaches community health nursing to BSN students. Her research interests are in the areas of domestic violence and culturally aware care. She was selected for a 2014-15 U.S. Fulbright-Nehru Scholar Teaching Award.
Erika Metzler Sawin, PhD, RN
320 PART 3 Conceptual and Scientific Frameworks
Knowledge about the risk of communicable diseases has changed dramatically in recent years. For example, in the decades following the development of antibiotics in the 1940s, sexually transmitted diseases (STDs) were considered to be a problem of the past. The recent emergence of new viral STDs and antibiotic-resistant strains of bacterial STDs has posed new challenges. Left unchecked, STDs can cause poor pregnancy outcomes, infertility, and cervical cancers. There is also the problem of co-infection, with one STD increasing the suscep- tibility to other STDs, such as human immunodeficiency virus (HIV). STDs are also called sexually transmitted infections (STIs) because many times, the infections are asymptomatic. In this chapter, the term STDs will be used.
This concern about infectious diseases has prompted the development of standards for STDs, HIV and acquired immu- nodeficiency syndrome (AIDS), hepatitis, and tuberculosis (TB) in the Healthy People 2020 report. The Healthy People 2020 box shows some objectives used to evaluate progress toward decreasing communicable diseases by the year 2020.
Several communicable diseases and all STDs are acquired through behaviors that can be avoided or changed, and thus intervention efforts by nurses have focused on disease preven- tion. Prevention can take the form of vaccine administration (as with hepatitis A and hepatitis B), early detection (of infec- tions like TB, for example), or instruction of clients about absti- nence or safer sex. Individuals who live with chronic infections can transmit them to others.
This chapter describes selected communicable diseases and their nursing management. It concludes with implications for nursing care in primary, secondary, and tertiary prevention.
HUMAN IMMUNODEFICIENCY VIRUS INFECTION Human immunodeficiency virus (HIV) infection has had an enormous political and social impact on society. Controversies have arisen over many aspects of HIV. Fears about HIV may lead to attitudes of blaming clients for their infections and to discrimination. These beliefs are magnified by the fact that this disease has commonly afflicted two groups who have been largely scorned by society: homosexuals and injection drug users (Fair and Ginsberg, 2010). Debates have arisen over how to control disease transmission and how to pay for related health services. An ongoing debate involves whether clean needles should be distributed to injection drug users to prevent the spread of HIV.
Economic costs of HIV/AIDS result from premature treat- ment and disability. The fact that nearly 55% of HIV infections occur in persons between the ages of 20 and 39 years may result in disrupted families and lost creative and
K E Y T E R M S — cont’d injection drug use, p. 323 non-gonococcal urethritis, p. 329 partner notification, p. 334 pelvic inflammatory disease, p. 328 perinatal HIV transmission, p. 323
prevalence, p. 322 sexually transmitted diseases, p. 320 syphilis, p. 328 tuberculosis, p. 332
C H A P T E R O U T L I N E Human Immunodeficiency Virus Infection
Natural History of HIV Transmission Epidemiology of HIV/AIDS HIV Surveillance HIV Testing Perinatal and Pediatric HIV Infection HIV Stage 3 (AIDS) in the Community Resources
Sexually Transmitted Diseases Gonorrhea Syphilis Chlamydia Herpes Simplex Virus (Genital Herpes) Human Papillomavirus Infection
Hepatitis Hepatitis A Virus Hepatitis B Virus Hepatitis C Virus Non-ABC Hepatitis
Tuberculosis Epidemiology Diagnosis and Treatment
Nurse’s Role in Providing Preventive Care for Communicable Diseases Primary Prevention Secondary Prevention Tertiary Prevention
HEALTHY PEOPLE 2020
The following selected objectives pertain to the communicable diseases discussed in this chapter: • HIV-3: Reduce the rate of HIV transmission among adults and adolescents. • STD-8: Reduce congenital syphilis. • IID-26: Reduce new hepatitis C infections. • STD-1: Reduce the proportion of adolescents and young adults with
Chlamydia trachomatis infections.
From U.S. Department of Health and Human Services: Healthy People 2020 Objectives, Washington, DC, 2010, Office of Disease Prevention and Health Promotion, USDHHS.
321CHAPTER 14 Communicable and Infectious Disease Risks
Many of the AIDS-related opportunistic infections are caused by microorganisms that are commonly present in healthy individuals but do not cause disease in persons with an intact immune system. These microorganisms proliferate in persons with HIV/AIDS because of a weakened immune system. Opportunistic infections may be caused by bacteria, fungi, viruses, or protozoa. The most common opportunistic diseases are Pneumocystis jiroveci (carinii) pneumonia and oral candi- diasis, but also include pulmonary TB, invasive cervical cancer, or recurrent pneumonia.
In 2008 the case definition for HIV infection was revised to include the HIV classification/staging system based on the number of CD4+ T-lymphocytes. Criteria for defining HIV infection include a positive result from the antibody screening test or a positive result from a nucleic acid test (DNA or RNA). In situations where the mother of a newborn is HIV infected, the HIV nucleic acid test (DNA or RNA) is used to identify HIV/AIDS in infants (CDC, 2008).
TB, an infection that is becoming more prevalent because of HIV infection, can spread rapidly among immunosuppressed individuals. Thus, HIV-infected individuals who live in close proximity to one another, such as in long-term care facilities, prisons, drug treatment facilities, or other settings, must be carefully screened and in some instances deemed noninfec- tious before admission to such settings. TB is covered in more depth later in this chapter. See the following QSEN box for suggestions about implementing quality and safety in the care of patients with HIV and other communicable and infec- tious diseases.
economic productivity at a period of life when vitality is the norm (CDC, 2013l). In 2009, 39% of new HIV infections occurred in the 13- to 29-year-old age group (CDC, 2013i). Medicaid and Medicare primarily support the health care delivery costs of those infected. Many people with HIV qualify for Medicaid or Medicare because they are indigent or fall into poverty when paying for health care over the course of the illness. The lifetime cost of HIV care for one client is $379,668 (CDC, 2013j). The Ryan White HIV/AIDS Program, through the Ryan White HIV/AIDS Treatment Extension Act of 2009, provides care for persons with HIV infection (USDHHS, 2014a). This program provides funds for health care in the geographic areas with the largest number of AIDS cases. Health services that are covered include emergency ser- vices, services for early intervention and care (sometimes including coverage of health insurance), and drug reimburse- ment programs for HIV-infected individuals. The AIDS Drug Assistance Programs (ADAPs) are awards that pay for medica- tions on the basis of the estimated number of persons living with AIDS in the individual state (USDHHS, 2014b).
Natural History of HIV The natural history of HIV includes three stages: the primary infection (within about 1 month of contracting the virus), fol- lowed by a period when the body shows no symptoms (clinical latency), and then a final stage of symptomatic disease (Buttaro et al, 2013).
When HIV enters the body, a person may experience a mononucleosis-like syndrome, referred to as a primary infec- tion, which lasts for a few weeks. This may go unrecognized. The body’s CD4 white blood cell count drops for a brief time when the virus is most plentiful in the body. The immune system increases antibody production in response to this initial infection, which is a self-limiting illness. Symptoms include lymphadenopathy, myalgias, sore throat, lethargy, rash, and fever (CDC, 2013g). Even if the client seeks medical care at this time, the antibody test at this stage is usually negative, so it is often not recognized as HIV.
After a variable period of time, commonly from 6 weeks to 3 months, HIV antibodies appear in the blood. Although most antibodies serve a protective role, HIV antibodies do not. However, their presence helps in the detection of HIV infection because screening tests show their presence in the bloodstream.
HIV-infected persons live several years before developing symptomatic disease. During this prolonged incubation period, clients have a gradual deterioration of the immune system and can transmit the virus to others. The use of highly active anti- retroviral therapy (HAART) has greatly increased the survival time of persons with HIV/AIDS.
Acquired immunodeficiency syndrome (AIDS, a.k.a. HIV Stage 3) is the last stage in the long continuum of HIV infection and may result from damage caused by HIV, secondary cancers, or opportunistic organisms. AIDS is defined as a disabling or life-threatening illness caused by HIV; it is diagnosed in a person with a CD4 T-lymphocyte count of less than 200/mL with documented HIV infection (CDC, 2008).
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency Evidence-based practice (EBP): Integrate best current evidence with clinical expertise and client/family preferences and values for delivery of optimal care. Knowledge: Explain the role of evidence in determining best clinical
practice. Skills: Locate evidence reports related to clinical practice topics and
guidelines Attitudes: Value the concept of EBP as integral to determining best clinical
practice.
Client-centered Care Question Evidence supports the fact that some medications previously effective in treating STDs no longer are effective. If you learned that a colleague was planning to use a treatment that is no longer considered effective to treat a specific STD, what would you do to assure that the care the client receives is based on current evidence?
Answer: With your colleague collect current treatment guidelines informa- tion about that specific STD. The first place that you might look would be the Centers for Disease Control and Prevention guidelines for that disease. For example, you might look at “HIV treatment guidelines for adults and adoles- cents updated” at the following website to find out what is the most effective antiretroviral therapy (ART) for the treatment of HIV infection. See http:// aids.info.nih.gov/guidelines.
Sexually Transmitted Diseases
322 PART 3 Conceptual and Scientific Frameworks
factors used to treat hemophilia and other blood disorders are made safe through heat treatments to inactivate the virus. Screening has significantly reduced the risk of transmission of HIV by blood products and organ donations.
When a person has an STD infection such as chlamydia or gonorrhea, the risk of HIV infection increases and HIV may also increase the risk for other STDs. This may result from any of the following: open lesions providing a portal of entry for pathogens; STDs decreasing the host’s immune status, resulting in a rapid progression of HIV infection; and HIV changing the natural history of STDs or the effectiveness of medications used in treating STDs (Heymann, 2014).
The nurse serves both as an educator about the modes of transmission and as a role model for how to behave toward and provide supportive care for those with HIV infection. An understanding of how transmission does and does not occur will help family and community members feel more comfortable in relating to and caring for persons with HIV (see Box 14-1).
Epidemiology of HIV/AIDS Worldwide 35.3 million persons live with HIV infection. Sub- Saharan Africa accounts for more than 70% of all HIV infec- tions (UNAIDS, 2013). The epidemic is also growing in Eastern Europe, the Middle East, and central Asia (UNAIDS, 2012). Women are at highest risk for infection because of unprotected sex with infected partners. However, there is some evidence that HIV prevention programs may be changing risk behavior in southern Africa. Worldwide, the treatment of HIV infection has been given higher priority, and the use of highly active antiret- roviral therapy has increased to 61% for those who need it under the 2010 WHO Guidelines, and 34% of those eligible under the 2013 guidelines (UNAIDS, 2013).
Nurses must identify the trends of HIV infection in the populations they serve, so that they can screen clients who may be at risk and can adequately plan prevention programs and illness care resources. For example, knowing that AIDS dispro- portionately affects minorities helps nurses set priorities and plan services for these groups. Factors such as geographic loca- tion, age, and ethnic distribution are tracked to more effectively target programs. It is important to identify persons infected with HIV before symptomatic AIDS develops, so that treatment can begin as early as needed. It is estimated that about 1.1 million people in the United States are infected with HIV, but 15.8% (180,900 people) are not aware of their infection (CDC, 2013k).
Since the first cases of AIDS were identified in 1981, the total reported number of persons living with AIDS in the United States grew to 487,692 by the end of 2010 (CDC, 2013l). Note that this number reflects only those who are living; it does not include those who have died. The prevalence of AIDS has increased from 2004 to 2007, reflecting increased life expec- tancy from the use of antiretroviral therapy (CDC, 2013l).
Figure 14-1 shows the exposure categories for persons with HIV in 2011. Men who have sex with men (MSM) make up the largest group with HIV in the United States, and the number of persons contracting HIV through heterosexual transmission is
Transmission HIV is transmitted through exposure to blood, semen, trans- planted organs, vaginal secretions, and breast milk (Heymann, 2014). Persons who had blood exposure or sexual or needle- sharing contact with an HIV-infected person are at risk for contracting the virus. The virus is not transmitted through casual contact such as touching or hugging someone who has HIV infection or through mosquitoes or other insects. Although HIV has been found in saliva and tears in some instances, there are no reports of transmission through contact with these body fluids (Heymann, 2014). The modes of transmission are listed in Box 14-1, and the exposure categories of HIV are shown in Figure 14-1.
Potential donors of blood and tissues are screened through interviews to assess for a history of high-risk activities and screened with the HIV antibody test. Blood or tissue is not used from individuals with a history of high-risk behavior or who are HIV infected. In addition to being screened, coagulation
FIG 14-1 Estimated numbers of cases of HIV by exposure category in 2011, United States. Note that the “other” category includes hemophilia, blood transfusion, perinatal exposure, and risk factors not reported or not identified. (Data from Centers for Disease Control and Prevention: HIV Surveillance Report; vol. 23, Diagnoses of HIV infection in the United States and Dependent Areas, 2011. Published February 2013. Available at http://www.cdc.gov/hiv/library/reports/surveillance/2011/ surveillance_Report_vol_23.html. Accessed March 9, 2014.)
Injection drug use 3,648
Men who have sex with men
30,573
Other/risk not reported or
identified 51
Heterosexual contact 13,402
Men who have sex with men
and inject drugs 1,407
HIV can be transmitted in the following ways: • Sexual contact, involving the exchange of body fluids, with an infected
person • Sharing or reusing needles, syringes, or other equipment used to prepare
injectable drugs • Perinatal transmission from an infected mother to her fetus during preg-
nancy or delivery, or to an infant when breastfeeding • Transfusions or other exposure to HIV-contaminated blood or blood prod-
ucts, organs, or semen
BOX 14-1 Modes of Transmission of Human Immunodeficiency Virus (HIV)
From Heymann D: Control of Communicable Diseases Manual, Washington, DC, 2008, APHA.
323CHAPTER 14 Communicable and Infectious Disease Risks
United States and the U.S. territories of the Virgin Islands and Puerto Rico report the highest rates (CDC, 2013l). States with AIDS prevalence greater than 12.5 per 100,000 population in 2011 were Delaware (13.8), Florida (21.2), Georgia (27.9), Louisiana (22.4), Maryland (24.0), Mississippi (16.4), New
the second largest. Heterosexual transmission has surpassed injection drug use (IDU) as the primary mode of HIV trans- mission in women (CDC, 2013l).
The distribution of pediatric HIV infection has fallen dra- matically as a result of prenatal care that includes HIV testing, antiretroviral therapy for the mother, and cesarean delivery. Perinatal HIV transmission has declined, and two thirds of pediatric HIV infection results from perinatal exposure (CDC, 2013l).
As seen in Table 14-1, HIV has disproportionately affected minority groups. African Americans have the largest HIV disease burden of any racial/ethnic group in the United States; African American rates of new HIV infection are 8 times higher than in whites, the highest prevalence of those living with HIV is in the African American community, and the highest propor- tions of people diagnosed with HIV Stage 3 (AIDS) are African American (CDC, 2014h). This overrepresentation is associated with poverty, since African Americans have a higher poverty rate than other groups do. This reflects decreased access to prevention and treatment, and lack of awareness of HIV infec- tion. Stigma, fear, and homophobia play a role as well (CDC, 2014h). Transgender people are also at high risk, particularly transgender women. Because of data collection limitations, it is difficult to estimate HIV prevalence in transgender communi- ties. However, data from countries that collect data for trans- gender women separately from men who have sex with men indicate that HIV prevalence is nearly 50 times higher than for other adults of reproductive age (CDC, 2013h).
As seen in Figure 14-2, the geographic distribution of HIV infection is clustered in urban areas. Regionally, the southern
Centers for Disease Control and Prevention: HIV Surveillance Report: Diagnoses of HIV Infection and AIDS in the United States and Dependent Areas, 2011; vol. 23. Accessed at http://www.cdc.gov/hiv/ topics/surveillance/resources/reports/. Published, February 2013. Accessed February 22. 2014.
Race/ Ethnicity
HIV Infection
Rate Per 100,000
Rate, Males
Rate, Females
Stage 3 (AIDS)
Black, African American
23,168 60.4 112.8 40.0 15,966
White 13,846 7.0 14.5 2.0 8,304 Hispanic/ Latino 10,159 19.5 43.4 7.9 6,849 Asian 982 6.5 13.8 2.3 492 American Indian/
Alaska Native 212 9.3 18.0 5.5 146
Native Hawaiian/ Pacific Islander
78 15.3 34.2 3.9 51
Multiple races 827 14.2 38.5 7.5 753 Total 49,272 15.8 30.8 7.7 32,561
TABLE 14-1 Estimated Numbers of New HIV Infections and Stage 3 (AIDS) Infections in Adults and Adolescents, 2011 (50 States, the District of Columbia, and 6 U.S. Dependent Areas)
FIG 14-2 Map of rates of diagnosis of HIV infection among adults and adolescents, 2011, in the United States and 6 dependent areas. (Data from Centers for Disease Control and Prevention: HIV Surveillance Report; vol. 23, Diagnoses of HIV infection in the United States and Dependent Areas, 2011. Published February 2013. Available at http://www.cdc.gov/hiv/library/reports/ surveillance/2011/surveillance_Report_vol_23.html. Accessed March 9, 2014.)
9.5
2.6 2.6
N = 50,007 Total rate = 19.1
7.2 5.7
5.0
11.2
20.0 9.5
9.6
12.6
9.4
17.3
31.4
33.2
22.0
20.8
16.2
14.3
30.1
5.2
6.6
10.0
25.3
36.6
20.9
8.0 3.0
3.4 3.8
5.1
6.2
10.7
24.5
8.6
4.6
6.8
VT 2.3
NH MA RI CT NJ DE MD DC
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting
4.5 22.5 14.0 14.2 21.1 16.7 36.4
177.9
American Samoa Guam Northern Mariana Islands Puerto Rico Republic of Palau U.S. Virgin Islands
Rates per 100,000 population
<10.0 10.0–19.9 20.0–29.9 ≥30.00.0
0.0 5.3
28.6 0.0
39.5
9.6 4.3
19.2
17.7
13.3
324 PART 3 Conceptual and Scientific Frameworks
Rapid HIV antibody testing using oral fluid samples (e.g., OraQuick, Home Access HIV-1 Test System) is 99.5% accurate and provides results within 20 minutes, allowing immediate results to be given (CDC, 2013q; USPSTF 2013). In addition to the rapid results, this test may appeal to persons who fear having their blood drawn. If the test is positive, it requires a second specific confirmatory test.
Routine voluntary HIV testing is recommended for all adults ages 15 to 65 (USPSTF, 2013). Voluntary screening programs for HIV may be either confidential or anonymous; the process for each is unique. Confidential testing involves reporting by identifying the person’s name and other identifying informa- tion; this information is considered protected by confidentiality. With anonymous testing, the client is given an identification code number that is attached to all records of the test results and is not linked to the person’s name and address (CDC, 2013q). Demographic data such as the person’s sex, age, and race may be collected, but there is no record of the client’s name and associated identifying information. An advantage of anony- mous testing may be that it increases the number of people who are willing to be tested, because many of those at risk are engaged in illegal activities. The anonymity eliminates their concern about the possibility of arrest or discrimination. However, anon- ymous testing does not allow for follow-up if the test is positive because the client’s name and address are not available.
Perinatal and Pediatric HIV Infection Perinatal transmission accounts for nearly all HIV infection in children and can occur during pregnancy, labor and delivery, or breastfeeding. The effectiveness of antiretroviral therapy in pregnant women and newborns in preventing transmission from mother to fetus or infant has made pediatric HIV rates decline sharply. On the basis of the effectiveness of antiviral therapy, it is recommended that HIV testing be a routine part of prenatal care and that all pregnant women be tested for HIV—even a mother who presents in labor who is untested and whose HIV status is not known (USPSTF, 2013). Rapid testing allows rapid results in women who are giving birth, but have not been previously tested for HIV. HIV prevention in women must remain the primary focus of efforts to reduce pediatric HIV infection.
If left untreated, the clinical picture of pediatric HIV infec- tion involves a shorter incubation period than in adults, and symptoms may occur within the first year of life. The physical signs and symptoms in children include failure to thrive, unex- plained persistent diarrhea, developmental delays, and bacterial infections such as TB and severe pneumonia (WHO, 2010b).
Detection of HIV infection in infants of infected mothers is made through different tests from those used in children over 18 months. Virologic assays that directly detect HIV (e.g., nucleic acid amplification tests [NAT] such as HIV DNA, RNA polymerase chain reaction [PCR] assays, and related RNA qual- itative or quantitative assays) must be used (Panel on Antiret- roviral Therapy and Medical Management of HIV-Infected Children, 2014). The EIA test is not valid because it tests for antibodies, which in the infant reflect passively acquired mater- nal antibodies.
Jersey (13.0), New York (21.7), South Carolina (16.4), Texas (16.5), and the District of Columbia (94.2) (CDC, 2013l). As shown in Table 14-2, both HIV and HIV Stage 3 (AIDS) affect people across the life span, with peak HIV rates occurring for those in the 25- to 29-year-old age group. Peak HIV Stage 3 (AIDS) rates occur in individuals age 40 to 44.
HIV Surveillance A study of diagnosed cases of AIDS does not reveal current HIV infection patterns because of the interval between infection with HIV and the onset of clinical disease. Moreover, the effec- tiveness of antiretroviral drugs given early in the HIV infection before symptoms start provides impetus for early identification of infection. Thus in 2008 confidential laboratory reporting of HIV-positive status by name was required in all 50 states and the District of Columbia (CDC, 2013l), although not all states require viral load and CD4 counts (CDC, 2013o).
HIV Testing The HIV antibody test is the most commonly used screening test for determining infection. This test does just as its name implies: it does not reveal whether an individual has symptom- atic AIDS, nor does it isolate the virus. It does indicate the presence of the antibody to HIV. The most commonly used form of this test is the enzyme-linked immunosorbent assay (EIA). The EIA effectively screens blood and other donor prod- ucts. To minimize false-positive results, a confirmatory test, the Western blot, is used to verify the results. False-negative results may also occur after infection and before antibodies are pro- duced. Sometimes referred to as the window period, this can last from 6 weeks to 3 months.
Centers for Disease Control and Prevention: HIV Surveillance Report: Diagnoses of HIV Infection and AIDS in the United States and Dependent Areas, 2011; vol. 23. Accessed at http://www.cdc.gov/hiv/ topics/surveillance/resources/reports/. Published, February 2013. Accessed February 22. 2014.
Age HIV Infection
Rate per 100,000
Stage 3 (AIDS)
Rate per 100,000
<13 193 0.4 15 0 13-14 53 0.6 49 0.6 15-19 2263 10.3 510 2.4 20-24 8140 36.3 2429 10.9 25-29 7608 35.3 3433 16.1 30-34 6318 30.4 4001 19.5 35-39 5384 27.1 4071 20.8 40-44 5883 27.6 4783 22.7 45-49 5706 25.4 4994 22.5 50-54 4051 17.7 3567 15.8 55-59 2369 11.6 2198 10.9 60-64 1258 7.0 1107 6.2 ≥65 974 2.3 899 2.2
TABLE 14-2 Estimated Numbers of New HIV Infections and Stage 3 (AIDS) Infections in Adults and Adolescents, 2011 (50 States, the District of Columbia, And 6 U.S. Dependent Areas) By Age
325CHAPTER 14 Communicable and Infectious Disease Risks
nurse, and the child’s parent or guardian should make decisions about educational and care needs.
Because of impaired immunity, children with HIV infection are more likely to get childhood diseases and suffer serious sequellae. Therefore, DPT (diphtheria, pertussis, tetanus), IPV (inactivated polio virus), and MMR (measles, mumps, rubella) vaccines should be given at regularly scheduled times for chil- dren infected with HIV. HiB (Haemophilus influenzae type B), hepatitis B, pneumococcus, and influenza vaccines may be rec- ommended after medical evaluation (CDC, 2009a). Addition- ally the Panel on Opportunistic Infections in HIV-Exposed and HIV–Infected Children guidelines (2013) recommends menin- gococcal disease vaccination, as well as hepatitis A and varicella vaccination, provided that the infant or child is not severely immunocompromised.
Individual decisions about risk to the infected child or others should be based on the behavior, neurological development, and physical condition of the child. Attendance may be inadvis- able in the presence of cases of childhood infections, such as chickenpox or measles, within the school, because the immu- nosuppressed child is at greater risk of suffering complications. Alternative arrangements, such as homebound instruction, might be instituted if a child is unable to control body secre- tions or displays biting behavior.
Resources As the number of individuals with HIV/AIDS has increased, services to meet these needs have grown. Voluntary and faith- based service organizations, such as community-based organi- zations or AIDS support organizations, have developed in many localities to address these needs. These services may include counseling, support groups, legal aid, personal care services, housing programs, and community education programs. Nurses collaborate with workers from community-based orga- nizations in the client’s home and may advise these groups in their supportive work. The federal government and many orga- nizations have established toll-free numbers and websites to provide information, as noted on the Evolve website at http:// evolve.elsevier.com/Stanhope.
SEXUALLY TRANSMITTED DISEASES The number of new cases (the incidence) of STDs such as gonorrhea, herpes simplex virus, human papillomavirus (HPV), and chlamydia continues to increase. Chlamydia is the most commonly reported infectious disease; gonorrhea is the second most common. Because of the impact of STDs on long-term health and the emergence of eight new STDs since 1980, con- tinued attention to their prevention and treatment is vital.
The common STDs listed in Table 14-3 are categorized by cause, either viral or bacterial. The bacterial infections include gonorrhea, syphilis, and chlamydia. Most of these are curable with antibiotics, with the exception of the newly emerging antibiotic-resistant strains of gonorrhea.
STDs caused by viruses cannot be cured. These are chronic diseases resulting in a lifetime of symptom management and infection control. The viral infections include herpes simplex
Despite having an HIV-infected mother, many children do not acquire HIV. However, one or both parents may die from HIV infection. The families of many children with AIDS are impoverished, with limited financial, emotional, social, and health care resources. The added strain of this illness makes many individuals and families unable to provide for the emotional, physical, and developmental needs of affected children.
HIV Stage 3 (AIDS) in the Community AIDS is a chronic disease, so individuals continue to live and work in the community. Persons with AIDS have bouts of illness interspersed with periods of wellness when they are able to return to school or work. When ill, much of their care is pro- vided in the home. The nurse teaches families and significant others about personal care and hygiene, medication administra- tion, standard precautions to ensure infection control, and healthy lifestyle behaviors such as adequate rest, balanced nutri- tion, and exercise.
Adherence to HAART is critical for clients because adminis- tration must be consistent to be effective (CDC, HRSA, NIH, et al., 2014). It is important for nurses to educate clients about accurate medication administration. Peer advocates and persons living with HIV infection who are trained to work with infected persons play a vital role in advocacy and teaching self-care management.
The Americans with Disabilities Act of 1990 and other laws protect persons with asymptomatic HIV infection and AIDS against discrimination in housing, at work, and in other public situations (USDJ, 2012). Policies regarding school and worksite attendance have been developed by most states and localities on the basis of these laws. These policies provide direction for the community’s response when a person develops HIV infection. The nurse can identify resources such as social and financial support services and interpret school and work policies.
Mental health issues such as depression, substance abuse, and bipolar disorder are often present in someone newly diag- nosed with HIV. These conditions must be addressed prior to or simultaneously with HIV treatment to be effective. It is vitally important that a variety of health and social services be available to support persons with HIV (CDC, HRSA, NIH, et al, 2014).
Nurses can assist employers by educating managers about how to deal with ill or infected workers to reduce the risk of breaching confidentiality or wrongful actions such as termina- tion. Disclosing a worker’s infection to other workers, terminat- ing employment, and isolating an infected worker are examples of situations that have led to litigation between employees and employers. The CDC supports workplace issues through pro- grams offered by its Business and Labor Resource Service. (See resources on the Evolve website at http://evolve.elsevier.com/ Stanhope.)
HIV-infected children should attend school because the benefit of attendance far outweighs the risk of transmitting or acquiring infections. None of the cases of HIV infection in the United States have been transmitted in a school setting. An interprofessional team that includes the child’s physician, the
326 PART 3 Conceptual and Scientific Frameworks
Disease/ Pathogen Incubation
Signs and Symptoms Diagnosis Treatment
Nursing Implications
Bacterial Chlamydia:
Chlamydia trachomatis
3-21 days Man: None or non-gonococcal urethritis (NGU); painful urination and urethral discharge; epididymitis
Woman: None or mucopurulent cervicitis (MPC), vaginal discharge; if untreated, progresses to symptoms of PID: diffuse abdominal pain, fever, chills
Nucleic acid amplification test (NAAT) of male urine and female endocervix
One of following treatments: Doxycycline 100 mg PO bid × 7 days Azithromycin 1 g PO × 1 Alternative regimens: Erythromycin base 500 mg PO qid ×
7 days Erythromycin ethylsuccinate 800 mg
PO qid × 7 days Levofloxacin 500 mg PO, daily × 7
days Ofloxacin 300 mg PO bid × 7 days Doxycycline, effective and cheap Azithromycin, good because single
dose is sufficient
Refer partners of past 60 days; counsel client to use condoms and to avoid sex for 7 days after start of therapy and until symptoms are gone in both client and partners; medication teaching
Annual screening recommended for all sexually active women under 25, and women over 25 with new or multiple sexual partners
Gonorrhea: Neisseria gonorrhoeae
3-21 days Man: Urethritis, purulent discharge, painful urination, urinary frequency; epididymitis
Woman: None, or symptoms of PID
Nucleic acid amplification test (NAAT)
For uncomplicated gonorrhea: Ceftriaxone 250 mg. IM PLUS EITHER Azithromycin 1 gm PO × 1 OR Doxycycline 100 mg PO qd × 7 days If ceftriaxone not readily available,
PO cefixime may be used in combination with doxycycline or azithromycin, but patient should return at one week for a test-of-cure at the site of infection
Refer partners of past 60 days; return for evaluation if symptoms persist; counsel client to use therapy until complete and symptoms are gone in both client and partners; medication teaching
Syphilis: Treponema pallidum
10-90 days 6 weeks to 6 months
Within 1 year of infection
After 1 year from date of infection
Late active: 2-40 years 20-30 years 10-30 years
Primary: usually single, painless chancre; if untreated, heals in few weeks
Secondary: low-grade fever, malaise, sore throat, headache, adenopathy, and rash
Early latency: Asymptomatic, infectious lesions may recur
Late latency: Asymptomatic, noninfectious except to fetus of pregnant women
Gummas of skin, bone, mucous membranes, heart, liver
CNS involvement: Paresis, optic atrophy
Cardiovascular involvement: Aortic aneurysm, aortic value insufficiency
Visualization of pathogen on dark field microscopic examination; single painless ulcer (chancre); FTA-ABS or MHA-TP, VDRL (reactive 14 days after appearance of chancre)
Clinical signs of secondary syphilis
VDRL: FTA-ABS or MHA-TP
Lumbar puncture, CSF cell count, protein level determination and VDRL
Penicillin G 2.4 million units, IM once
If penicillin allergy: Doxycycline 100 mg PO bid × 14
days (p.30) Tetracycline 500 mg four times daily × 14 days
Tetracycline should not be administered to pregnant women or those with neurosyphilis or congenital syphilis
Early syphilis: Ceftriaxone (1 g daily either IM or IV
for 10-14 days) Azythrmomycin 2-g PO once Early latent: Benzathine penicillin G 2.4 million
units IM in a single dose Late latent or latent: Benzathine penicillin G 7.2 million
units total in three doses of 2.4 million units IM at 1-week intervals
Tertiary: Benzthine penicillin G 7.2 million
units total, in three doses of 2.4 million units IM each at 1-week intervals
In general, penicillins are prescribed in varying doses depending on diagnosis
Counsel to be tested for HIV; screen all partners of past 3 months; re-examine client at 3 and 6 months
TABLE 14-3 Summary of Sexually Transmitted Diseases
327CHAPTER 14 Communicable and Infectious Disease Risks
Disease/ Pathogen Incubation
Signs and Symptoms Diagnosis Treatment
Nursing Implications
Viral Human
immunodeficiency virus (HIV)
4-6 weeks Seroconversion: 6
weeks to 3 months
AIDS: month to years (average, 11 years)
Possible: Acute mononucleosis-like illness (lymphadenopathy, fever, rash, joint and muscle pain, sore throat)
Appearance of HIV antibody
Opportunistic diseases: Most commonly Pneumocystis jiroveci pneumonia, oral candidiasis, Kaposi’s sarcoma
HIV antibody test: EIA or Western blot test; OraSure (SmithKline Beecham) is an oral HIV-1 antibody testing system, test results in about 3 days
CD4+ T-lymphocyte count of less than 200/µl with documented HIV infection, or diagnosis with clinical manifestation of AIDS as defined by CDC
Prophylactic administration of zidovudine (ZDV) immediately after exposure may prevent seroconversion
Post-exposure prophylaxis (PEP) should begin as soon as possible. Choice of antiviral drug therapy is made based on toxicity and drug resistance. Combinations of drugs are considered such as zidovudine (ZDV) and 3TC. Drug selection is complicated and evolving.
Pre-exposure prophaylaxis (PrEP) was approved in 2012, consisting of daily tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC), for use among sexually active, at-risk adults.
HIV education and counseling; partner referral for evaluation; medication education; assessment and referral
Men who have sex with men should be tested annually for HIV, chlamydia, syphilis, and gonorrhea
Genital warts: human papillomavirus (HPV)
4-6 weeks most common; up to 9 months
Often subclinical infection; painless lesions near vaginal openings, anus, shaft of penis, vagina, cervix; lesions are textured, cauliflower appearance; may remain unchanged over time
Visual inspection for lesions; Pap smear; hybrid capture 2 HPV DNA test; colposcopy
Prevention: Gardasil vaccine No cure; one third of lesions will
disappear without topical treatment
Client-applied: topical podofilix 0.5% bid × 3 days, 4 days of no therapy; or imiquimod 5% cream daily at bedtime for up to 16 weeks
Provider-administered: podophyllum resin 10%-25% or trichloroacetic acid 80%-90%; repeat weekly if needed; cryotherapy with liquid nitrogen, laser, or surgical removal
Education about HPV vaccine
Warts and surrounding tissues contain HPV, so removal of warts does not completely eradicate virus; examination of partners not necessary, since treatment is only symptomatic; condom use may reduce transmission; medication application
Genital herpes simplex virus (HSV)
2-20 days; average, 6 days
Vesicles, painful ulceration of penis, vagina, labia, perineum, or anus; lesions last 5-6 weeks and recurrence is common; may be asymptomatic
Presence of vesicles; viral culture (obtained only when lesions present and before they have scabbed over)
No cure; treatment may be episodic or suppressive for frequent recurrence
Episodic treatment: acyclovir 400 mg PO tid × 7-10 days;
OR Acyclovir 200 mg PO five times a day × 7-10 days;
OR famciclovir 250 mg PO tid 7-10 days;
or valacyclovir 1 g PO bid × 7-10 days
Refer partners for evaluation; teach client about likelihood of recurrent episodes and ability to transmit to others even if asymptomatic; condom use; annual Pap smear
TABLE 14-3 Summary of Sexually Transmitted Diseases—cont’d
From: Centers for Disease Control and Prevention: Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR Morb Mortal Wkly Rep 59(RR-12), 2010. Centers for Disease Control and Prevention: Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines 2010: Oral Cephalosporins no longer a recommended treatment for Gonococcal infections. MMWR Morb Mortal Wkly Rep 61(31), 2012. Centers for Disease Control and Prevention: Pre-exposure prophylaxis (2013m). Available at: http://www.cdc.gov/hiv/prevention/research/prep/. Accessed March 12, 2014. Centers for Disease Control and Prevention: Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae. MMWR Morb Mortal Wkly Rep 63(RR-2), 2014.
328 PART 3 Conceptual and Scientific Frameworks
virus and human papillomavirus (HPV), also referred to as genital warts. The hepatitis A, B, and C viruses, which may also be transmitted via sexual activity, are discussed later in this chapter.
Gonorrhea Neisseria gonorrhoeae is a gram-negative intracellular diplococ- cal bacterium that infects the mucous membranes of the genitourinary tract, rectum, and pharynx. It is transmitted through genital–genital contact, oral–genital contact, and anal–genital contact.
Gonorrhea is identified as either uncomplicated or compli- cated. Uncomplicated gonorrhea refers to limited cervical or urethral infection. Complicated gonorrhea includes salpingitis, epididymitis, systemic gonococcal infection, and gonococcal meningitis. The signs and symptoms of infection in males are purulent and copious urethral discharge and dysuria. Symp- toms in males are usually sufficient to seek treatment. Gonococ- cal infection in women however, is commonly asymptomatic, and treatment may not be sought. The disease will continue to be spread to others through sexual activity and may not be recognized until pelvic inflammatory disease (PID) occurs (CDC, 2010b).
Some individuals may continue to be sexually active and infect others while symptomatic. Co-infection with gonorrhea and chlamydia is common; therefore treatment containing cef- triaxone combined with either doxycycline or azithromycin is recommended (CDC, 2012g).
Reported gonorrhea rates are on the rise again after a long period of decline, particularly in the Northeast, Midwest, and West, although overall rates are still highest in the South (CDC, 2014b). The reported number of cases in the United States in 2012 was 334,826. The difference between the actual cases and reported cases occurs because gonorrhea may be unreported by health care providers, and because clients who are asymptomatic do not seek treatment and are therefore not identified. Groups with the highest incidence of gonorrhea are African Americans, persons living in the southern United States, and women 15 to 24 years of age (CDC, 2014b).
The number of antibiotic-resistant cases of gonorrhea in the United States has risen at an alarming rate. Penicillin- resistant gonorrhea was first identified in 1976 when 15 cases were reported (Phillips, 1976). By 1990, 64,972 resistant cases were reported (J. Blount, personal communication, January 18, 1991). Antibiotic-resistant N. gonorrhoeae has continued to develop exponentially, with gonorrhea becoming resistant to every antibiotic used for treatment, starting with penicillin and moving through sulfonamides, tetracycline, and fluoroquino- lones, (CDC, 2013a). In 2012, the CDC revised its treatment guidelines and no longer recommended oral cephalosporins, specifically cefixime, as a first-line treatment for gonorrhea (CDC, 2012g), in an effort to preserve the last remaining treatment option (CDC, 2013a). At this time, combination therapy of ceftriaxone IM along with either oral doxycycline or azithromycin is the most reliably effective treatment for uncomplicated gonorrhea (CDC, 2012g). The injection
route versus the previously recommended oral cefixime may make treatment more challenging due to patient fear of injec- tion and health care facilities having to stock injectable medi- cation (CDC, 2013a).
The increase in antibiotic-resistant infections is partially attributed to the indiscriminate or illicit use of antibiotics as a prophylactic measure by persons with multiple sexual partners. To ensure proper treatment and cure, those diagnosed with gonorrheal infection should return for health care if symptoms persist, have their partners of the previous 60 days evaluated for infection, and remain sexually abstinent until antibiotic therapy is completed (CDC, 2010b).
The development of PID is a risk for women who remain asymptomatic and do not seek treatment. PID is a serious infec- tion involving the fallopian tubes (salpingitis) and is the most common complication of gonorrhea, but may also result from chlamydia infection. Its symptoms include fever, abnormal menses, and lower abdominal pain, but PID may not be recog- nized because the symptoms vary among women. PID can result in ectopic pregnancy and infertility related to fallopian tube scarring and occlusion. It may also cause stillbirths and premature labor (CDC, 2010b).
Syphilis Syphilis is caused by a member of the treponemal group of spirochetes called Treponema pallidum. It infects moist mucous or cutaneous membranes and is spread through direct contact, usually by sexual contact or from mother to fetus. Transmission via blood transfusion may occur if the donor is in the early stages of disease (Heymann, 2014).
Syphilis rates in the United States declined between 1990 and 2000, but then increased between 2001 and 2009. Rates increased again in 2012 (CDC, 2014d). The highest rates are among men having sex with men, but in recent years the number of infected women has increased.
The clinical signs of syphilis are divided into primary, sec- ondary, and tertiary infections. Latency, a period when an indi- vidual is free of symptoms but has serologic evidence, may occur early or late in the infection. Latency that occurs during the first year of infection is called early latency. Late latency may occur after this first year. During latency, the possibility of relapse remains (CDC, 2010b).
Primary Syphilis When syphilis is acquired sexually, the bacteria produce infec- tion in the form of a chancre at the site of entry. The lesion begins as a macula, progresses to a papule, and later ulcerates. If left untreated, this chancre persists for 3 to 6 weeks and then in most cases disappears (Heymann, 2014).
Secondary Syphilis Secondary syphilis occurs when the organism enters the lymph system and spreads throughout the body. Signs include rash, lymphadenopathy, and mucosal ulceration. Symptoms of secondary syphilis may include skin rash, lymphadenopathy, and lesions of the mucous membranes (CDC, 2010b).
329CHAPTER 14 Communicable and Infectious Disease Risks
Herpes Simplex Virus (Genital Herpes) Herpes simplex viruses (HSV-1 and HSV-2) cause genital herpes, and an increasing number of genital herpes infections are caused by HSV-1 (CDC, 2013c). The majority of genital herpes infections are caused by HSV-2, and these herpes infec- tions are more likely to be recurrent (Buttaro, 2013).
As is true for other viral STDs, there is no cure for herpes infection, and it is considered a chronic disease. The virus is transmitted through direct exposure and infects the genitalia and surrounding skin. After the initial infection, the virus remains latent in the sacral nerve of the central nervous system and may reactivate periodically with or without visible vesicles.
Signs and symptoms of HSV infection include the presence of painful lesions that begin as vesicles and ulcerate and crust within 1 to 4 days. The first episode is typically longer and is usually characterized by more lesions than seen in subsequent infections. Lesions may occur on the vulva, vagina, upper thighs, buttocks, and penis and have an average duration of 11 days (Figure 14-3). The vesicles can cause itching and pain and may be accompanied by dysuria or rectal pain. Although the ability to pass the infection to others is higher with active lesions, some individuals can spread the virus even when they are asymptom- atic. There can be a prodromal phase before lesions develop that includes tingling and paresthesia at the site (Heymann, 2014).
HSV-2 occurs in 16.2% of American adolescents and adults (CDC, 2013c). This prevalence is likely underrated because HSV-1 infections are rising, and a large number of people have no symptoms, thus HSV is difficult to identify. The conse- quences of genital herpes are of particular concern for women and their children. HSV-2 infection is linked with the develop- ment of cervical cancer. There is also an increased risk of fatal newborn infection during vaginal delivery with active lesions (Heymann, 2014). A pregnant woman who has active lesions at the time of giving birth should have a cesarean delivery before the rupture of amniotic membranes to avoid fetal contact with the herpetic lesions, whereas those who have no clinical evi- dence of herpes lesions should be delivered vaginally. A small number of infants are infected in utero. The clinical infection
Tertiary Syphilis Tertiary syphilis can lead to blindness, congenital damage, car- diovascular damage, or syphilitic psychoses. A further compli- cation can be the development of lesions of the bones, skin, and mucous membranes, known as gummatous lesions. Tertiary syphilis usually occurs several years after initial infection and is rare in the United States because the disease is usually cured in its early stages with antibiotics. Tertiary syphilis is a major problem in developing countries.
Congenital Syphilis When primary and secondary syphilis rates increase, so do the rates of congenital syphilis (CS), which increased 23% in 2008 (CDC, 2010a). Syphilis is transmitted transplacentally and, if untreated, can cause premature stillbirth, blindness, deafness, facial abnormalities, crippling, or death. Signs include jaundice, skin rash, hepatosplenomegaly, or pseudoparalysis of an extrem- ity. Treatment consists of penicillin given intravenously or intramuscularly (CDC, 2010a).
Chlamydia Chlamydia infection results from the bacterium Chlamydia tra- chomatis. It infects the genitourinary tract and rectum of adults and causes conjunctivitis and pneumonia in neonates. Trans- mission occurs when mucopurulent discharge from infected sites, such as the cervix or urethra, comes into contact with the mucous membranes of a noninfected person. Like gonorrhea, the infection is often asymptomatic in women, where up to 70% may experience no symptoms (Heymann, 2014). If left untreated, chlamydia can result in PID. When symptoms of chlamydial infection are present in women, they include dysuria, urinary frequency, and purulent vaginal discharge. In men, the urethra is the most common site of infection, resulting in non-gonococcal urethritis (NGU). The symptoms of NGU are dysuria and urethral discharge. Epididymitis is a possible complication (CDC, 2013p). The CDC recommends annual chlamydial screening of all sexually active women younger than 26 (CDC, 2014a). Older women with new or more than one sex partner and all pregnant women should also be tested (CDC, 2014g).
Chlamydia is the most common reportable infectious disease in the United States, and in 2012 a total of 1,422,976 cases of genital chlamydial infection were reported. Between 1992 and 2012, the rate of reported chlamydia infection increased from 182.3 to 456.7 cases per 100,000 population, reflecting increased screening rates, an emphasis on case reporting, and more sensi- tive testing (CDC, 2014a). Prevention is important because chlamydia can cause PID, ectopic pregnancy, infertility, and neonatal complications. Women under 25 years of age are the most commonly infected with chlamydial infection because of inconsistent use of barrier contraceptives, multiple sexual part- ners, and a history of infection with other STDs (CDC, 2014g). The high frequency of chlamydial infections in individuals infected with gonorrhea requires that effective treatment for both organisms be given when a gonorrheal infection is identi- fied (CDC, 2010b).
FIG 14-3 Herpes genitalis. (From Habif TP: Clinical dermatol- ogy: a color guide to diagnosis and therapy, ed 5. St Louis, 2010, Mosby.)
330 PART 3 Conceptual and Scientific Frameworks
HEPATITIS Viral hepatitis refers to a group of infections that primarily affect the liver. These infections have similar clinical presenta- tions but different causes and characteristics. Brief profiles of the types of hepatitis are presented in Table 14-4.
Hepatitis A Virus Hepatitis A virus (HAV) is most commonly transmitted through the fecal–oral route. Sources may be water, food, feces, or sexual contact. The virus level in the feces appears to peak 1 to 2 weeks before symptoms appear, making individuals highly contagious before they realize they are ill (Heymann, 2014).
The vaccine for hepatitis A infection has been available since 1995, and since that time the incidence has steadily declined (CDC, 2011). The vaccine makes HAV a completely preventable disease. Persons most at risk for HAV infection are travelers to countries with high rates of the disease, children living in areas with high rates of HAV infection, injection drug users, MSM, and persons with clotting disorders or chronic liver disease. Since routine childhood vaccination was recommended in 1996, the overall hepatitis A rate has declined 53%, from 2,979 cases reported in 2007 to 1,398 in 2011 (CDC, 2011).
Hepatitis A is found worldwide. In developing countries where sanitation is inadequate, epidemics are not common because most adults are immune from childhood infection. In countries with improved sanitation, outbreaks are common in daycare centers whose staff must change diapers, among household and sexual contacts of infected individuals, and among travelers to countries where hepatitis A is endemic. In many outbreaks, one individual is the source of an infection that may spread in the community. In other cases, hepatitis A is spread through food contaminated by an infected food- handler, contaminated produce, or contaminated water. The source of infection may never be identified in many outbreaks (Heymann, 2014).
The clinical course of hepatitis A ranges from mild to severe and often requires prolonged convalescence. Onset is usually acute, with fever, nausea, lack of appetite, malaise, and abdomi- nal discomfort followed by jaundice after several days.
Vaccination and appropriate sanitation and personal hygiene remain the best means of preventing infection. The HAV vaccine is recommended for those who travel frequently or who spend long periods in countries where the disease is endemic. In cases of exposure through close contact with an infected individual or contaminated food or water, an injection of prophylactic immunoglobulin (IG) is indicated. IG should be given as soon as possible, but can be given within 2 weeks of exposure. Candidates for hepatitis A vaccine are listed in Box 14-2 (CDC, 2013d).
Hepatitis B Virus The number of new cases of hepatitis B virus (HBV) has steadily declined since HBV vaccination became available. In 2011 a total of 2,890 acute hepatitis B cases were reported, down 36% overall since 2007 (CDC, 2011). The groups with the highest prevalence are users of injection drugs, persons with
in infants may present as liver disease, encephalitis, or infection limited to the skin, eyes, or mouth (Heymann, 2014).
Human Papillomavirus Infection Human papillomavirus (HPV) results in genital warts. Spe- cific types of HPV cause cervical cancer, which is the second most common cancer worldwide (Heymann, 2014). HPV is the most common STD in the United States (CDC, 2014f ). Trans- mission of HPV occurs through direct contact with warts that result from HPV and can infect the mouth, genitals, and anus. Genital warts are most commonly found on the penis and scrotum in men, and on the vulva, labia, vagina, and cervix in women. They appear as textured surface lesions, with what is sometimes described as a cauliflower appearance. The warts are usually multiple and vary between 1 mm to 1 cm in diameter. They may be difficult to visualize, so careful examination is required (Buttaro et al, 2013).
Since 2006, two FDA-licensed vaccines have been developed, bivalent and quadrivalent, both of which stimulate the immune system to block cancer-causing HPV infection before it occurs. The quadrivalent vaccine has the added benefit of preventing anogenital warts (CDC, 2014f ). The recommended age for vac- cination in both girls and boys is 11 to 12 years old, but it can be given in those aged 9 to 26 years old (CDC, 2014c). Complete vaccination coverage is an issue, however. In 2012, first dose vaccination rates for adolescent girls was low at 53.8%, and this dropped to 33.4% for all three doses. Experts recommend several strategies to increase vaccination rates in adolescent girls and boys, such as a reminder/recall system to increase vaccina- tion rates and consideration of use of schools as a vaccination site. In some areas, requiring HPV vaccination for school entry has been successful, but this practice is not widely utilized to date (CDC, 2014f ).
Once HPV infection occurs, the goal of therapy is to elimi- nate the warts. Genital warts spontaneously disappear over time, as do skin warts. However, because the condition is worrisome for the client and HPV may lead to the develop- ment of cervical neoplasia, treatment of the warts through surgical removal, laser therapy, or cytotoxic agents is often done (Buttaro, 2013).
Complications of HPV infection may be especially serious for women. The link between HPV infection and cervical cancer has been established and is associated with specific types of the virus. Other cancers attributed to HPV include vaginal, anal, and oropharyngeal (CDC, 2014f ). Pap smears are vitally impor- tant because they allow for microscopic examination of cells to detect HPV, which can be surgically removed if detected early (Heymann, 2014). HPV infection is exacerbated in both preg- nancy and immune-related disorders, which are believed to result from a decrease in cell-mediated immune functioning. HPV may infect the fetus during pregnancy and can result in a laryngeal papilloma that can obstruct the infant’s airway. Genital warts may enlarge and become friable during pregnancy, and therefore surgical removal may be recommended. One chal- lenge of HPV prevention is that condoms do not necessarily prevent infection. Warts may grow where barriers, such as condoms, do not cover and skin-to-skin contact may occur.
331CHAPTER 14 Communicable and Infectious Disease Risks
Hepatitis A Hepatitis B Hepatitis C
Incubation period
Average, 28 days; range, 15-50 days Average, 90 days; range, 60-150 days Average, 45 days; range, 14-180 days
Mode of transmission
Fecal–oral, contaminated food/water, sexual Bloodborne, sexual, perinatal Primarily bloodborne; also sexual and perinatal
Incidence Estimated number of new infections: 17,000 in 2010 in the United States. Reported in the U.S. in 2011: 1,398
Estimated 38,000 cases/yr in United States in 2010. Reported in the U.S. in 2011: 2,890
Estimated 16,500 cases/yr in United States in 2011. Reported in the U.S. in 2011: 1,229
Chronic carrier state?
No Yes, 5% of adult cases; 90% of infants; 25-50% of children aged 1-5 years
Yes, 75-85% or more of cases
Diagnosis Serologic test (anti-HAV), viral isolation Serologic tests (e.g. HBsAg), viral isolation Serologic tests (anti-HCV) Sequelae No chronic infection Chronic liver disease; liver cancer Chronic liver disease; liver cancer Vaccine
availability Yes, vaccination of all children at one year,
children in areas of high disease rates recommended; travelers to endemic regions; men who have sex with men; injection and noninjection drug users.
Yes, vaccination of infants recommended; All children who have not been already immunized; individuals with exposure risks; men who have sex with men; people with end stage renal disease, people with HIV infection
No
Control and prevention
Good hygiene (e.g., handwashing); proper sanitation
Pre-exposure vaccination; reduce exposure risk behaviors
Screening of blood/organ donors; reduce exposure risk behaviors
TABLE 14-4 Viral Hepatitis Profiles
FROM: Centers for Disease Control and Prevention: Viral hepatitis surveillance, United States, 2011. Available at http://www.cdc.gov/hepatitis/ Statistics/2011Surveillance/PDFs/2011HepSurveillanceRpt.pdf. Accessed February 13. 2014. Centers for Disease Control and Prevention: Hepatitis B FAQs for health professionals, 2012a. Available at http://www.cdc.gov/hepatitis/HBV/ HBVfaq.htm#overview. Accessed February 14. 2014. Centers for Disease Control and Prevention: Hepatitis A for health professionals: hepatitis A vaccination, 2013d. Last updated. Available at http://www.cdc.gov/hepatitis/HAV/HAVfaq.htm#vaccine. Accessed February 14, 2014. Centers for Disease Control and Prevention: Hepatitis C information for health professionals: testing recommendations for chronic hepatitis C infection, 2013e. Available at http://www.cdc.gov/hepatitis/hcv/guidelinesc.htm. Accessed February 17, 2014.
• All household or sexual contacts of persons with HAV • Persons who have shared illicit drugs with someone with HAV • All staff and attendees of daycare centers if a case of HAV occurs among
children or staff • Household members whose children attend a daycare center where two or
more families are infected • Food-handlers who have a coworker infected with HAV; patrons in unhy-
gienic situations or involvement where food is not heated
BOX 14-2 Recommendations for Administration of Hepatitis A Vaccine or Ig After Exposure
STDs or multiple sex partners, immigrants and refugees and their descendants who came from areas where there is a high endemic rate of HBV, health care workers, clients on hemodi- alysis, and inmates of long-term correctional institutions (Buttaro, 2013).
The HBV is spread through blood and body fluids and, like HIV, is a bloodborne pathogen. It has the same transmission properties as HIV, and thus individuals should take the same precautions to prevent spread of both HIV and HBV. A major difference is that HBV remains alive outside the body for a longer time than does HIV and thus has greater infectivity. The virus can survive for at least 1 week dried at room temperature on environmental surfaces, and thus infection control measures are paramount in preventing transmission from client to client (Heymann, 2014).
Infection with HBV results in either acute or chronic HBV infection. The acute infection is self-limited, and individuals develop an antibody to the virus and successfully eliminate the virus from the body. They subsequently have lifelong immunity against the virus. Symptoms range from mild, flu-like symp- toms to a more severe response that includes jaundice, extreme lethargy, nausea, fever, and joint pain. Any of these more severe symptoms may result in hospitalization. A second possible outcome from infection is chronic HBV infection, which more likely occurs in persons with immunodeficiency (Heymann, 2014). Chronically infected individuals are unable to rid their bodies of the virus and remain lifelong carriers of the hepatitis B surface antigen (HBsAg). As carriers, they are able to transmit the HBV to others. They may develop hepatic carcinoma or chronic active hepatitis. The signs and symptoms of chronic hepatitis B include anorexia, fatigue, abdominal discomfort, hepatomegaly, and jaundice (Heymann, 2014).
Strategies for preventing HBV infection include immuniza- tion, prevention of nosocomial occupational exposure, and pre- vention of sexual and injection drug–use exposure. Vaccination is recommended for persons with occupational risk, such as health care workers, and for infants. The series of vaccines required for protection from HBV consists of three intramus- cular injections, with the second and third doses administered 1 and 6 months after the first (CDC, 2014e). Pregnant women should be tested for HBsAg; if the mother is positive, newborns require hepatitis B immune globulin in addition to the hepatitis B vaccine within 12 hours of birth, and then at 1 and 6 months
332 PART 3 Conceptual and Scientific Frameworks
thereafter (CDC, 2014e). In instances in which the individual is not protected by vaccination and exposure to HBV occurs, hepatitis B immune globulin is given as soon as possible (within 24 hours is optimal) and the hepatitis B vaccine given (CDC, 2012a).
OSHA Regulations The Occupational Safety and Health Administration (OSHA) mandates specific activities to protect workers from HBV and other bloodborne pathogens. Potential exposures for health care workers are needlestick injuries and mucous membrane splashes. The OSHA standard requires employers to identify the risk of blood exposure to various employees. If employees perform work that involves a potential exposure to others’ body fluids, employers are mandated to offer the HBV vaccine to the employee at the employer’s expense, and to offer annual educa- tional programs on preventing HBV and HIV exposure in the workplace. Employees have the right to refuse the vaccine. Employees may decline the vaccine for a variety of reasons including thinking they are not at risk since they are married or in a monogamous relationship, that the vaccine is too new to have adequate information about it, or that there may be side effects to the vaccine (CDC, 2013b).
Hepatitis C Virus Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States (USPSTF, 2014). The HCV is transmitted when blood or body fluids of an infected person enter an uninfected person. Those groups at highest risk include health care workers and emergency person- nel who are accidentally exposed, infants who are born to infected mothers, those born between 1945 and 1965 (CDC, 2012d), and 1-time or chronic injection drug users, particularly those who share needles or other drug-use equipment (Hande, 2014). Others at risk include hemodialysis patients (from dialy- sis equipment shared with infected persons) and recipients of donor organs and blood products before 1992 (USPSTF, 2014). The greatest risk factor is past or current injection drug use, with a hepatitis C prevalence rate of 50% (USPSTF, 2014).
During the 1980s, HCV spread rapidly. It is estimated that 2.7 to 3.9 million people are infected in the United States, and they are often unaware that they have hepatitis C. Although those born between 1945 and 1965 represent only 27% of the population, they account for a disproportionate 75% of all hepatitis C cases in the United States (CDC, 2012d). Chronic liver disease from hepatitis C is the most common indication for liver transplants, representing 30% of all transplants (USPSTF, 2014).
The clinical signs of hepatitis C may be so mild that an infected individual does not seek medical attention. The incu- bation period ranges from 2 weeks to 6 months. Clients may experience fatigue and other nonspecific symptoms. Although some have spontaneous resolution of the infection, 50% to 80% develop chronic liver disease. HCV infection may lead to cir- rhosis or hepatocellular carcinoma (Heymann, 2014). Hepatitis C infection is related to about half of hepatocellular carcinoma cases, which have increased threefold (USPFTF, 2014).
Primary prevention of HCV infection includes screening of blood products and donor organs and tissue; risk reduction counseling and services, including obtaining injection drug use (IDU) history; and infection control practices. Secondary pre- vention strategies include testing of high-risk individuals, including those who seek HIV testing, and appropriate medical follow-up of infected clients. HCV testing should be offered to persons who received blood or an organ transplant before 1992; persons who have been on dialysis for many years; persons with signs and symptoms of liver disease; persons born between 1945 and 1965; and persons who received clot- ting factor before 1987. Routine testing for HCV is not recom- mended for health care workers, pregnant women, household contacts of HCV-positive persons, or the general population (CDC, 2013e).
Non-ABC Hepatitis Hepatitis viruses exist that are structurally unrelated to hepatitis A, B, or C. All are very uncommon in the United States, repre- senting less than 5% of total cases (CDC, 2009b). Hepatitis D (HDV), called Delta hepatitis, can be acute or chronic and can only exist in people who are already infected with hepatitis B, either as a co-infection or as a superinfection. In the United States, between 1.5% and 7.2% of HBV cases had serologic evidence of HDV co-infection (CDC, 2009b). It is possible to become a chronic carrier in 70% to 80% of cases. Although there is no vaccination for HDV, infection can be prevented by being vaccinated for HBV (CDC, 2013f ).
Hepatitis E virus (HEV) is an acute hepatitis infection that is transmitted through the fecal–oral route. Because it is not a chronic infection, one cannot become a chronic carrier for HEV. Although there is no hepatitis E vaccination, HEV can be prevented by protecting water systems from fecal contamina- tion (CDC, 2012b).
Another type of hepatitis virus is hepatitis G (GB virus C). This type of virus has been isolated from patients with post- transfusion hepatitis, but has not been found to be the cause of either acute or chronic hepatitis (CDC, 2009b).
TUBERCULOSIS Tuberculosis is a mycobacterial disease caused by Mycobacte- rium tuberculosis. Transmission usually occurs through expo- sure to the tubercle bacilli in airborne droplets from persons with pulmonary tuberculosis who talk, cough, or sneeze. Common symptoms are cough, fever, hemoptysis, chest pains, fatigue, and weight loss. The incubation period is 4 to 12 weeks. The most critical period for development of clinical disease is the first 6 to 12 months after infection. About 5% of those initially infected may develop pulmonary tuberculosis or extra- pulmonary involvement. The infection in about 95% of those initially infected becomes latent, but in about 10% of otherwise healthy individuals, it may be reactivated later in life. The chance of reactivation of latent infections increases in immu- nocompromised persons, substance abusers, underweight and undernourished persons, and persons with diabetes, silicosis, or gastrectomies (Heymann, 2014).
333CHAPTER 14 Communicable and Infectious Disease Risks
Diagnosis and Treatment The standard and preferred TB screening test is the Mantoux tuberculin skin test (TST) (CDC, 2012f ). The TST, previously referred to as the purified protein derivative (PPD) test, is used for initial screening. It can be followed by chest radiography for persons with a positive skin reaction and pulmonary symptoms. Persons who are immunosuppressed by drugs or who have diseases such as advanced tuberculosis, measles, or chicken pox may not have the ability to mount an immune response to the TST, so the result may be a false-negative skin test reaction resulting from cutaneous anergy (nonreaction due to weakened immune system). A second issue with the TST is that a positive result may come from an earlier TST or BCG vaccination boost- ing one’s ability to respond to the infection, and not reflecting a recent infection. Therefore, it is difficult to determine if the infection is old or recent. A blood test (in vitro gamma release interferon assays or IVGRA) is available and is increasingly used for providing clinical care in lieu of the TST (CDC, 2012e; Buttaro, 2013). One example is the QuantiFeron-TB blood test to detect M. tuberculosis infection. Diagnosis can also be made through stained sputum smears and other body fluids to deter- mine the presence of acid-fast bacilli (for presumptive diagno- sis), and culture of the tubercle bacilli for definitive diagnosis. The following How To box describes how to read a TST.
Epidemiology The WHO (2013) reported 8.6 million new cases of TB world- wide in 2012, and 1.3 million deaths due to TB. Prevalence is more difficult to determine, but WHO has reported 12 million prevalent cases in 2012, a number that has fallen dramatically since 1990. Worldwide, the Southeast Asia and Western Pacific Region accounts for 58% of the cases, and Africa accounts for 25% in 2012. India and China are the countries with the highest number of cases in the world (WHO, 2013). TB infection preva- lence in Africa reflects the infection with HIV, where 37% of TB cases are co-infected with HIV (WHO, 2013). In the United States, the incidence of TB increased between 1985 and 1992, but since then has shown a steady rate of decline (CDC, 2013n). Of the new cases, 59% are foreign-born persons living in the United States, with Asians and Hispanics being the most common ethnic groups, representing 30% and 28% of national TB cases. Half of all new cases are concentrated in four states: New York, Florida, Texas, and California (CDC, 2013n). Table 14-5 shows TB case rates in the United States by race/ethnicity.
Worldwide, TB drug resistance is a significant issue. This can be caused by people not completing the full course of treatment, provider prescription error, poor quality drugs, or lack of TB drug availability. Types of drug-resistant TB include multidrug resistant TB (MDRTB), defined by resistance to rifampin and isoniazid, and extremely drug-resistant TB (XDRTB), which is MDRTB plus added resistance to fluoroquinolones and at least three injectable second-line drugs (e.g., amikacin, kanamycin, and capreomycin) (WHO, 2013). Drug-resistant TB is a signifi- cant concern to people with weak immune systems, such as HIV-infected individuals.
To prevent TB, the CDC works with public health agencies in other countries to improve screening and reporting of cases and to improve treatment strategies. This includes coordination of treatment for infected individuals who migrate to the United States. This coordination is particularly significant between Mexico and the United States (WHO, 2013).
Ethnicity/Sex Number of Cases
TB Case Rate Per 100,000
Asian 2,957 18.9 Native Hawaiian/other Pacific Islander 64 12.3 Black/African American 2,234 5.8 Hispanic/Latino 2,790 5.3 American Indian/Alaska Native 146 6.3 White 1,572 0.8 Multiple Race 148 2.5 Female 3,914 2.5 Male 6,028 3.9 Total population 9,945 3.2
TABLE 14-5 U.S. Tuberculosis (TB) Case Rates by Ethnicity and Sex, 2012
Fr: Centers for Disease Control and Prevention: Reported tuberculosis in the United States, 2012. Atlanta: U.S. Department of Health and Human Services, CDC, October, 2013. Available at http:// www.cdc.gov/tb/statistics/reports/2012/pdf/report2012.pdf.
Clients with TB should be treated promptly with the appro- priate combination of multiple antimicrobial drugs. Effective
(CDC, 2003; CDC, 2012e; Buttaro, 2013)
HOW TO How to Perform a Tuberculin Skin Test (TST) Apply and Read the TST • For the Mantoux test, inject 0.1 mL containing 5 tuberculin units
of purified protein derivative PPD tuberculin. • Read the reaction 48 to 72 hours after injection. • Measure only induration, not redness. • Record results in millimeters. Interpret the TST (Buttaro, 2013) Test is positive if the induration is greater than or equal to 5 mm in the following: • Immunosuppressed clients • Persons known to have HIV infection • Persons whose chest radiograph is suggestive of previous TB
that was untreated • Close contacts of a person with infectious TB • Organ transplant recipients
Test is positive if the induration is greater than or equal to 10 mm in the following: • Persons with certain medical conditions, such as diabetes, alco-
holism, or drug abuse • Persons who inject drugs (if HIV negative) • Foreign-born persons from areas where TB is common • Children under 4 years old • Residents and staff of long-term care facilities, jails, and prisons
Test is positive if the induration is greater than or equal to 15 mm in the following: • All persons more than 4 years of age with no risk factors for TB
Fr: Heymann D: Control of Communicable Diseases Manual, Washington, DC, 2008, American Public Health Association.
334 PART 3 Conceptual and Scientific Frameworks
especially challenging when STDs are the object of the study. In these situations, the nurse should obtain a sexual and IDU history for clients and their partners. The sexual history provides information that leads to the need for specific diag- nostic tests, treatment modalities, and partner notification. It also facilitates evaluation of risk factors and is necessary for the nurse to be able to provide relevant education for the client’s lifestyle.
Assessing a client’s risk of acquiring an STD should be done with all sexually active individuals. Such risk assessments should be included as baseline assessment data for those attending all clinics and those who receive school health, occupational health, public health, and home nursing services.
A thorough sexual history requires obtaining personal and sensitive information. It includes information about the types of relationships, the number of sexual partners and encounters, and the types of sexual behaviors practiced. The confidential nature of the information and how it will be used should be shared with the client to establish open communication and goal-directed interaction. Most clients feel uneasy disclosing such personal information. The nurse can ease this discomfort by remaining supportive and open during the interview to facilitate honesty about intimate activities. The nurse serves as a model for discussing sensitive information in a candid manner. When discussing precautions, direct and simple language should be used to describe specific behaviors. This encourages the client to openly discuss sexuality during this interaction and with future partners.
Nurses who are uncomfortable discussing topics such as sexual behavior or sexual orientation are likely to avoid assess- ing risk behaviors with the client. They will, consequently, be ineffective in identifying risks and helping clients modify risky behaviors. Nurses need to be adept at helping clients prevent and control STDs. Nurses can gain confidence in conducting sexual risk assessments by understanding their own values and feelings about sexuality and realizing that the purpose of the interaction is to improve the client’s health. The nurse’s comfort in discussing sexual behavior can be improved by using role playing to practice assessments of sexual and IDU behavior, and by contracting with clients to make behavior changes.
Identifying the number of sexual and injection drug–using partners and the number of contacts with these partners pro- vides information about the client’s risk. The chance of expo- sure decreases as the number of partners decreases, so people in mutually monogamous relationships are at low risk for acquiring STDs. You can gather this information by asking, “How many sex (or drug) partners have you had over the past 6 months?” Try to avoid basing assumptions about the sexual partner or partners on the client’s sex, age, ethnicity, or any other factor. Stereotypes and assumptions about who people are and what they do are common problems that keep interviewers from asking the questions that lead to obtaining useful informa- tion. For example, it should not be taken for granted that a homosexual man always has more than one partner. Be aware also that the long incubation of HIV and the subclinical phase of many STDs lead some monogamous individuals to assume erroneously that they are not at risk.
drug regimens used in the United States include isoniazid, and in some instances, rifampin. Treatment regimens for persons with active symptomatic infection may be different from the regimens used for persons with latent TB infection or with HIV (Buttaro, 2013). Treatment failure may be due to clients’ poor adherence in taking the medication, which can result in drug resistance. Nurses usually administer TSTs and provide educa- tion on the importance of compliance to long-term therapy. They may also be involved in directly observed therapy (DOT) and contact investigations of cases in the community.
NURSE’S ROLE IN PROVIDING PREVENTIVE CARE FOR COMMUNICABLE DISEASES
From prevention to treatment, the nurse functions as a coun- selor, educator, advocate, case manager, and primary care pro- vider. Appropriate interventions for primary, secondary, and tertiary prevention are reviewed in the following sections (see Levels of Prevention box). In the following discussion of primary prevention, the nursing process is applied to the care of clients with communicable diseases. Nurses are in an ideal position to affect the outcomes of communicable diseases, and their influence begins with primary prevention.
LEVELS OF PREVENTION
Primary Prevention • Provide community education about prevention of communicable diseases
to well populations. • Vaccinate for hepatitis A virus (HAV) or hepatitis B virus (HBV). • Provide community outreach for education and needle exchange.
Secondary Prevention • Administer tuberculin skin test (TST). • Test and counsel for human immunodeficiency virus (HIV). • Notify partners and trace contacts.
Tertiary Prevention • Educate caregivers of persons with HIV about standard precautions. • Maintain long-term directly observed therapy (DOT) for tuberculosis
treatment. • Identify community resources for providing supportive care (e.g., funds for
purchasing medications). • Set up support groups for persons with genital herpes.
Primary Prevention Primary prevention consists mainly of activities to keep people healthy before the onset of disease. This begins with assessing for risk behavior and providing relevant intervention through education on how to avoid infection, mostly through healthy behaviors.
Assessment To assess the risk of acquiring an infection, the nurse takes a history that focuses on risk behaviors and potential exposure, which varies with the specific organism by its mode of trans- mission. The specific questions that must be asked can be
335CHAPTER 14 Communicable and Infectious Disease Risks
It is important to identify whether the person has sexual contact with men, women, or both. This information can be obtained by simply asking, “Do you have sex with men, women, or both?” This lets the client know that the nurse is open to hearing about these behaviors, and thus the nurse is more likely to obtain information that is relevant to sexual practices and risk. Women who are exclusively lesbian are at low risk for acquiring STDs, but bisexual women may transmit STDs between male and female partners. In addition, it is possible for men to have sexual contact with other men and not label them- selves as homosexual. Therefore, education to reduce risk that is aimed at homosexual men will not be heeded by men who do not see themselves as homosexual. In such situations the nurse can ask, “When was the last time you had sex with another man?”
Certain sexual practices are more likely to result in exposure to and transmission of STDs. Dangerous sexual activities include all unprotected intercourse (anal, oral, or vaginal), oral– anal contact, and insertion of finger or fist into the rectum.
Vaccination to prevent transmission of HPV has been recommended for several years for young men as well as women, with primary vaccination recommended for boys at 11-12 years and secondary vaccination to catch those never vaccinated through age 26. There is an emphasis on vaccination because half of new HPV infections occur in young people between the ages of 15 and 24.
In this study, nurse researchers surveyed 735 male college students (ages 18-25) who were sexually active (previously or currently) with men, women, or both, and examined their vaccination rates, personal perceptions of risk for sexually transmitted infections, and barriers to vaccination. Researchers col- lected both quantitative and qualitative data from the student participants, consisting of demographic data, vaccination rates, data about sexual prac- tices, and qualitative data about perspectives on the HPV vaccination, such as why they had not received it, or why they may not have completed the three-dose vaccination.
The researchers found that, although the student participants engaged in risky sexual practices such as high number of lifetime sexual partners (mean 6.3) and over half either never using condoms (10%) or sometimes using condoms (41%), 93% of participants did not view themselves as being at risk for sexually transmitted infections. Multivariate analysis revealed that partici- pants who always wore condoms were more likely to have received the vaccine, and the older the participant was, the less likely he was to have received the vaccine.
Quantitative data about the HPV vaccination focused on barriers to obtaining the vaccine, such as cost and inconvenience. Many participants had not heard of either HPV itself or the vaccine, or did not know that men could get the vaccine. The male participants also did not know about the link between oropharyngeal cancer and HPV for men, and only some participants knew about the link between cervical cancer and HPV for women.
Nurse Use This study highlights the importance of education and awareness about HPV and the HPV vaccination for both men and women. Nurses can play a large role in information dissemination and vaccination promotion effort.
EVIDENCE-BASED PRACTICE
Fontenot HB, Fantasia HC, Charyk A, et al: Human papillomavirus (HPV) risk factors, vaccination patterns, and vaccine perceptions among a sample of male college students. Journal of American College Health 62(3):186–192, 2014. DOI: 10.1080/07448481.2013.872649.
These practices introduce a high risk of transmission of enteric organisms or result in physical trauma during sexual encoun- ters. The nurse can obtain information about sexual encounters by asking, “Can you tell me the kinds of sexual practices in which you engage? This will help determine what risks you may have and the type of tests we should do.” Clients who engage in genital–anal, oral–anal, or oral–genital contact will need throat and rectal cultures for some STDs as well as cervical and ure- thral cultures.
Drug use is linked to STD transmission in several ways. Drugs such as alcohol put people at risk because they can lower inhibitions and impair judgment about engaging in risky behaviors. Addictions to drugs may cause individuals to acquire the drug or money to purchase the drug through sexual favors. This increases both the frequency of sexual contacts and the chances of contracting STDs. Thus, the nurse should obtain information on the type and frequency of drug use and the presence of risk behaviors.
The administration of immunizations is another example of primary prevention, because they prevent infection. Of the dis- eases presented here, vaccines are available for human papillo- mavirus and hepatitis A and B.
Interventions Interventions to prevent infection are aimed at preventing spe- cific infections. These interventions can take several forms and include things such as education on how to prevent infection or the availability of vaccines. For example, on the basis of the information obtained in the sexual history and risk assessment just described, the nurse can identify specific education and counseling needs of the client. The nursing interventions focus on contracting with clients to change behavior and reduce their risk in regard to sexual practice.
HOW TO How to Effectively Obtain a Client’s Sexual History To be most effective, the nurse obtaining a client’s sexual history should do the following: • Remain supportive and open to facilitate honesty. • Use terms the client will understand (be prepared to suggest
multiple terms). • Speak candidly so the client will feel comfortable talking. • Ask open-ended questions in a nonthreatening and nonjudgmen-
tal manner. • Acknowledge that many people are uneasy disclosing personal
information. • Use the Five P’s Approach (CDC, 2010b). Sample questions in
each category are: • Partners: “In the past 2 months, how many partners have you
had sex with?” • Prevention of pregnancy: “What are you doing to prevent
pregnancy?” • Protection from STDs: “What do you do to protect yourself
from STDs and HIV?” • Practices: “To understand your risk for STDs, I need to under-
stand the kind of sex you’ve had recently.” • Past history of STDs: “Have you ever had an STD?”
336 PART 3 Conceptual and Scientific Frameworks
Sexual Behavior Sexual abstinence is the best way to prevent STDs. However, for many people, sexual abstinence is not realistic and providing instruction about how to make sexual behavior safer is critical. Safer sexual behavior includes masturbation, dry kissing, touch- ing, fantasy, and vaginal and oral sex with a condom.
If used correctly and consistently, properly fitted condoms can prevent both pregnancy and most STDs because they prevent the exchange of body fluids during sexual activity. Condom failure may occur from incorrect use rather than condom failure. Thus, information about proper use and how to communicate about them with a partner is also necessary. The nurse has many opportunities to convey this information during counseling. Most agency protocols recommend the use of latex condoms. Some may be lubricated with nonoxynol-9, a spermicide. If used frequently, nonoxynol-9 may result in genital lesions, which may provide openings for viruses to enter the body.
Condom use may be viewed as inconvenient, messy, or decreasing sensation. Moreover, alcohol consumption may accompany sexual activity, which may also decrease condom use. The nurse can help clients become more skilled in discuss- ing safer sex through role modeling and practicing communica- tion skills through role play. Role-playing scenarios with partners who are reluctant to use condoms can help individuals prepare for situations before they occur.
Female condoms are a barrier to body fluid contact and there- fore protect against pregnancy and STDs. The main advantage of the female condom is that its use is controlled by the woman. The FC2 Female Condom is the only female condom that is FDA approved for use in the United States. Since it is made of nitrile it is also useful if a latex sensitivity develops to male condoms. Symptoms of latex allergy include penile, vaginal, or rectal itching or swelling after use of a male condom or diaphragm. The female condom consists of a sheath over two rings, with one closed end that fits over the cervix. The condoms are often free at public health clinics, or can be purchased in boxes of multiple condoms, making the overall cost per condom less than $1.50 each. Figure 14-4 provides instructions on its insertion.
Clients should understand the importance of knowing the risk behavior of their sexual partners, including a history of IDU and STDs, sexual preference, and any current symptoms. Each sexual partner is potentially exposed to all the STDs of all the persons with whom the other partner has been sexually active.
Drug Use IDU is risky because the potential for injecting bloodborne pathogens, such as HIV, HBV, and HCV exists when needles and syringes are shared. During IDU, small quantities of drugs are repeatedly injected. Blood is withdrawn into the syringe and is then injected back into the user’s vein. Individuals should be advised against using injectable drugs and sharing needles, syringes, or other drug paraphernalia (a.k.a. works) (CDC, 2014i). If equipment is shared, it should be in contact with full- strength bleach for 30 seconds, and then rinsed with water
FIG 14-4 Insertion and positioning of the female condom. (Reproduced from The Female Health Company, Chicago, IL.)
Inner ring
Open end
Open end
Use your thumb and middle finger, and squeeze the ring toward the bottom so that it becomes thin and narrow. If you squeeze the inner ring near the top, when you insert it, your hand will be in the way.
1
Push the inner ring into your vaginal canal, behind your pubic bone. You will feel the female condom slide into place. IF you can feel the inner ring, or IF it causes any pain or discomfort, the ring is not up high enough near the cervix. Don’t worry, you can’t push it too far inside.
2
Next, take your index finger, put it inside the condom, and push the condom up higher into the vagina. This way, the outer ring will be closer to the outside of your vagina. YES, it has to be on the outside of you, because HE has to go inside the condom.
3
The condom is in place. Be sure that: • Your partner puts his penis inside of the female condom • Enough lubricant so the penis slips easily inside and out • A new female condom for each sex act
4
several times to prevent injecting bleach (CDC, 2004). This is a last-resort option.
People who inject drugs are difficult to reach for health care services. Effective outreach programs include using community peers, increasing accessibility of drug treatment programs
337CHAPTER 14 Communicable and Infectious Disease Risks
Testing and Counseling for HIV Universal testing for HIV infection should be routine for all clients aged 15 to 65 years (USPSTF, 2013). Younger adolescents and older adults who are at increased risk should be screened as well (CDC, 2013q; USPSTF, 2013). Therefore, routine HIV testing should be a part of all annual physicals, labs for every pregnancy, and all hospital visits, without securing special per- mission. Clients can decline or “opt out” of HIV testing, but the benefits of testing are considerable. For persons who have engaged in high-risk behavior, the nurse should recommend annual HIV testing (Box 14-3). Individuals with the following characteristics are considered at risk and should be offered HIV testing: those with a history of STDs (which are transmitted through the same behavior and may decrease immune func- tioning), multiple sex partners, or IDU; those who have unpro- tected intercourse (i.e., without using a condom or pre-exposure prophalyaxis [PrEP]) (CDC, 2013m); those who have inter- course with someone who has another partner and those who have had sex with a prostitute; men with a history of homo- sexual or bisexual activity; and those who have been a sexual partner to anyone in one of these groups.
Testing enables clients to benefit from early detection and treatment, as well as risk reduction education. If HIV infection is discovered before the onset of symptoms, early monitoring of the disease process and CD4 lymphocyte counts or viral loads is indicated. In addition, prophylactic therapy with antiretrovi- ral therapy and/or antibiotics may begin in order to delay the onset of symptomatic illness.
combined with HIV testing and counseling, and encouraging long-term repeat contacts after completion of the program.
Community Outreach Because of the illegal nature of injectable drugs and the poverty associated with HIV, many people at risk have neither the incli- nation nor the resources to seek health care. Nurses may work to establish programs within communities because the oppor- tunities for counseling on the prevention of HIV and other STDs are increased by bringing services into the neighborhoods of those at risk. Workers go into communities to disseminate information on safer sex, drug treatment programs, and discon- tinuation of drug use or safer drug use practices (e.g., using new needles and syringes with each injection). Some programs provide sterile needles and syringes, condoms, and literature about testing services.
Community Education Education of well populations about prevention of communi- cable diseases by a nurse educator is an example of primary prevention. Relevant information about the modes of transmis- sion, testing, availability of vaccines, and early symptoms can be provided to groups in the community. Providing accurate health information to large numbers of people is vital for preventing the spread of STDs. Nurses can provide educational sessions to com- munity groups about HIV and other STDs. Such educational sessions are most effective in settings where groups normally meet and may include schools, businesses, and churches.
When addressing groups about HIV infection, it is impor- tant to discuss the number of people infected with HIV, the number of people living with AIDS, modes of transmission of the virus, how to prevent infection, testing services, common symptoms of illness, the need for a compassionate response to those afflicted, and available community resources. Teaching about other STDs can be incorporated into these presentations because the mode of transmission (sexual contact) is the same. Other information on these diseases can include the distribu- tion and incidence in society, and the consequences of the infec- tion for individuals and families.
Evaluation Evaluation is based on the extent of vaccination within a popula- tion, whether risky behavior has changed to safe behavior, and, ultimately, whether illness is prevented. Condom use can be evaluated for consistency of use if the client is sexually active. Other behaviors, such as abstinence or monogamy, can be evalu- ated for their implementation. At the community level, behav- ioral surveys can be done to measure reported condom use and condom sales, and measures of disease incidence and prevalence can be calculated to evaluate the effectiveness of intervention.
Secondary Prevention Secondary prevention includes screening for diseases to ensure their early identification, treatment, and follow-up with contacts to prevent further spread. In general, client teaching and counsel- ing should include education about avoiding self-reinfection, managing symptoms, and preventing the infection of others.
For clients in all health care settings: • HIV screening is recommended for clients in all health care settings after
the client is notified that testing will be performed unless the patient declines (opt-out screening).
• Persons at high risk for HIV infection should be screened for HIV at least annually.
• Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.
• Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health care settings.
For pregnant women: • HIV screening should be included in the routine panel of prenatal screening
tests for all pregnant women. • HIV screening is recommended after the client is notified that testing will
be performed unless the client declines (opt-out screening). • Separate written consent for HIV testing should not be required; general
consent for medical care should be considered sufficient to encompass consent for HIV testing.
• Repeat screening in the third trimester is recommended in certain jurisdic- tions with elevated rates of HIV infection among pregnant women.
BOX 14-3 Who Should Be Advised to Receive HIV Testing and Counseling?
From Centers for Disease Control and Prevention: Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings, MMWR Morbid Mortal Wkly Rep 55(RR-14), 2006.
338 PART 3 Conceptual and Scientific Frameworks
Post-test Counseling. Persons who have a negative test should be counseled about risk reduction activities to prevent any future transmission. Clients should understand that the test may not be truly negative because it does not reveal infections that may have been acquired within the several weeks before the test. Evidence of HIV antibody takes from 6 to 12 weeks to develop. Newer immunoassay tests can produce results in as little as three weeks (CDC, 2013q)
Clients must be aware of the ways viral transmission occurs, and how to avoid infection. All clients who are antibody positive should be counseled about the need to reduce their risks and notify partners. If the client is unwilling or hesitant to notify past partners, the nurse will do partner notification (or contact tracing), as described later in this chapter. Clients should seek treatment from their primary health care provider so physical evaluation can be performed and, if indicated, antiviral or other therapies begun. Box 14-4 describes the responsibilities of indi- viduals who are HIV positive.
Psychosocial counseling is indicated when positive HIV test results precipitate acute anxiety, depression, or suicidal ide- ation. The client should be informed about available counseling services. The person should be cautioned to consider carefully who should be informed of the test results. Many individuals have told others about their HIV-positive test, only to experi- ence isolation and discrimination. Plans for the future should be explored, and clients should be advised to avoid stress, drugs, and infections in order to maintain optimal health.
Partner Notification and Contact Tracing Partner notification, also known as contact tracing or disclo- sure, is an example of a population-level intervention aimed at controlling communicable diseases. Partner notification pro- grams usually occur in conjunction with reportable disease requirements and are carried out by most health departments. It involves confidentially identifying and notifying exposed individuals of clients who are found to have reportable diseases, especially sexually transmitted diseases.
Individuals diagnosed with a reportable STD are asked to provide the names and locations of all partners so that these individuals can be informed of their exposure, receive counsel- ing, and obtain the necessary referral and/or treatment. The originally diagnosed (index case) clients may be encouraged to notify their partners (can be sexual and/or injection drug part- ners) and to encourage them to seek treatment. If the client agrees to do so, suggestions on how to inform their partners
• Have regular medical evaluations and follow-ups. • Do not donate blood, plasma, body organs, other tissues, or sperm. • Take precautions against exchanging body fluids during sexual activity. • Inform sexual or injection drug–using partners of the potential exposure to
HIV, or arrange for notification through the health department. • Inform health care providers of the HIV infection. • Consider the risk of perinatal transmission and follow up with
contraceptive use.
BOX 14-4 Responsibilities of Persons Who Are HIV Infected
and how to deal with possible reactions may be explored. In some instances, clients may feel more comfortable if the nurse notifies those who are exposed. If clients contact their partners about possible infection, the nurse contacts health care provid- ers or clinics to verify positive test results or microscopic find- ings and treatment of the index case.
If the originally diagnosed client prefers not to participate in notifying partners, the public health nurse contacts the partners by phone, certified delivery letter, or home visit, depending on the nature of the individual circumstances, and counsels them to seek evaluation and treatment. Many times the client is treated for the sexually transmitted infection at the health department. At this appointment, the client is offered literature regarding the STD for which they need treatment, receives risk- reduction counseling, and is offered testing for the other STDs. The identity of the infected client who names sexual and injec- tion drug–using partners cannot be revealed. Maintaining con- fidentiality is critical with all STDs.
Tertiary Prevention Tertiary prevention can apply to many of the chronic viral STDs and TB. For viral STDs, much of this effort focuses on manag- ing symptoms and maintaining psychosocial support. Many clients report feeling contaminated and thus feel lower self- worth. Support groups may be available to help clients cope with chronic STDs, such as genital herpes or genital warts.
Directly Observed Therapy In directly observed therapy (DOT) programs for TB medica- tion nurses observe and document individual clients taking their TB drugs. When clients prematurely stop taking TB medi- cations, there is a risk of the TB becoming resistant to the medications. This can affect an entire community of people who are susceptible to this airborne disease. Health profession- als share in the responsibility of adhering to treatment, and
LINKING CONTENT TO PRACTICE
This chapter emphasizes the epidemiology and prevention of selected com- municable diseases, as well as the public health nursing services provided to clients. The Council on Linkages Between Academia and Public Health Prac- tice (2010) Domains and Core Competencies are addressed through activities in caring for clients with communicable diseases. Examples of how these eight domains are used in providing nursing care to clients with communicable disease are as follows: Domain #1, Analytic/Assessment Skills, is achieved through the review of the
incidence and prevalence rates of communicable diseases to determine population health status.
Domain #3, Communication Skills, is applied when PHNs teach how to prevent and treat infections.
Domain #4, Cultural Competency Skills, is met through understanding the various social and behavioral factors that make health care acceptable to diverse populations (groups of people who are diverse in terms of culture, socioeconomic status, education level, race, gender, age, ethnicity, sexual orientation, profession, religious affiliation, and mental/physical capability).
From Public Health Foundation, Council on Linkages: Core Competencies for Public Health Professionals, 2008. Available at http://www.phf.org/link/corecompetencies.htm. Accessed March 2010.
339CHAPTER 14 Communicable and Infectious Disease Risks
DOT ensures that TB-infected clients have adequate medica- tion. Thus, DOT programs are aimed at the population level to prevent antibiotic resistance in the community and to ensure effective treatment at the individual level. Many health depart- ments have DOT home health programs to ensure adequate treatment (CDC, 2012c). Directly observed treatment, short course (DOTS) is a variation applied worldwide to combat multidrug-resistant TB (WHO, 2010a).
The management of AIDS in the home may include moni- toring physical status and referring the family to additional care services for maintaining the client in the home. Case manage- ment is important in all phases of HIV infection. It is especially important to ensure that clients have adequate services to meet their needs. This may include ensuring that medication can be obtained through identifying funding resources, maintaining infection control standards, reducing risk behaviors, identifying sources of respite care for caretakers, or referring clients for home or hospice care. Nursing interventions include teaching families about managing symptomatic illness by preventing deteriorating conditions such as diarrhea, skin breakdown, and inadequate nutrition.
Standard Precautions It is important to teach caregivers about infection control in the home. Clients, families, friends, and others may express
concerns about the transmission of HIV. Whereas fear may be expressed by some, others who are caring for loved ones with HIV may not take adequate precautions, such as glove wearing, because of concern about appearing as though they do not want to touch a loved one. Others may believe myths that suggest they cannot be infected by someone they love.
Standard precautions must be taught to caregivers in the home setting. All blood and articles soiled with body fluids must be handled as if they were infectious or contaminated by bloodborne pathogens. Gloves should be worn whenever hands might touch nonintact skin, mucous membranes, blood, or other fluids. A mask, goggles, and gown should also be worn if there is potential for splashing or spraying of infectious material during any care. All protective equipment should be worn only once and then disposed of. If the skin or mucous membranes of the caregiver come in contact with body fluids, the skin should be washed with soap and water, and the mucous mem- branes should be flushed with water as soon as possible after the exposure. Thorough handwashing with soap and water—a major infection control measure—should be conducted when- ever hands become contaminated and whenever gloves or other protective equipment (e.g., mask, gown) is removed. Soiled clothing or linen should be washed in a washing machine filled with hot water using bleach as an additive and dried on a hot-air cycle of a dryer.
P R A C T I C E A P P L I C A T I O N Yvonne Jackson is a 20-year-old woman who visits the Hope- town City Health Department’s maternity clinic. Examination reveals she is at 14-weeks’ gestation. She is single but has been in a steady relationship for the past 6 months with Ramón. She states that she has no other children. A routine test taken during the initial prenatal visit is an HIV test; the results are positive.
Ms. Jackson is shocked and emotionally distraught about the positive test results. Understanding that the client will not be able to concentrate on all of the questions and information that
need to be covered, the nurse prioritizes essential information to obtain and provide during this visit. A. List the relevant factors to consider on the basis of this
information. B. What questions do you need to ask with regard to controlling
the spread of HIV to others? C. What information is most important to give to Ms. Jackson
at this time? D. What follow-up does the nurse need to arrange for this client?
Answers can be found on the Evolve site.
K E Y P O I N T S • Nearly all communicable diseases discussed in this chapter
are preventable because they are transmitted through spe- cific, known behaviors.
• STDs are among the most serious public health problems in the United States. Not only is there an increased incidence of drug-resistant gonococcal infection, but other STDs, such as HPV (genital warts), HIV, and HSV (genital herpes), are associated with cancer.
• STDs affect certain groups in greater numbers. Factors asso- ciated with risk include being less than 25 years of age, being a member of a minority group, living in an urban setting, being poor, and using crack cocaine.
• The increasing incidence, morbidity, and mortality of spe- cific communicable diseases highlight the need for nurses to educate clients about ways to prevent communicable diseases.
• Many STDs do not produce symptoms in clients. • Aside from death, the most serious complications caused by
STDs are pelvic inflammatory disease, infertility, ectopic preg- nancy, neonatal morbidity and mortality, and neoplasia.
• Hepatitis A is often silent in children, and children are a significant source of infection to others; thus, the use of the vaccination in children has caused a reduction in the number of cases.
340 PART 3 Conceptual and Scientific Frameworks
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• Hepatitis C is the most common bloodborne pathogen in the United States.
• The emergence of multidrug-resistant TB has prompted the use of directly observed therapy (DOT) to ensure adherence with drug treatment regimens.
• Early detection of communicable diseases is important because it results in early treatment and prevention of addi- tional transmission to others. Treatment includes effective medications, stress reduction, and proper nutrition.
• Partner notification, or contact tracing, is done by identify- ing, contacting, and ensuring evaluation and treatment of
persons exposed to sexual and injectable drug–using partners. Contact tracing is also conducted with TB and HAV.
• HIV infection has created an entirely new group of people needing health care. This rapidly growing population is straining a health care system that is already unable to meet the needs of many.
• Most of the care (both home and outpatient) that is pro- vided for HIV is done within the community setting, which reduces direct health care costs but increases the need for financial support of home and community health services.
K E Y P O I N T S — cont’d
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Identify sources of TB treatment in your community. Is there
a DOT program available through the health department or home health agency? What factors make TB infection a dif- ficult problem?
2. To whom does one report communicable diseases, such as HAV, in your community? How is this information given?
3. Identify the number of reported cases of AIDS and the number of reported cases of HIV infection within your state
and locale (if reportable in your state). How are the cases distributed by age, sex, geographic location, and ethnicity?
4. Identify the location(s) of HIV testing services in your com- munity. Are the test results anonymous or confidential? Describe how and to whom the results are reported.
5. Form small groups and role play a nurse–client interaction involving risk assessment and counseling regarding safer sex and injection drug–using practices.
341CHAPTER 14 Communicable and Infectious Disease Risks
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Centers for Disease Control and Prevention: HIV Prevention, 2014i. Available at: http://www.cdc.gov/ hiv/basics/prevention.html. Accessed February 24, 2014.
Centers for Disease Control and Prevention, Health Resources and Services Administration, National Institutes of Health, American Academy of HIV Medicine, Association of Nurses in AIDS Care, International Association of Providers of AIDS Care, National Minority AIDS Council, Urban Coalition for HIV/AIDS Prevention Services: Recommendations for HIG Prevention with Adults and Adolescents with HIV in the United
States, 2014, Summary for Clinical Providers. Available at: http://stacks.cdc.gov/view/ cdc/26063.
The Council on Linkages Between Academia and Public Health Practice: Core Competencies for Public Health Professionals, 2010. Available at: http://www.phf.org/ programs/corecompetencies.
Fair C, Ginsburg B: HIV-related stigma, discrimination, and knowledge of legal rights among infected adults. J HIV/AIDS Social Serv 9(1):77–79, 2010. Available at: http://dx .doi.org/10.1080/153 81500903583470. Accessed January 25, 2014.
Fontenot HB, Fantasia HC, Charyk A, et al: Human papillomavirus (HPV) risk factors, vaccination patterns, and vaccine perceptions among a sample of male college students. J Am College Health 62(3):186– 192, 2014. doi:10.1080/07448481.2 013.872649.
Hande K: Hepatitis C screening and guideline update. J Nurse Practitioners 10(1):64–66, 2014.
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Panel on Opportunistic Infections in HIV-Exposed and HIV–Infected Children: Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV–Infected Children, 2013. Available at: aidsinfo.nih.gov/contentfiles/ lvguidelines/oi_guidelines_ pediatrics.pdf. Accessed March 16, 2014.
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Phillips I: Beta-lactamase producing penicillin-resistant gonococcus. Lancet 2:656, 1976.
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Evidence-Based Practice
15
Marcia Stanhope, PhD, RN, FAAN Dr. Marcia Stanhope is currently an Associate of the Tufts and Associates Search Firm, Chicago, Ill. She is also a consultant for the nursing program at Berea College, Kentucky. She has practiced community and home health nursing, has served as an administrator and consultant in home health, and has been involved in the development of two nurse-managed centers. At one time in her career, she held a public policy fellowship and worked in the office of a U.S. Senator. She has taught community health, public health, epidemiology, policy, primary care nursing, and administration courses. Dr. Stanhope formerly directed the Division of Community Health Nursing and Administration and served as Associate Dean of the College of Nursing at the University of Kentucky. She has been responsible for both undergraduate and graduate courses in population-centered nursing. She has also taught at the University of Virginia and the University of Alabama, Birmingham. During her career at the University of Kentucky she appointed to the Good Samaritan Foundation Chair and Professorship in Community Health Nursing, and was honored with the University Provost’s Public Scholar award. Her presentations and publications have been in the areas of home health, community health and community-focused nursing practice, as well as primary care nursing.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Define evidence-based practice. 2. Understand the history of evidence-based practice in
health care. 3. Analyze the relationship between evidence-based practice
and the practice of nursing in the community.
4. Provide examples of evidence-based practice in the community.
5. Identify barriers to evidence-based practice. 6. Apply evidence-based resources in practice.
K E Y T E R M S evidence-based medicine, p. 343 evidence-based nursing, p. 343 evidence-based practice, p. 343 evidence-based public health, p. 343 grading the strength of evidence, p. 348 integrative review, p. 347
meta-analysis, p. 347 narrative review, p. 347 randomized controlled trial (RCT), p. 345 research utilization, p. 343 systematic review, p. 347 — See Glossary for definitions
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks—Of special note see the links for these sites:
• Guidelines for Clinical Preventive Services • National Guideline Clearinghouse • Partners in Informational Access for the Public Health
Workforce • National Center for Health Statistics
• Quiz • Case Studies • Glossary • Answers to Practice Application • Appendix
• Focus on Quality and Safety Education for Nurses
C H A P T E R O U T L I N E Definition of Evidence-Based Practice History of Evidence-Based Practice Paradigm Shift in Use of Evidence-Based Practice Types of Evidence Factors Leading to Change
Barriers to Evidence-Based Practice Steps in the Evidence-Based Practice Process
Approaches to Finding Evidence Approaches to Evaluating Evidence
Approaches to Implementing Evidence-Based Practice
343CHAPTER 15 Evidence-Based Practice
Emphasis on evidence-based practice (EBP) is a standard to be met in health care delivery in the United States. It is a relevant approach to providing the highest quality of health care in all settings, which will result in improved health outcomes. EBP is important for all professionals who work in social and health care environments, regardless of the client or the setting with which professionals are dealing, including public health nurses who work with populations. Emphasis on EBP has resulted from increased expectations of consumers, changes in health care economics, increased expectations of accountability, advancements in technology, the knowledge explosion fueled by the Internet, and the growing number of lawsuits occurring when there is injury or harm as a result of practice decisions that are not based on the best available evidence (Makic et al, 2014). Nurses at all levels have an opportunity to improve the practice of nursing and client outcomes.
The Institute of Medicine has set a goal that by 2020, the best available evidence will be used to make 90% of all health care decisions, yet most nurses continue to be inconsistent in imple- menting EBP. An even greater concern in public health is that the field is lagging behind in developing evidence-based guide- lines for the community setting. It is important to recognize that regardless of the level of education, undergraduate or grad- uate, nurses can be involved in the development, implementa- tion, and evaluation of the effects of EBP (Florin et al, 2012; Gerrish and Cooke, 2013; Mattila et al, 2013; Merrill et al, 2013; Sprayberry, 2014).
Comprehensive databases are available through various Internet sites to assist nurses in applying the most recent best evidence to their clinical practice, like the Cochrane Library Database, the Centers for Disease Control and Prevention: Guide to Community Preventive Services, and others. (See the WebLinks for this chapter on the book’s Evolve website.)
DEFINITION OF EVIDENCE-BASED PRACTICE The term evidence-based was first attributed to Gordon Gyatt, a Canadian physician at McMaster University in 1992 (Evidence Based Medicine Working Group, 1992). The term was first applied in medicine to begin the development of new ways of guiding professional decision making by using the best available evidence. Because the concept was developed in medicine, some of the first definitions focused on evidence-based medicine.
The definition of evidence-based medicine by Sackett and associates (Sackett et al, 1996) became the industry standard. Sackett et al (1996) defined evidence-based medicine as “the conscientious, explicit, and judicious use of current best
C H A P T E R O U T L I N E — cont’d Current Perspectives
Cost Versus Quality Individual Differences Appropriate Evidence-Based Practice Methods for
Population-Centered Nursing Practice
Healthy People 2020 Objectives Example of Application of Evidence-Based Practice to
Public Health Nursing
evidence in making decisions about the care of individual clients” (p. 71). Without current best external evidence, they said, “practice risks become rapidly out of date, to the detriment of clients” (Sackett et al, 1996, p. 72). A more succinct definition was proposed as the conscientious use of the current best evidence in making decisions about patient care (Sackett et al, 2000).
Adapting the definition by Sackett et al (1996), Rychetnik et al (2003) defined evidence-based public health as “a public health endeavor in which there is an informed, explicit, and judicious use of evidence that has been derived from any of a variety of science and social science research and evaluation methods” (p. 538). Brownson et al (2009) expanded the defini- tion of evidence-based public health to include “making deci- sions on the basis of the best available evidence, using data and information systems, applying program planning frameworks, engaging the community in decision making, conducting evalu- ations, and disseminating what has been learned” (p. 175).
In a position statement on EBP, the Honor Society of Nursing, Sigma Theta Tau International, defined evidence- based nursing as “an integration of the best evidence available, nursing expertise, and the values and preferences of the indi- viduals, families, and communities who are served” (Honor Society of Nursing, Sigma Theta Tau International, 2005). The definition of EBP continues to be broadened in scope and now includes a life-long problem-solving approach to clinical practice, integrating both external and internal evidence to answer clinical questions and to achieve desired client outcomes (Melnyk and Fineout-Overholt, 2011). External evidence includes research and other evidence such as reports and profes- sional guidelines for example, whereas internal evidence includes the nurse’s clinical experiences and the client’s preferences.
Applied to nursing, evidence-based practice includes the best available evidence from a variety of sources including research studies, nursing experience and expertise, and com- munity leaders. Culturally and financially appropriate interven- tions need to be identified when working with communities. The use of evidence to determine the appropriate use of interventions that are culturally sensitive and cost-effective is essential.
HISTORY OF EVIDENCE-BASED PRACTICE During the mid to late 1970s, there was growing consensus among nursing leaders that scientific knowledge should be used as a basis for nursing practice. During that time, the Division of Nursing in the U.S. Public Health Service began funding research utilization projects. Research utilization has been defined as
344 PART 3 Conceptual and Scientific Frameworks
Although nursing continued to focus on research utilization projects, medicine also began to call for physicians to increase their use of scientific evidence to make clinical decisions. In the late 1970s, David Sackett, a medical doctor and clinical epide- miologist at McMaster University, published a series of articles in the Canadian Medical Association Journal describing how to read research articles in clinical journals. The term critical appraisal was used to describe the process of evaluating the validity and applicability of research studies (Guyatt and Rennie, 2002). Later, Sackett proposed the phrase “bringing critical appraisal to the bedside” to describe the application of evidence from medical literature to client care. This concept was used to train resident physicians at McMaster University and evolved into a “philosophy of medical practice based on knowledge and understanding of the medical literature supporting each clinical decision” (Guyatt and Rennie, 2002, p. xiv).
With Gordon Guyatt as Residency Director of Internal Medi- cine at McMaster, the decision was made to change the program to focus on “this new brand of medicine” that Guyatt eventually called evidence-based medicine (Guyatt and Rennie, 2002, p. xiv). Guyatt and Rennie described the goal of evidence-based medicine as being “aware of the evidence on which one’s prac- tice is based, the soundness of the evidence, and the strength of inference the evidence permits” (2002, p. xiv).
PARADIGM SHIFT IN USE OF EVIDENCE-BASED PRACTICE In 1992 the Evidence-Based Medicine Working Group pub- lished an article in the Journal of the American Medical Associa- tion expanding the concept of evidence-based medicine and calling it a paradigm shift. A paradigm shift simply means a change from old ways of knowing to new ways of knowing and practicing. Ways of knowing in nursing have included the empirical knowledge, or the science of nursing; the aesthetic knowledge, or the art of nursing; personal knowledge, or inter- personal relationships and caring; and ethical knowledge, or moral and ethical codes of conduct usually established by pro- fessional organizations (Bradshaw, 2010; Sandström et al, 2011). Nursing practice in the past often focused less on science and more on the other four ways of knowing described here.
According to the Working Group (Evidence-Based Medicine Working Group, 1992), the old paradigm viewed unsystematic clinical observations as a valid way for “building and maintain- ing” knowledge for clinical decision making (p. 2421). In addi- tion, principles of pathophysiology were seen as a “sufficient guide for clinical practice” (p. 2421). Training, common sense, and clinical experience were considered sufficient for evaluating clinical data and developing guidelines for clinical practice. The Working Group cited developments in research over the past 30 years as providing the foundation for the paradigm shift and a “new philosophy of medical practice” (p. 2421).
The new paradigm, evidence-based medicine, acknowledged clinical experience as a crucial, but insufficient, part of clinical decision making. Systematic and unbiased recording of clinical observations in the form of research will increase confidence in the knowledge gained from clinical experience. Principles of
Jenkins C, Pope C, Magwood G: Expanding the chronic care framework to improve diabetes management: The REACH Case Study. Prog Community Health Partnersh 4(1):65–79, Spring 2010.
Chronic diseases are considered a major disease burden in the United States, accounting for 75% of all medical care costs, and 7 of 10 deaths per year. Diabetes is one of the chronic diseases considered to have a major public health impact. To meet the Healthy People 2010 goal of eliminating racial and ethnic disparities, the CDC created a demonstration project called REACH. Community projects were funded to develop, implement, and evaluate com- munity action plans to improve health care and outcomes for racial and ethnic groups. One funded project was the Charleston and Georgetown, South Caro- lina Diabetes Coalition. The coalition is described as a community campus partnership with the Medical College of South Carolina and community agen- cies, organizations, and neighborhoods. The project serves about 12,000 African Americans with diabetes.
To implement the project, the coalition looked at the Chronic Care Model and after a systematic review of the literature, decided to expand the model and developed the Community Chronic Care Model. The goals of the project were to use community-based participatory actions to decrease disparities, improve health systems using the continuous quality improvement process, educate and empower communities, and build and sustain interpersonal and interorganizational links among communities and health professionals to improve diabetes outcomes and eliminate disparities. Local coalitions were developed, funds were provided to sustain diabetes activities, two new health facilities were opened in areas of need, and free medications were offered as samples.
One of the specific health outcomes was to reduce amputations among African American males. The University’s college of nursing participated by developing and marketing a self-paced foot care educational program to train professionals in foot care. Lay educators were trained and health profession- als provided patient care to the uninsured. A center for community health partnerships was established in the college of nursing and is a part of the ongoing plans for the college.
Nurse Use Nurses can be active in establishing small groups of partners in the community to develop a plan to meet a health care need, or participate in larger coalitions like this one. The focus on developing projects to meet needs and improve health care outcomes must be based on the evidence that shows these part- nerships are needed to solve the health care need and improve health care outcomes (Jenkins et al, 2010).
EVIDENCE-BASED PRACTICE
“the process of transforming research knowledge into practice” (Stetler, 2001, p. 272) and “the use of research to guide clinical practice” (Estabrooks, Winther, and Derksen, 2004, p. 293).
Three projects funded by the Division of Nursing received the most attention and were the most influential in shaping nursing’s view of using research to guide practice: the Nursing Child Assessment Satellite Training Project (NCAST) (Barnard and Hoehn, 1978; King, Barnard, and Hoehn, 1981), the Western Interstate Commission for Higher Education (WICHE) Regional Program for Nursing Research Develop- ment (WICHEN) (Krueger, 1977; Krueger, Nelson, and Wolanin, 1978; Lindeman and Krueger, 1977), and the Conduct and Utilization of Research in Nursing Project (CURN) (Horsley, Crane, and Bingle, 1978; Horsley et al, 1983). Using very different approaches and methods, each project tested interventions to facilitate research use in practice.
345CHAPTER 15 Evidence-Based Practice
locating, critiquing, synthesizing, translating, and evaluating evidence upon which to base practice changes. Systematic reviews of research evidence can potentially assist nurses in putting evidence into practice. Systematic reviews, also known as evidence summaries, provide reliable evidence-based summaries of past research, making it easier for health care professionals to stay current on best practices without having to read a lot of research papers (Holly, Salmond, and Saimbert, 2011).
Scott and McSherry (2009) engaged in a process using an extensive literature review to arrive at a definition of evidence- based nursing and to differentiate the definition from evidence- based practice. Based on their review they arrived at the following definition: evidence-based nursing is a process whereby evi- dence, nursing theory, and the nurse’s clinical expertise are evaluated and used, in conjunction with the client’s involve- ment, to make critical decisions about the best care for the client. Continuous evaluation of the implementation of care is essen- tial to make clinical decisions about client care for the best possible outcomes. In Chapter 9 there is extensive discussion of an example of how public health nurses have developed and used evidence on which to base population-centered nursing.
TYPES OF EVIDENCE No matter which definition of EBP is supported, what counts as evidence has been the issue most hotly debated. A hierarchy of evidence, ranked in order of decreasing importance and use, has been accepted by many health professionals. The double- blind randomized controlled trial (RCT) generally ranks as the highest level of evidence followed by other RCTs, nonrandom- ized clinical trials, quasi-experimental studies, case-controlled reports, qualitative studies, and expert opinion (Russell-Babin, 2009). Some nurses would argue that this hierarchy ignores evidence gained from clinical experience. However, the defini- tion of evidence-based nursing presented previously indicates that clinical expertise as evidence, when used with other types of evidence, is used to make clinical decisions. Also in the hier- archy of evidence, expert opinion can be gained from non- research–based published articles, professional guidelines, national guidelines, organizational opinions, and panels of experts, as well as the nurse’s clinical expertise.
Because it is difficult to find or perform RCTs in the com- munity, other types of evidence have been highlighted as the best evidence in public health literature on which to base evidence-based public health practice: scientific literature found in systematic reviews, scientific literature used or quoted in one or more journal articles, public health surveillance data, program evaluations, qualitative data obtained from commu- nity members and other stakeholders, media/marketing data such as the results of a media campaign to reduce smoking, word of mouth, and personal/professional experience (Brown- son et al, 2009; Jacobs et al, 2012).
Within public health practice, guidelines for finding and using evidence include the following: • Engaging the community in assessment and decision making; • Using data and information systems systematically;
pathophysiology were seen as necessary but not sufficient knowledge for making clinical decisions. The Working Group emphasized that physicians needed to be able to critically appraise the research literature in order to appropriately apply research findings in practice. Knowledge gained from authorita- tive figures was also deemphasized in the new paradigm (Working Group, 1992).
In the years since the Working Group began, the term evidence-based practice has been proposed as a term to integrate all health professions. The underlying principle was that high- quality care is based on evidence rather than on tradition or intuition (Beyers, 1999).
Nurses have always used various resources for problem solving. Intuition, trial and error, tradition, authority, institu- tional standards, prior knowledge, and clinical experience have often been used as the basis for decision making in clinical set- tings. However, not all of these resources are reliable and all have not consistently produced desired outcomes (Bradshaw, 2010; Sandström et al, 2011). A procedure performed based on intuition or trial and error might be performed successfully sometimes and not at other times. For example, tradition and authority, which comes from texts and policy and procedure manuals, can lead to faulty clinical decision making.
Institutional standards are developed by accrediting agencies (e.g., The Joint Commission), by licensing agencies, and by professional organizations. These standards have been devel- oped in the past primarily by expert opinion and past experi- ences. The standards may not reflect the best practices in the current environment or from the literature.
Although prior knowledge gained in educational programs, through continuing education, or through experience can be a good teacher, it can also contain bias and quickly become out- dated unless a nurse participates in constantly refreshing knowl- edge. For example, just because a nurse has experience in successfully performing an intervention a certain way today does not mean it is the best way or that it will be successful every time and in the future unless practices are changed based on the most current data.
When EBP was first emphasized in medicine, the focus was on the answer to clinical questions concerning an individual client problem in order to provide the best diagnosis to imple- ment the best treatment. When nursing became involved in EBP, the focus seemed to shift to answering a clinical question about a health problem experienced by a group of clients (Levin et al, 2010).
The current nursing literature on EBP is primarily associated with applications in the acute and primary care settings and little is reported about its use in community settings. However, the basic principles of EBP can be applied at the individual level or at the community level. Although definitions of EBP vary widely in the literature, the common thread across disciplines is the application of the best available evidence to improve practice (Makic et al, 2014).
EBP has been described as both a process and a product (Bradshaw, 2010; Sandström et al, 2011; Scott and McSherry, 2009). The product is the use of evidence to make practice changes, whereas the process is a systematic approach to
346 PART 3 Conceptual and Scientific Frameworks
can also be a barrier if the clinical decision or change will require more funds than the agency has available. Compliance can be a barrier if the client will not follow the recommended interven- tion. Public health departments are moving toward EBP and are seeking accreditation through the national public health accred- itation board. The accreditation process began in 2011. As of March 2014, 31 public health departments had achieved national accreditation (Public Health Accreditation Board, 2014).
STEPS IN THE EVIDENCE-BASED PRACTICE PROCESS EBP is a philosophy of practice that respects client values. Melnyk and associates (2010) have described a seven-step EBP process: 0. Cultivating a spirit of inquiry 1. Asking clinical questions 2. Searching for the best evidence 3. Critically appraising the evidence 4. Integrating the evidence with clinical expertise and client
preferences and values 5. Evaluating the outcomes of the practice decisions or changes
based on evidence 6. Disseminating EBP results
Yes, their first step is step zero. This process was initially described as a five-step process by others (Dawes et al, 2004; Dicenso et al, 2005; Craig and Smyth, 2007). The unique fea- tures of the Melnyk et al (2010) model are the emphasis on the spirit of inquiry and the sharing of the results of the process.
Step zero involves a curiosity about the interventions that are being applied. Do they work, or is there a better approach? In public health nursing, for example, are there better parenting outcomes if the parents attend classes at the health department? Or are home visits to new mothers and babies more effective for achieving a healthy baby? Step one requires asking questions in a “PICOT” format.
Although Melnyk et al have developed a specific process for the PICOT, the process was first described by Sackett (1996), who discussed the need to define the (P)opulation of interest, the (I)ntervention or practice strategy in question, the popu- lation or intervention to be used for (C)omparision, the (O)utcome desired, and the (T)ime frame. Step two involves searching for the best evidence to answer the question. This step involves searching the literature. In the case of the previous example, a literature search would focus on a search of key terms like public health nursing, parenting of new babies, parent- ing classes, and home visits. Step three requires a critical appraisal of the evidence found in step two.
To appraise the literature found, Melnyk suggests asking three questions about each of the articles found in the literature search: (1) the validity, (2) the importance, and (3) whether or not the results of the article will help you as a nurse provide quality care for your clients. Step four is the step in which the evidence found is integrated with clinical expertise and client values. Institutional standards and practice guidelines, as well as cost of care and support of the health care environment to implement the findings, are all factors considered in this step.
• Making decisions on the basis of the best available peer- reviewed evidence (both quantitative and qualitative);
• Applying program planning frameworks (often based in health behavior theory);
• Conducting sound evaluation; and • Disseminating what is learned (Jacobs et al, 2012).
FACTORS LEADING TO CHANGE EBP represents a cultural change in practice. It provides an environment to improve both nursing practice and client out- comes. Nursing is known for providing care based on environ- mental and client assessments; critical observations; development of questions or hypotheses to be explored; collecting data from the environment through community or organizational assess- ments, or from the client through history, physical assessment, and review of past heath records; analyzing the data to develop plans of care, whether for the individual client, family, group or community; and drawing conclusions upon which to base care for the purpose of improving client outcomes (Gerrish and Cooke, 2013). However, several factors have been identified in the literature that support implementation of EBP or that will need to be overcome for nursing and other disciplines to suc- cessfully implement EBP. These factors include the following: • Knowledge of research and current evidence • Ability to interpret the meaning of the evidence • Individual professional’s characteristics, such as a willing-
ness to change, or personal viewpoints about the quality and credibility of evidence
• Commitment of the time needed to implement EBP and to engage in education and directed practice
• The hierarchy of the practice environment and the level of support of managers and the ability to engage in autono- mous practice,
• The philosophy of the practice environment and the willing- ness to embrace EBP
• The resources available to engage in EBP, such as amount of work, proper equipment, computer-based EBP programs, and information systems
• The practice characteristics, such as leadership and colleague attitudes
• Links to outside supports such as teaching facilities like a teaching health department or a university
• Political constraints and the lack of relevant and timely public health practice research (Asadoorian Hearson, Saty- anarayana, and Ursel, 2010; Brownson et al, 2009; Gerrish and Cooke, 2013)
BARRIERS TO EVIDENCE-BASED PRACTICE Although a community agency may subscribe in theory to the use of EBP, actual implementation may be affected by the reali- ties of the practice setting. Community-focused nursing agen- cies may lack the resources needed for its implementation in the clinical setting, such as time, funding, computer resources, and knowledge. Nurses may be reluctant to accept findings and feel threatened when long-established practices are questioned. Cost
347CHAPTER 15 Evidence-Based Practice
health can be found in the Guide to Community Preventive Services, the Cochrane Public Health Group, the Center for Reviews and Dissemination, and the Campbell Collaboration (Box 15-1).
Step five requires an evaluation of the outcomes of practice decisions and changes that were based on the answers to the first four steps. The goal in evaluation is a positive change in quality of care and health care outcomes. In the example of group parenting classes versus home visits to new mothers and babies, current literature suggests improved quality and health care outcomes with home visits (The Pew Center, 2010).
Step six is disseminating outcomes of the results to others, to colleagues, to the employing agency’s administration, to faculty and other students, and through a poster or podium presentation of student nurse organizations or professional organizations. Professional organizations often sponsor student presentations for undergraduates as well as graduate students. Sharing of information is most important because it prevents each individual nurse from trying to find the best answer to the same question answered by someone else, and it gives us the basis for asking new questions. Sharing makes practice more efficient and improves quality and health care outcomes.
In a busy community practice setting, it is often difficult for nurses to access evidence-based resources. Using evidence- based clinical practice guidelines is one way for nurses to provide evidence-based nursing care in an efficient manner. Clinical practice guidelines are usually developed by a group of experts in the field who have reviewed the evidence and made recommendations based on the best available evidence. The recommendations are usually graded according to the quality and quantity of the evidence. The Public Health Practice Refer- ence is an example of practice guidelines developed for population-centered nurses’ use (AHRQ, 2014).
Approaches to Finding Evidence Returning to the previous example, the clinical question has been stated and the population has been defined as new mothers and babies. Two interventions will be compared. The outcome is stated as healthy babies and the time frame may be 6 months or 1 year, or another time at which the outcomes of the inter- ventions will be evaluated.
Four approaches are described that allow the nurse to read research/nonresearch evidence in a condensed format. The first, a systematic review, is “a method of identifying, appraising, and synthesizing research evidence. The aim is to evaluate and interpret all available research that is relevant to a particular research question” (Cochrane Library, 2014). A systematic review is usually done by more than one person and describes the methods used to search for and evaluate the evidence. Systematic reviews can be accessed from most databases, such as Medline and CINAHL.
The Cochrane Library is an electronic database that contains regularly updated evidence-based health care databases main- tained by the Cochrane Collaboration, a not-for-profit organi- zation (http://www.cochrane.org). The Cochrane Library is composed of three main branches: systematic reviews, trials register, and methodology database. The Cochrane Library publishes systematic reviews on a wide variety of topics. Sys- tematic reviews differ from traditional literature review publi- cations in that systematic reviews require more rigor and contain less opinion of the author. Systematic reviews for public
HOW TO Develop an Evidence-Based Practice Guide to a Community Preventive Service • Form a development team, preferably an interprofessional team,
to choose a topic based on a community issue that needs to be addressed.
• Develop a structured approach to organize, group, select, and evaluate the interventions from the literature that work to address the issue.
• Select the interventions the group wishes to evaluate for use. • Assess the quality of the evidence found in the literature. • Summarize the findings. • Make recommendations. • Write a protocol or step-by-step guide to resolving the commu-
nity issue.
From Task Force on Community Preventive Services: Guide to community preventive services. 2007. Available at http:// www.thecommunityguide.org/diabetes/default.htm. Accessed September 26, 2010.
The second approach, meta-analysis, is a specific method of statistical synthesis used in some systematic reviews, where the results from several studies are quantitatively combined and summarized (GWU, 2014). A well-designed systematic review or meta-analysis can provide stronger evidence than a single randomized controlled trial.
The integrative review is a form of a systematic review that does not have the summary statistics found in the meta-analysis because of the limitations of the studies that are reviewed (e.g., small sample size of the population). Narrative review is a review done on published papers that support the reviewer’s particular point of view or opinion and is used to provide a general discussion of the topic reviewed. This review does not often include an explicit or systematic review process.
Undergraduate students often perform narrative reviews. However, it is important to learn the process for systematic reviews, especially the use of the results of systematic reviews. Reading systematic reviews that have been completed is helpful in answering the question related to the EBP process.
What counts as evidence has also been argued in the public health literature (Earle-Foley, 2011). RCTs, which are the highest level of evidence used to make clinical decisions, are appropriate for evaluating many interventions in medicine, but are often inappropriate for evaluating public health interventions. For example, an RCT can be designed ethically to test a new medica- tion for diabetes, but not for a smoking cessation intervention. In a smoking cessation intervention, subjects could not be assigned randomly to smoking or nonsmoking groups because a smoking cessation intervention is not appropriate for someone who does not smoke. In this situation, a case-control study would be most appropriate (see Chapter 12). Today there are many community-based clinical trials assisting in finding answers to the questions of which population-level intervention has the best outcomes. (Visit the CDC website to review these trials.)
348 PART 3 Conceptual and Scientific Frameworks
used to evaluate the usefulness of studies and strength of evi- dence. The report reviewed 40 systems and identified three domains for evaluating systems for the grading of evidence: quality, quantity, and consistency. The quality of a study refers to the extent to which bias is minimized. Quantity refers to the number of studies, the magnitude of the effect, and the sample size. Consistency refers to studies that have similar findings, using similar and different study designs (Haine-Schlagel et al, 2014). An example of how the U.S. Preventive Services Task
Approaches to Evaluating Evidence One approach used in evaluating evidence is grading the strength of evidence. When evidence is graded, the evidence is assigned a “grade” based on the number and type of well- designed studies, and the presence of similar findings in all of the studies. Grading evidence has been debated so strongly that in 2002 the Agency for Healthcare Research and Quality (AHRQ) commissioned a study to describe existing systems
The following resources can assist nurses in developing evidence-based nursing practice: 1. The Evidence-Based Practice for Public Health Project at the University of
Massachusetts Medical School Library has developed a website for evidence-based practice in public health (http://library.umassmed.edu/ ebpph/). Many bibliographic databases, such as Medline, do not list all the journals of interest to public health workers. The project provides access to numerous databases of interest concerning public health. From the project’s website, nurses can access free public health online journals and databases.
2. The Agency for Healthcare Quality and Research (AHRQ) developed clinical guidelines based on the best available evidence for several clinical topics, such as pain management. The guidelines are accessible via the agency’s website (http://www.ahrq.gov) and serve as a resource to nurses involved in individual client care.
3. The National Guideline Clearinghouse (http://www.guideline.gov/), an ini- tiative of the AHRQ, is an online resource for evidence-based clinical prac- tice guidelines. AHRQ also supports Evidence-Based Practice Centers, which write evidence reports on various topics.
4. PubMed (http://www.pubmed.gov/) is a bibliographic database developed and maintained by the National Library of Medicine. Bibliographic informa- tion from Medline is covered in PubMed and includes references for nursing, medicine, dentistry, the health care system, and preclinical sciences. Full texts of referenced articles are often included. Searches can be limited to type of evidence (e.g., diagnosis, therapy) and systematic reviews.
5. The Cochrane Database of Systematic Reviews is a collection of more than 1000 systematic reviews of effects in health care internationally. These reviews are accessible at a cost via the website (http://www.cochrane.org). Nurses may also have free access from a medical library.
6. The Evidence-Based Nursing Journal (http://ebn.bmjjournals.com/) is pub- lished quarterly. The purpose of the journal is to select articles reporting studies and reviews from health-related literature that warrant immediate attention by nurses attempting to keep pace with advances in their profes- sion. Using predefined criteria, the best quantitative and qualitative original articles are abstracted in a structured format, commented on by clinical experts, and shared in a timely fashion. The research questions, methods, results, and evidence-based conclusions are reported. The website for the journal is http://www.evidencebasednursing.com.
7. The Honor Society of Nursing, Sigma Theta Tau International, sponsors the online peer-reviewed journal Worldviews on Evidence-Based Nursing that publishes systematic reviews and research articles on best evidence that supports nursing practice globally. The journal is available by subscription (http://www.nursingsociety.org/).
8. The Task Force on Community Preventive Services is an independent, non- federal task force appointed by the director of the Centers for Disease Control and Prevention. Information about the Task Force may be found at the website http://www.thecommunityguide.org. The Task Force is charged with determining the topics to be addressed by the CDC’s Community Guide and the most appropriate means to assess evidence regarding
population-based interventions. The Task Force reviews and assesses the quality of available evidence on the effects of essential community preven- tive services. The multidisciplinary Task Force determines the scope of the Community Guide that will be used by health departments and agencies to determine best practices for preventive health in populations.
9. The U.S. Preventive Services Task Force (USPSTF) is an independent panel of private-sector experts in prevention and primary care. The USPSTF con- ducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the “gold standard” for clinical preventive services. The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care. Recommendations of the USPSTF are published as the Guide to Clinical Preventive Services. The guide is avail- able online at http://www.ahrq.gov/clinic/uspstfix.htm.
10. The Centers for Disease Control and Prevention (www.cdc.gov) publishes guidelines on immunizations and sexually transmitted diseases. Guidelines are developed by experts in the field appointed by the U.S. Department of Health and Human Services and the CDC.
11. Cochrane Public Health Group (PHRG), formerly the health promotion and public health field, aims to work with contributors to produce and publish Cochrane reviews of the effects of population-level public health interven- tions. The PHRG undertakes systematic reviews of the effects of public health interventions to improve health and other outcomes at the population level, not those targeted at individuals. Thus, it covers interventions seeking to address macroenvironmental and distal social environmental factors that influence health. In line with the underlying principles of public health, these reviews seek to have a significant focus on equity and aim to build the evidence to address the social determinants of health. (Visit http:// www.ph.cochrane.org/.)
12. Center for Reviews and Dissemination (CRD) is part of the National Institute for Health Research and is a department of the University of York. CRD, which was established in 1994, is one of the largest groups in the world engaged exclusively in evidence synthesis in the health field. CRD under- takes systematic reviews evaluating the research evidence on health and public health questions of national and international importance. (Visit http://www.york.ac.uk/inst/crd/index.htm.)
13. Campbell Collaboration, named after Donald Campbell, was founded on the principle that systematic reviews on the effects of interventions will inform and help improve policy and services. The collaboration strives to make the best social science research available and accessible. Campbell reviews provide high-quality evidence of what works to meet the needs of service providers, policy makers, educators and their students, professional researchers, and the general public. Areas of interest include crime, justice, education, and social welfare. (Visit http://www.campbellcolla boration.org/.)
BOX 15-1 Resources for Implementing Evidence-Based Practice
349CHAPTER 15 Evidence-Based Practice
Force 2003 graded the strength of evidence for the Guidelines for Clinical Preventive Services can be found at the website at the end of this chapter.
As indicated, many frameworks exist for evaluating the strength and the usefulness of the evidence found in the litera- ture and other sources, such as professional standards. A popular framework was developed by the Agency for Healthcare Quality. Fineout-Overholt et al (2010) have also developed an approach for evaluating evidence. Although these approaches vary in the factors they evaluate, the best approach to choose is one that not only evaluates the strength, but also the usefulness of the
From McEuen JA, Gardner KP, Barnachea DF, et al: An evidence- based protocol for managing hypoglycemia. AJN 110(7): 40–45, 2010.
HOW TO Develop an Evidence-Based Protocol Evidence-based protocols are a recognized approach to providing quality client care. Such protocols enhance the abilities of providers and can reduce health care errors. The following are steps to devel- oping a protocol: • Identify the problem. • Identify stakeholders. • Form a team of others to help develop the protocol. • Develop an action plan with project goals and a timeline. • Review the available evidence. • Examine current practice and identify gaps as well as best
practices. • Develop the protocol focusing on gaps. • Initiate the approval process with the setting. • Evaluate current practices and modify as needed. • Educate others who will use the protocol. • Implement the protocol. • Evaluate protocol for safety, effectiveness, and adherence
(McEuen and Gardner, 2010).
From Brownson RC, Fielding JE, Maylahn CM: Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health 30:175–201, 2009.
Type/ Category
Strength/How Established
Considerations for the Level of Scientific Evidence—Quality
Quantity/Consistency Data Source Examples
Evidence-based I Peer review via systematic or narrative review
Based on study design and execution External validity Potential side benefits or harms Costs and cost-effectiveness
Community Guide Cochrane reviews Narrative reviews based on published
literature
Effective II Peer review Based on study design and execution External validity Potential side benefits or harms Costs and cost-effectiveness
Articles in the scientific literature Research-tested intervention programs (123) Technical reports with peer review
Promising III Written program evaluation without formal peer review
Summative evidence of effectiveness Formative evaluation data Theory-consistent, plausible, potentially
high-reach, low-cost, replicable
State or federal government reports (without peer review)
Conference presentations
Emerging IV Ongoing work, practice-based summaries, or evaluation works in progress
Formative evaluation data Theory-consistent, plausible, potentially
high-reaching, low-cost, replicable Face validity
Evaluability assessments Pilot studies NIH CRISP database Projects funded by health foundations
TABLE 15-1 Typology for Classifying Interventions by Level of Scientific Evidence
evidence. Table 15-1 provides an example of an approach for evaluating evidence.
The strength of the literature is measured by the type of evidence it represents. For example, the RCT is the evidence that has the greatest strength upon which to make a clinical decision. In contrast, opinion articles, descriptive studies, and profes- sional reports of expert committees have less strength. The usefulness of the evidence is measured by whether the evidence is valid, whether it is important, and whether it can be used to assist in making practice decisions or changes in the community environment and with the population of interest to improve outcomes (Scott and McSherry, 2009).
The best RCT conducted in a hospital setting on using an intervention to prevent falls may not be applicable at all in a community setting. Therefore, although it may be a strong study with outcomes that improve health, it may not have the usefulness for applicability in the community because of the setting in which it was conducted.
Shaughnessy, Slawson, and Bennett (1994) proposed criteria for evaluating the usefulness of evidence, calling the process patient oriented evidence that matters (POEM). In general, the reader should ask the following questions: “What are the results? (Are they important?) Are the results valid? How can the results be applied to client care?” (p. 489). Application of POEM (2014) can be found at www.essentialevidenceplus.com. Brownson et al (2009) proposed that the following questions be asked for EBP (plus suggested application examples): • What is the size of the public health problem? What is the
need for improved health outcomes for new mothers and babies in our community?
• Can interventions be found in the literature to address the problem (e.g., home visits or parenting classes)?
350 PART 3 Conceptual and Scientific Frameworks
that supports evidence-based care. Public health nurses con- sider EBP a process to improve practice and outcomes and use the evidence to influence policies that will improve the health of communities.
• Is the intervention useful in this community, with this popu- lation, or with populations at risk (e.g., the low income or uninsured)?
• Is the intervention the best one or are there other ways to address the problem considering cost and potential health outcomes for the population? (Assess cost and health out- comes of both of the interventions before choosing, includ- ing the nurses available to make home visits or who have the skills to teach the parenting class.)
Several variables are considered important in determining the quality of evidence used to make clinical decisions (Polit and Beck, 2011): • Sample selection: Sample selection should be as unbiased as
possible. For example, a sample is randomly selected when each subject has an equal chance of being selected from the population of interest. Random selection offers the least bias of any type of sample selection. Other types of sample selec- tion such as convenience sampling contain researcher or evaluator bias.
• Randomization: When testing an intervention, randomly assign participants to either the intervention or control group. This type of assignment is less biased than if partici- pants are allowed to choose the group they want to join.
• Blinding: The researcher or evaluator should not know which participants are in the experimental (treatment) group or which are in the control group. The researcher or evaluator is “blinded” as to who is receiving the treatment and who is not receiving the treatment.
• Sample size: The sample size should be large enough to show an effect of the intervention. In general, the larger the sample size, the better.
• Description of intervention: The intervention should be described in detail and explicitly enough that another person could duplicate the study if desired.
• Outcomes: The outcomes should be measured accurately. • Length of follow-up: Depending on the intervention, the par-
ticipants should be followed for a long enough period of time to determine if the intervention continued to work or if the results just happened by chance.
• Attrition: Few subjects should have dropped out of the study. • Confounding variables: Variables that could affect the
outcome should be accounted for either by statistical methods or by study measurements.
• Statistical analysis: Statistical analysis should be appropriate to determine the desired outcome.
APPROACHES TO IMPLEMENTING EVIDENCE-BASED PRACTICE The first step toward implementing EBP in nursing is recogniz- ing the current status of one’s own practice and believing that care based on the best evidence will lead to improved client outcomes (Melnyk et al, 2010). Since EBP is a relatively new concept, many practicing nurses are not familiar with the application of EBP and may lack computer and Internet skills necessary to implement EBP. Also, implementation will be successful only when nurses practice in an environment
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Evidence-Based Practice Integrate best current evidence with clinical expertise and client and family preferences and values for delivery of optimal interventions.
Important aspects of EBP include: • Knowledge: Describe EBP to include the components of research evi-
dence, clinical expertise and client and family values • Skills: Locate evidence reports related to clinical practice topics and
guidelines • Attitudes: Value the need for continuous improvement in clinical practice
based on new knowledge
Evidence-Based Practice Question As a nurse in the community you are working within a Native American com- munity that has a high prevalence of diabetes. As you visit with clients in their homes, you notice that many have a standardized “Diabetes Care” handout they received from the same primary care clinic. Your clients comment that the nutritional recommendations are unrealistic in the context of their regular diet. You decide to initiate a focus group with clients who attend the diabetes clinic at the health department to customize nutritional diabetic guidelines for this community. 1. Go to The National Guideline Clearinghouse website at http://www
.guideline.gov. This website is an initiative of the Agency for Healthcare Research and Quality and is a reservoir for evidence-based clinical guidelines.
2. On the home page, type “diabetes” in the search box. 3. The second result is: Guideline Synthesis: Nutritional Management of Dia-
betes Mellitus. 4. Review the various areas of the guidelines: Medical Nutritional Therapy,
Carbohydrates, Protein, Fiber, Sucralose, Alcohol Consumption, Dietary Fat and Cholesterol, Micronutrients, Nutritional Interventions for Preventing and Managing Complications, and Physical Activity and Weight Management.
5. What baseline data might you gather from your focus group participants to be best informed in how to tailor the evidence-based recommendation for this community?
6. What might be effective strategies in writing up the community-specific guidelines and distributing them that might enhance their adoption?
Answer • Understanding the common elements of this community’s diet is a good
place to start. What are common carbohydrates, proteins, sources of sugar, dietary fat, and cholesterol that are commonly consumed?
• How does the common diet compare to the National Clearinghouse Guide- lines? Are there healthy sources of carbohydrates, healthy fats that are part of the diet that can be emphasized?
• What are common patterns in the community around alcohol consumption? Would educational efforts around the deleterious effects of alcohol on diabetes be helpful?
• Writing up community-based guidelines with assistance from leaders in the community would be a helpful strategy. You could include healthy recipes from community leaders in your guidelines.
Your community-based guidelines might be distributed at a community cel- ebration or gathering by members of the community who helped develop them.
351CHAPTER 15 Evidence-Based Practice
CURRENT PERSPECTIVES Cost Versus Quality Much of the pressure to use EBP comes from third-party payers and is a response to the need to contain costs and reduce legal liability. Nurses must question whether the current agenda to contain health care costs creates pressure to focus on those research results that favor cost saving at the expense of quality outcomes for clients. Outcomes include client and com- munity satisfaction and the safety of care. Costs can be weighed against outcomes when EBP is used to show the best practices available to reduce possible harm to clients (Makic et al, 2014; Asadoorian et al, 2010).
From Task Force on Community Preventive Services: National Center for Chronic Disease Prevention and Health Promotion. Available at http://www.cdc.gov. Accessed December 26, 2010.
LEVELS OF PREVENTION
According to evidence collected by the Task Force on Community Preventive Services, the following are interventions supported by the literature at each level of prevention:
Primary Prevention Extended and extensive mass media campaigns reduce youth initiation of tobacco use.
Secondary Prevention Client reminders and recalls via mail, telephone, e-mail, or a combination of these strategies are effective in increasing compliance with screening activi- ties such as those for colorectal and breast cancer.
Tertiary Prevention Diabetes self-management education in community gathering places improves glycemic control.
Using Evidence-Based Practice
Individual Differences EBP cannot be applied as a universal remedy without attention to client differences. When EBP is applied at the community level, best evidence may point to a solution that is not sensitive to cultural issues and distinctions and thus may not be accept- able to the community. Ethical practice in communities requires attention to community differences.
Appropriate Evidence-Based Practice Methods for Population-Centered Nursing Practice Gaining a number of perspectives in a situated community is important for nurses using EBP. Nursing has a legitimate role to play in interprofessional community-focused practice and can contribute to its evidence base. Nurses are obliged to ensure that the evidence applied to practice is acceptable to the com- munity. Establishing an EBP culture depends on the use of both qualitative and quantitative research approaches, or the best evidence available at the time. For example, a quantitative research study of a community health center could provide information about patterns of client use, the cost of various services, and the use of different health care providers. However,
when quantitative research is combined with qualitative research, the nurse can gain an understanding of why clients use or do not use the services and help the health center be both clinically effective and cost-effective. Evidence from multiple research methods has the potential to enrich the application of evidence and improve nursing practice (Blakely et al, 2013).
The rising cost of health care will demand a more critical look at the benefits and costs of EBP. Finding resources to implement EBP will continue to be a challenge requiring cre- ative strategies. An emphasis on quality care, equal distribution of health care resources, and cost control will continue. Imple- menting EBP can assist nurses in addressing these issues in the clinical setting. However, EBP can save money by providing the best care possible.
As nurses implement EBP in an environment focused on cost savings, the potential for governments, managed care organiza- tions, or other health care agencies to endorse reimbursement of health care options solely on the basis of cost, without allow- ing for individual variation or considering environmental issues, will continue to be a concern. Nurses must use caution in adopting EBP in a prescriptive manner in different commu- nity environments. One aspect of the new health care reform act (PL 111-148) addresses the development of task forces on preventive services and community preventive services to develop, update, and disseminate EBP recommendations of the use of community preventive services. In addition, grant pro- grams to support EBP delivery in the community are addressed in the Affordable Care Act of 2010.
Although the Internet is one source of evidence data (see Box 15-1), there may be a lack of quality indicators to evaluate the myriad websites claiming to contain evidence-based infor- mation. It is essential to evaluate the quantity of the informa- tion on the website, whether it comes from a reputable agency or scholar, and whether the source of the website has a financial interest in the acceptance of the evidence presented. (Refer to Chapter 16 on health education, which discusses the Internet as a source of data and how to evaluate its usefulness and reliability.)
HEALTHY PEOPLE 2020 OBJECTIVES Healthy People 2020 objectives offer a systematic approach to health improvement. See the Healthy People 2020 box for the most recent objectives to improve clients’ understanding of EBP and how they can contribute to health care decisions.
EXAMPLE OF APPLICATION OF EVIDENCE-BASED PRACTICE TO PUBLIC HEALTH NURSING Chapter 9 describes the Intervention Wheel, a population-based practice model for public health nursing. The model consists of three levels of practice at the community, systems, and individual/ family levels. It also consists of 17 public health interventions for improving population health. The model was originally developed using a qualitative grounded theory process but did
352 PART 3 Conceptual and Scientific Frameworks
From U.S. Department of Health and Human Services: Healthy People 2020: Roadmap to Improving All Americans’ Health. Washington, DC, 2010, U.S. Government Printing Office.
HEALTHY PEOPLE 2020
Information access is important to assure clients and communities have the correct information to make EBP health care decisions. The Healthy People 2020 objectives related to providing resources are as follows: • HC/HIT-6.3: Increase the proportion of persons who use electronic personal
health management tools. • HC/HIT-4: Increase the proportion of patients whose doctor recommends
personalized health information resources to help them manage their health.
• HC/HIT-12: Increase the proportion of crisis and emergency risk messages, intended to protect the public’s health, that demonstrate the use of best practices.
• HC/HIT-11: Increase the proportion of meaningful users of health information technology.
• HC/HIT-13: Increase the social marketing in health promotion and disease prevention U.S. Department of Health and Human Services, 2010.
not include a systematic review of evidence to support the inter- ventions or their application to practice. Initially, the model was developed from an extensive analysis of the actual work of 200 practicing public health nurses working in a variety of settings. The 17 interventions grew out of this analysis, as did the three levels of practice. The authors indicated that the original intent was to provide a description of the scope and breadth of public health nursing practice.
Because of the positive response to the Intervention Wheel, the decision was made to complete a systematic review of the evidence supporting the use of the Intervention Wheel. The goal was to examine the evidence underlying the interventions and the levels of practice. The systematic review involved answering six questions, a comprehensive search of literature, a survey of 51 BSN programs in five states, and a critique (by five graduate
students) of the 665 pieces of evidence found in the literature review for rigor (strength and usefulness). After limiting the final review to 221 sources of evidence, each source was inde- pendently rated by at least two members of a 42-member panel of practicing public health nurses and educators. The 42-member panel met to reach consensus on the outcomes of the reviews. The outcomes were field-tested with 150 practicing nurses, and then critiqued by a national panel of 20 experts.
The Intervention Wheel presented in Chapter 9 is the result of this systematic review and critique (Keller et al, 2004). Although this critique may appear overwhelming, the under- graduate or graduate student may be involved in such a system- atic critique as one of many participants contributing to the outcome of such a review. Table 15-2 applies some of the inter- ventions to the core functions of public health.
P R A C T I C E A P P L I C A T I O N A nurse who is the director of a public health clinic is in the process of analyzing how best to expand services to operate as a full-time clinic in the most cost-effective and clinically effec- tive manner. The director gathers evidence from the literature on public health clinics in rural settings to evaluate cost and clinical effectiveness of various models. The nurse also consid- ers evidence from the following sources in the decision-making
process: client satisfaction research data, knowledge of clinic staff, expert opinion of community advisory board members, evidence from community partners, and data on service needs in the state. Having examined the evidence, the nurse decides that incremental (step-by-step) growth toward full-time status is warranted. Evidence of needs in the community and analysis of statistical data indicate that the addition of wellness services
LINKING CONTENT TO PRACTICE
It is important for nurses to acknowledge and understand EBP. They can partici- pate by applying EBP or they can add to the research base for public health through active programs of research, participating in systematic reviews, or reviewing the best evidence available to them by reading published systematic reviews. Nurses can demonstrate leadership in supporting EBP by becoming change agents, fostering a cultural change in the practice environment, and assisting nurses who do not know how to use EBP to make a difference in practice.
For example, nurses who have recently graduated are knowledgeable about the use of evidence in practice. The new nurses can assist nurses who have been out of school for a while to find sources of evidence upon which to base their practice, such as referring them to the Guide to Community Preventive Services. Using evidence in practice will demonstrate its value, but implementa- tion can be difficult because of the sheer volume of evidence and increasing
population needs. Sharing knowledge and engaging in teamwork can help to overcome these barriers.
Nurses have an important role to play in developing and using clinical guide- lines for community practices. Use of a community development model and engaging in community partnerships will ensure that the community’s perspec- tive is included (see Chapter 18).
Nurses active in EBP can devote attention to understanding how best to incorporate the guidelines into practice demonstrating practice excellence. EBP offers the opportunity for shared decision making because it can help nurses focus their thinking, observe process outcomes, and thus improve care for clients by communicating with leaders and other nurses what they have observed. Participation in EBP offers continuing professional growth and a feeling of value, recognition for contributions, and respect from peers and administrators (Bradshaw, 2010; Sandström et al, 2011).
From Bradshaw WG: Importance of nursing leadership in advancing evidence-based nursing practice. Neonatal Netw 29(2):117–122, 2010; Sandström B, Borglin G, Nilsson R, et al: Promoting the implementation of evidence-based practice—a literature review focusing on the role of nursing leadership. Worldviews Evid Based Nurs Fourth quarter:212–223, 2011.
353CHAPTER 15 Evidence-Based Practice
Core Functions Related Nursing Interventions
Assessment Diagnose and investigate health problems and hazards in the community. Mobilize community partnerships to identify and solve health problems. Link people to needed health services. Use evidence-based practice for new insights and innovative solutions to health problems.
Policy development Inform, educate, and empower communities about health issues. Develop policies and plans using evidence-based practice that supports individual and community health efforts.
Assurance Monitor health status to identify community health problems. Enforce laws and regulations that protect health and ensure safety. Ensure the provision of health care that is otherwise unavailable. Ensure a competent public health and personal health care workforce. Use evidence-based practice to evaluate effectiveness, accessibility, and quality of personal and population-based services.
TABLE 15-2 Core Public Health Functions and Related Evidence-Based Nursing Interventions
K E Y P O I N T S • Evidence-based practice was developed in other countries
before its use in the United States. • The Institute of Medicine has indicated that by 2020, 90%
of all health care should be evidence based. • EBP is a paradigm shift in health care and nursing. • EBP is both a process and a product. • Application of EBP in relation to clinical decision making in
population-centered nursing concentrates on interventions and strategies geared to communities and populations rather than to individuals.
• Nurses at all levels have an opportunity to improve the prac- tice of nursing and client outcomes.
• The EBP process has seven steps.
• Approaches to EBP include systematic review, meta-analysis, integrative review, and narrative review.
• Evaluating the strength and usefulness of evidence is essen- tial to finding the best evidence on which to make practice decisions.
• Cost and quality of care are issues in EBP. • EBP includes interventions based on theory, expert opinions,
provider knowledge, and research. • Use of a community development model and community
partnership model involves community leaders in making decisions about best practices in their community.
• The Intervention Wheel is an example of a result of EBP. • Health care reform supports EBP.
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Give an example of how undergraduates can be involved in
EBP. 2. Explain how the nurse’s knowledge of the community relates
to EBP. Give examples. 3. What are the barriers to implementing EBP? How can these
barriers be resolved? 4. Is the cost or quality of care more important in EBP? Debate
this issue with classmates.
5. When working with a community to improve its health, is it more important to consider the perspectives of the com- munity or those of the provider when defining health prob- lems? Elaborate.
6. Invite the director of nursing from the local health depart- ment to speak to your class. Ask if evidence is used to develop nursing policies and practice guidelines. If not, why not?
7. Explain how you can apply evidence to your practice.
for children is a priority and a pediatric nurse practitioner is hired as a first step to assist the public health nurses while plan- ning for full-time status continues. A. Evaluation of the evidence gathered demonstrates which of
the following? 1. Effectiveness of the intervention in communities 2. Application of the data to populations and communities
3. Existence of positive or negative health outcomes 4. Economic consequences of the intervention 5. Barriers to implementation of the interventions in
communities B. Explain how this example applies principles of EBP.
Answers can be found on the Evolve site.
P R A C T I C E A P P L I C A T I O N — cont’d
354 PART 3 Conceptual and Scientific Frameworks
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355
Changing Health Behavior Using Health Education with Individuals,
Families, and Groups
16
Jeanette Lancaster, PhD, RN, FAAN Dr. Lancaster is Professor and Dean Emerita of Nursing at the University of Virginia. She has edited this book with Dr. Marcia Stanhope through its previous eight editions.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Describe the ways in which people learn. 2. Identify the steps and principles that guide community
health education. 3. Discuss the importance of understanding the needs of
learners including their cultural background, educational and health literacy level, and their motivation to learn and change behavior.
4. Describe how nurses can work with groups to promote the health of individuals and communities.
5. Examine types of health education including written, spoken, and the growing area of social media.
6. Explore ethical issues that arise in the practice of health education.
K E Y T E R M S affective domain, p. 358 andragogy, p. 363 change, p. 357 cognitive domain, p. 358 cohesion, p. 369 democratic leadership, p. 372 education, p. 357 established groups, p. 372 ethics, p. 356 evaluation, p. 367 formal groups, p. 368 goals, p. 359 group, p. 369 health belief model, p. 366
health education, p. 357 health literacy, p. 365 informal groups, p. 368 learning, p. 357 long-term evaluation, p. 368 maintenance functions, p. 369 maintenance norms, p. 370 motivational interviewing, p. 361 norms, p. 370 objectives, p. 359 patriarchal leadership, p. 371 pedagogy, p. 363 precaution adoption process model, p. 367 process evaluation, p. 367
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz
• Case Studies • Glossary • Answers to Practice Application
356 PART 3 Conceptual and Scientific Frameworks
One of the best ways to manage health care costs is for people to stay healthy. Nurses are in an ideal role to help individuals, families, and groups learn about health education and health promotion in order to change their behavior. Nurses can help clients by (1) educating across all three levels of prevention: primary, secondary, and tertiary; and (2) working with indi- viduals, families, groups, and communities. The goal is to assist clients to attain optimal health, prevent health problems, iden- tify and treat health problems early, and minimize disability. Education allows individuals to make knowledgeable health- related decisions, assume personal responsibility for their health, change behavior if needed, and cope effectively with alterations in their health and lifestyles. The Levels of Preven- tion box provides an example of how to use these three preven- tion levels in health education.
LEVELS OF PREVENTION
Primary Prevention Provide education at health fairs about diet, exercise, or environmental hazards.
Secondary Prevention Provide both education and health screenings at health fairs for such health issues as early diagnosis and treatment of diabetes and hypercholesterolemia in order to shorten the duration and severity of the disease.
Tertiary Prevention Provide education in rehabilitation centers to teach ways to increase function to individuals who have been in an accident that left them with either an amputation or some paralysis.
Related to Community Health Education
This chapter discusses ways to develop individual, group, and community health promotion programs. Specific content in the chapter includes information about how people learn; the sequence of actions that a nurse follows when developing an educational program; the process of making change; literacy, especially health literacy; and the ethics related to health educa- tion. The role of groups in health promotion is also presented. Many of the objectives of Healthy People 2020 address the importance of health promotion, and selected objectives are cited in this chapter.
HEALTHY PEOPLE 2020 OBJECTIVES FOR HEALTH EDUCATION
As mentioned in other chapters, Healthy People 2020 lists national health needs and outlines goals and objectives designed to improve health. The Healthy People 2020 educational objec- tives emphasize the importance of educating various popula- tions (based on age and ethnicity) about health promotion activities in the priority areas of unintentional injury; violence; suicide; tobacco use and addiction; alcohol or other drug use; unintended pregnancy, human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS), and sexu- ally transmitted disease (STD); unhealthy dietary patterns; and inadequate physical activity (U.S. Department of Health and Human Services [USDHHS], 2010).
In designing, implementing, and evaluating health educa- tion activities, it is useful to understand the primary health problems in the community as well as education principles related to both learning and teaching. Also, effective educational
K E Y T E R M S — cont’d psychomotor domain, p. 358 reality norms, p. 370 short-term evaluation, p. 368 social media, p. 360
task function, p. 369 task norm, p. 370 transtheoretical model, p. 367 —See Glossary for definitions
C H A P T E R O U T L I N E Healthy People 2020 Objectives for Health Education Education, Learning, and Change How People Learn
The Nature of Learning The Educational Process
Identify Educational Needs and Develop Goals and Objectives
Select Appropriate Educational Methods Skills of the Effective Educator Motivational Interviewing Develop Effective Health Education Programs
Educational Issues Population Considerations Based on Age and on Cultural
and Ethnic Backgrounds
Use of Technology in Learning Barriers to Learning Evaluation of the Educational Process
The Educational Product Evaluation of Health and Behavioral Changes
Groups as a Tool for Health Education Group: Definitions and Concepts Stages of Group Development Choosing Groups for Health Change Managing the Community Group Implementing the Educational Plan
357CHAPTER 16 Changing Health Behavior
help people change their attitudes, and the most difficult area to change is behavior. For this reason, nurses provide people with health information so they can improve their decision- making abilities and thereby decide if they will change their behavior. There is a difference between education and learning and between knowing and doing. Education is an activity “undertaken or initiated by one or more agents that is designed to effect changes in the knowledge, skill, and attitudes of indi- viduals, groups, or communities” (Knowles et al, 2005, p. 10). Education emphasizes the provider of knowledge and skills. In contrast, learning emphasizes the recipient of knowledge and skills and the person(s) in whom a change is expected to occur. Remember that learning involves change.
Change is not easy for most people. To change means to move away from one way of thinking, believing, and acting and move toward a new way. Thompson (2010) describes understanding and managing organizational change. Although much of the change regarding health education is directed toward clients, not organizations, the steps he uses also apply to health education. They are as follows: (1) identify the need for change—and this means that the client or clients being served need to believe that they need to make a change; (2) plan how to implement the change—and this step includes explaining the basis for the change, the benefits of the change, and seeking ideas from those being served about the best way to make an identified change; (3) implement the change; and (4) evaluate whether the change made a difference in health. Fielding (2013) offers a similar approach toward health education, consisting of the following five steps: (1) under- standing the problem, (2) understanding what works, (3) agree- ing on the approach or action, (4) implementing the plan, and (5) evaluating the effect. As nurses work with clients to make health changes, it is important to watch for resistance or reverting back to past behaviors.
HOW PEOPLE LEARN People learn in a variety of ways. Some people learn better by hearing a message; others learn by observing and/or participat- ing in what is being taught. Learners accept information on the basis of many factors including what they already know, what they believe, and the culture in which they have been raised; as well as how well they can understand and relate to the informa- tion that they receive. What a person hears is filtered through his past experiences, the social groups to which he belongs, assumptions, values, level of attention and knowledge, and the respect he has for the person communicating the information. In some cultures, elders are considered to be valued sources of information. In other cultures, people value individuals with more education than they have. Also, because social groups play a critical role in the development of understanding or learning, concepts related to groups are discussed later in this chapter. Effective health education is a competency that is included in many documents that describe the role of public health professionals, including nurses. The Linking Content to Practice box illustrates the relationship between health educa- tion and selected standards, expectations, and competencies in public health.
programs are built on the premise that the best approach is to teach what people think they want to learn and in ways that facilitate their learning. For this reason, a core public health principle relates to asking the learners to participate in identify- ing their learning needs. Then health education programs are designed to meet the health need or problem in that population. In general, these programs involve educating individual members of the population about health promotion, illness prevention, and treatment. For example, in a community where childhood and adolescent asthma is a problem, a community- based asthma education and training program can be devel- oped. If childhood obesity is a major health concern, a program to educate children in their schools and parents and other care- givers in an after-school program about healthy eating, cooking, and exercise may be useful.
To develop a community-based education program, nurses need to follow a set of steps. Typical steps that are discussed in detail throughout the chapter include the following: (1) identify a population-specific learning need for the community health client; (2) select one or more learning theories to use in the edu- cation program; (3) consider which educational principles are most likely to increase learning and choose those that are most appropriate and feasible; (4) examine educational issues, such as population-specific or cultural concerns, identify barriers to learning, such as limited literacy or limited or lack of health lit- eracy, and choose the most appropriate teaching and learning strategies based on the age, gender, education, and learning needs of the learners; (5) design and implement the educational program, using carefully chosen strategies; and (6) evaluate the effects of the educational program. The steps used in designing educational programs parallel those of the nursing process.
EDUCATION, LEARNING, AND CHANGE When helping people change their behavior, remember that people can most easily change knowledge. The next step is to
HEALTHY PEOPLE 2020
Selected examples of Healthy People 2020 are provided here. • ECBP-2: Increase the proportion of elementary, middle, and senior high
schools that provide comprehensive school health education to prevent health problems in the following areas: unintentional injury; violence; suicide; tobacco use and addiction; alcohol or other drug use; unintended pregnancy, immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and sexually transmitted infection (STI); unhealthy dietary pat- terns; and inadequate physical activity.
• ECBP-3: Increase the proportion of college and university students who receive information from their institution on each of the priority health-risk behavior areas listed previously.
• ECBP-8: Increase the proportion of worksites that offer a comprehensive employee health promotion program to their employees.
• ECBP-11: Increase the proportion of local health departments that have established culturally appropriate and linguistically competent community health promotion and disease prevention programs.
ECBP, Educational and community-based programs. From U.S. Department of Health and Human Services: Healthy People 2020: Understanding and Improving Health Promotion and Disease Prevention Objectives. Washington, DC, 2010, U.S. Government Printing Office.
358 PART 3 Conceptual and Scientific Frameworks
cognitive domain consists of the following components (Bloom et al, 1956): 1. Knowledge: Requires recall of information 2. Comprehension: Combines recall with understanding 3. Application: In which new information is taken in and used
in a different way 4. Analysis: Breaks communication down into parts in order to
understand both the parts and their relationships to one another 5. Synthesis: Builds on the first four levels by assembling them
into a new whole 6. Evaluation: In which learners judge the value of what has
been learned
Affective Domain The affective domain includes changes in attitudes and the development of values. For affective learning to take place, nurses consider and attempt to influence what learners feel, think, and value. Because the attitudes and values of nurses may differ from those of their clients, it is important to listen care- fully to detect clues to feelings or misperceptions that learners have that may influence learning. It is difficult to change deeply rooted attitudes, beliefs, interests, and values. To make such changes, people need support and encouragement from those around them. Affective learning, like cognitive learning, consists of a series of steps that the learner takes: 1. Knowledge: Receives the information 2. Comprehension: Responds to the information received 3. Application: Values the information 4. Analysis: Makes sense of the information 5. Synthesis: Organizes the information 6. Evaluation: Adopts behaviors consistent with new values
Psychomotor Domain The psychomotor domain includes the performance of skills that require some degree of neuromuscular coordination and emphasizes motor skills (Bloom et al, 1956). Clients are taught a variety of psychomotor skills including bathing infants, changing dressings, giving injections, measuring blood glucose levels, taking blood pressures, walking with crutches, as well as many skills related to health promotion exercises.
In teaching a skill, first show clients how to do a task requir- ing the skill being taught. You can use pictures, a model, or a device, or via a live demonstration, video, CD, or the Internet. Next, have clients practice through a repeat demonstration to validate that what is being taught was actually learned. Also, if the teaching is being done in a class, participants may learn by observing one another master a task. Psychomotor learning is dependent on learners meeting three conditions (Bloom et al, 1956; Dembo, 1994). The learner must have the following: • The necessary ability: This will include both cognitive and psy-
chomotor ability. For example, you may find that a person with Alzheimer’s disease can follow only one-step instructions. Thus, you need to tailor your education plan to that person.
• A sensory image of how to carry out the skill: For example, when teaching a group of women how to cook heart-healthy foods, ask the women to describe their kitchen and how they would actually go about the cooking process.
A variety of educational principles can be used to guide the selection of health information for individuals, families, com- munities, and populations. Three of the most useful categories of educational principles include those associated with the nature of learning, the educational process, and the skills of effective educators.
The Nature of Learning One way to think about the nature of learning is to examine the cognitive (thinking), affective (feeling), and psychomotor (acting) domains of learning. Each domain has specific behav- ioral components that form a hierarchy of steps, or levels. Each level builds on the previous one. Understanding these three learning domains is crucial in providing effective health educa- tion (Bloom et al, 1956). First, consider assumptions about how adults learn. Specifically, adults are motivated to learn when (1) they think they need to know something, (2) the new informa- tion is compatible with their prior life experiences, (3) they value the person(s) providing the information, and (4) they believe they can make any necessary changes that are implied by the new information (Knowles et al, 2005).
Cognitive Domain The cognitive domain includes memory, recognition, under- standing, reasoning, application, and problem solving and is divided into a hierarchical classification of behaviors. Learners master each level of cognition in order of difficulty (Bloom et al, 1956). Start by assessing the cognitive abilities of the learn- ers. This is especially important when learners have a limited level of literacy either of the language used in the instruction or of the content that is presented. A later section discusses both literacy in general and health literacy in particular. Teaching above or below a person’s level of understanding can lead to frustration and discouragement. It is therefore important to be sensitive to the value of the cognitive domain in learning. The
LINKING CONTENT TO PRACTICE
Just as objectives in Healthy People 2020 recommend that health education and promotion be used to provide public health care, so do other key docu- ments such as the American Nurses Association’s Scope & Standards of Practice: Public Health Nursing. Standard 5b, labeled “Health Education and Health Promotion,” says that the “public health nurse employs multiple strate- gies to promote health, prevent disease, and ensure a safe environment for populations” (American Nurses Association, 2007, p. 23). Similarly, the Core Competencies for Public Health Professionals of the Council on Linkages between Academia and Public Health Practice (2010) lists six competencies related to communication skills; five of them relate directly to this chapter. These competencies, listed below, are discussed and illustrated throughout this chapter: 1. Assessing the health literacy of populations served 2. Communicating in writing and orally, in person, and through electronic
means, with linguistic and cultural proficiency 3. Soliciting input from individuals and organizations 4. Using a variety of approaches to disseminate public health information 5. Applying communication strategies in interactions with individuals and
groups
359CHAPTER 16 Changing Health Behavior
Once you identify the needs, prioritize them to meet the most important needs first. Consider the many factors that influence a person’s learning needs and the ability to learn including demographic, physical, geographic, economic, psychological, social, and spiritual factors. Consider also the learner’s knowl- edge, skills, and his or her motivation to learn, as well as what resources are available to support or prevent learning. Resources include printed, audio or visual materials, equipment, agencies, and other individuals. Barriers for the presenter include lack of time, skill and/or confidence, money, space, energy, and orga- nizational support.
When you have identified the learning needs, develop the goals and objectives for the educational program. Goals are broad, long-term expected outcomes such as, “Each child in the third-grade class will participate in 30 minutes of daily physical exercise, 4 days per week for 2 months.” Program goals should deal directly with the clients’ overall learning needs. Regarding the third graders, their learning need is to know how important exercise is to their health and level of fitness.
Objectives are specific, short-term criteria that need to be met as steps toward achieving the long-term goal such as, “Within 2 weeks, each of the children will be able to demon- strate at least two exercises that they have learned.” Objectives are written statements of an intended outcome or expected change in behavior and should define the minimal degree of knowledge or ability needed by a client. Objectives must be stated clearly and defined in measurable terms, and they typi- cally imply an action (Knowles et al, 2005).
Select Appropriate Educational Methods Educational methods should be chosen to facilitate the efficient and successful accomplishment of program goals and objectives. The methods should also be appropriately matched to the client’s strengths and needs as well as those of the presenter. Choose the simplest, clearest, and most succinct manner of presentation and avoid complex program designs. Try to vary the methods in order to hold the attention of the learners and to meet the needs of different learners. Educators also need to be able to deliver presentations, lead group discussions, organize role plays, provide feedback to learners, share case studies, use media and materials, and, where indicated, administer examinations. You will want to think about what content to include, how to organize and sequence the information, what your rate of delivery will be, whether or not you need to include repetition, how much prac- tice time should be included, how you will evaluate the effective- ness of the teaching, and ways that you can provide reinforcement
• Opportunities to practice the new skills: Provide practice ses- sions during the program to help the client adapt the skill to the home or work environment where the skill will be performed.
• The following Quality and Safety Education for Nurses box describes the importance of clear and appropriate communication.
Source: Cronenwett L, Sherwood G, Barnsteiner J, et al: Quality and safety education for nurses. Nurs Outlook 55:122–131, 2007.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Important aspects of client-centered care include the following: Knowledge: Integrate understanding of multiple dimensions of client-
centered care: information, communication, and education Skills: Communicate client values, preferences, and expressed needs to other
members of the health care team Attitudes: Respect and encourage individual expression of client values,
preferences, and expressed needs
Client-Centered Care Question Providing health information in a way that is not understandable or useful to the recipient is a poor form of client-centered communication. If you were teaching a group of four women about wound care after surgery, what steps would you take to assure that the message the women received was the message that you intended to send?
Answer: In general, you would begin by providing the needed information by describing each step; you might include an easy-to-understand handout in the language that the four women understand, or you might give them a CD to take home with them that has the information on it. Next you would dem- onstrate how to clean the wound. Then you would ask each woman to repeat the cleaning process that you just demonstrated. Finally, you would ask each woman if she had the facilities and supplies to clean the wound at home; and then you would ask if they each had any questions or concerns that you might answer. What else would you do?
Targeted Competency: Client-Centered Care
In assessing a client’s ability to learn a skill, be sure to evaluate intellectual, emotional, and physical ability, and then teach at the level of the learner’s ability. Some clients do not have the intel- lectual ability to learn the steps that make up a complex proce- dure. Others may have cultural beliefs that conflict with healthy behaviors. Another client may be tremulous or have poor eye- sight, making him incapable of learning insulin self-injection.
THE EDUCATIONAL PROCESS The educational process builds on an understanding of educa- tion, learning, and how people learn. The five steps of the edu- cational process (identify educational needs, establish educational goals and objectives, select appropriate educational methods, implement the educational plan, and evaluate the educational process) are discussed next.
Identify Educational Needs and Develop Goals and Objectives Begin with a needs assessment to learn about health education needs. The steps of such an assessment are listed in Box 16-1.
1. Identify what the client wants to know. (Consider Healthy People 2020 educational objectives.)
2. Collect data systematically about learning needs, readiness to learn, and barriers to learning.
3. Analyze assessment data that have been collected and identify cognitive, affective, and psychomotor learning needs.
4. Think about what will increase the client’s ability and motivation to learn. 5. Assist the client to prioritize learning needs.
BOX 16-1 Steps of a Needs Assessment
360 PART 3 Conceptual and Scientific Frameworks
Edit information: Teach necessary information first. Be specific. Act on each teaching moment: Teach whenever possible. Develop
a good relationship. Clarify often: Make sure your assumptions are correct. Seek
feedback. Honor the client: Respect the client as a partner, share responsi-
bility, and build on the client’s experience. The goal of nurses who use Healthy People 2020 as a guide
in educating clients is to foster healthy communities mainly through primary and secondary prevention. Health fairs are a popular way to provide primary and secondary health educa- tion. The objectives of holding health fairs are to increase awareness by providing health screenings, activities, informa- tion and educational materials, and demonstrations. A health fair can target a specific population or focus on a specific health issue, as well as target a range of groups and cover a variety of health education and health promotion topics. The fair can be held in many locations and can be either inside or outside. The How To box lists guidelines to assist nurses who chair, co-chair, or serve on a planning committee for a health fair.
and rewards. The Internet and use of social media have created an entirely new way of providing health information. Sites such as Facebook, YouTube, and Twitter have large numbers of users (Bernhardt et al, 2013). Data from the Pew Internet & American Life Project (Pew Charitable Trusts, 2013) show that laptop computers are used more often than desktop computers and that the use of music players, video game equipment, electronic book readers, and tablet computers has grown rapidly. The most explosive growth has been in the use of mobile phones. These new forms of access to information affect the way in which health education is developed and delivered.
It is important to consider the ethical issues involved in using various forms of teaching tools, especially when using social media. According to the Pew Internet & American Life Project (Pew Charitable Trusts, 2013), 60% of patients seek both support and information online. Of 3,014 survey respondents, 77% said that they used Google, Bing, or Yahoo to find health information. Remember, not all websites are developed by health care professionals, nor have they all been peer reviewed. Also, when nurses use patient cases or data to illustrate a health education point, it is important to clearly understand the guide- lines of the Health Insurance Portability and Accountability Act (HIPAA) and avoid privacy ethical violations of the ethics code. When nurses use social media to provide health education, they should consult the ANA’s Principles for Social Networking and the Nurse (American Nurses Association, 2011) and the National Council of State Boards of Nursing’s White Paper: A Nurse’s Guide to the Use of Social Media (National Council of State Boards of Nursing, 2011). It is essential to protect the privacy of patients and their health data when making presenta- tions in person or via social media or any other medium (Lachman, 2013).
When choosing educational methods, consider age, gender, culture, hearing, sight or developmental disabilities or special learning needs, educational level, knowledge of the subject, and size of the group. For example, clients with a visual impairment need more verbal description than those with no impairment in sight. Persons who have hearing impairments or language deficits need more visual material and speakers or translators who can use sign language or speak their native language. Also, when the learners have limitations in attention and concentra- tion, the educator will need to use creative methods and tools to keep them focused. For example, you might include frequent breaks; simple surroundings with few or no distractions; use of small group interactions to keep learners involved and inter- ested; and the use of hands-on equipment such as mannequins, models, interactive games, and other materials and devices that the learner can physically manipulate. Try to involve the learner appropriately, actively, and creatively in learning. Interactive educational programs may be more effective than noninteractive ones. Interactive strategies include discussion, small group work, games, and role-playing, whereas noninter- active strategies include lectures, videos, or demonstrations. The mnemonic TEACH is a useful way to teach clients. The steps are as follows: Tune in: Listen before you start teaching. The client’s needs
should direct the content.
HOW TO Plan, Implement, and Evaluate a Health Fair • Form a planning committee (2-12 people who represent the groups
that will be part of the health fair). Possibilities include health professionals, representatives from health agencies, schools, churches, employers, the media, and the target audience.
• Identify the target group; develop a theme. • Establish goals, expected outcomes, and screening activities
consistent with the needs and wishes of the target group. Your primary goal might be to improve the health of a specific popula- tion such as workers at one plant or children in one school. You might have secondary goals such as reduced health care costs for the workers and reduced absenteeism for the children.
• Develop a timeline and schedule. • Choose a site and consider the site logistics: Do this about 1 year
ahead. Think about the size of the site you will need and the traffic flow from one booth or demonstration to another, whether parking is available and free or low cost, and whether there are toilets and places to get food and drinks. If the site is inside, consider adequate exits; the possible risks to children, the elderly, or handicapped people; and other safety and security issues. You may need to create maps: one for how to get to the fair and another one to help attendees get from one table, exhibit, or screening station to another. Be sure to include on the map the location of amenities such as toilets and food vendors.
• Plan for supplies that you will need: Tables, chairs, electronic equipment, and accessories such as extension cords, office sup- plies, sign-in sheets (and what information should be included), release forms for screenings, name tags, bags for attendees to gather the educational information, and evaluation forms. Set your budget. Obtain these supplies in advance.
• Recruit and manage exhibitors: Do this about 4 months ahead. Develop a list of possible exhibitors and sponsors, and contact them via letter, fax, e-mail, telephone, or in person. Follow-up with a confirmation letter (or fax) that outlines the details of the health fair.
• Publicize the health fair: The planning committee will have many good ideas about how to publicize in the specific community.
361CHAPTER 16 Changing Health Behavior
community group she leads who are overweight, eat high-calorie foods, and indicate they exercise little if any on a regular basis, how could the nurse use MI? First, the nurse needs to form a partnership with each of the women, in which she and the clients can communicate easily and in which each woman trusts the nurse. The nurse draws each woman out and learns what, if anything, each wishes to change. The nurse also learns about each one’s motivation to change and ability to do so. Consider the client, Anna, and examine her motivation to change her eating and activity patterns. Anna says that her family will eat only fried foods, so to get her husband and children to eat a meal she fries their meats and vegetables. The family does eat fresh fruit and drink milk. Anna says that she gets exercise by walking to the bus stop en route to work and cleaning her home. She has not considered other forms of regular exercise. If you want to use MI with Anna and incorporate these principles in designing your nursing plan you could begin as follows: 1. Expressing empathy by trying to see the world through
Anna’s eyes 2. Building on Anna’s strengths and helping her believe that she
has the ability to make a change (self-efficacy) 3. Rolling with resistance when Anna is ambivalent about her
ability to change 4. Developing discrepancy by helping Anna recognize that her
current actions conflict with her expressed goals of eating healthy foods and exercising regularly You could incorporate into your strategy the counseling skills
that are part of MI: open-ended questions, affirmations, reflec- tions, and summaries (OARS). These communication skills are useful in any nurse-client interaction. Open-ended questions refer to those that are not easily answered with yes or no or a short answer. These questions invite elaboration and more thinking about what is being asked. In helping Anna prepare healthier meals, ask her to describe the dinner she cooked the previous night. Affirmations are designed to recognize client strengths; they must be genuine and correct. Once Anna begins to explore the idea of preparing more nutritious food, you would affirm her progress and encourage her to continue working toward that goal. Reflections or reflective listening is possibly the most critical skill in that it conveys empathy because you are listening carefully. You can then guide Anna toward dealing with her ambivalence about change by examining the positive and negative aspects of the present situation. Using reflective listening, if Anna expresses concern or difficulty in her goal of preparing different meals, you can focus on her concern and possible ambivalence about sticking to the plan for change.
MI uses the term change talk to refer to statements by clients that they are motivated and willing to make change. An easy-to- use mnemonic is “DARN-CAT,” which refers to the following:
Examples might include fliers/posters, memos, brochures, e-mail blasts, local print, or radio/television.
• On the day of the fair: Greet health care professionals, agency representatives, sponsors, and members of the population being served.
• Evaluate the health fair: By exhibitors, participants and volun- teers. You will need a specific form for each of these groups.
• Between 1 week and 1 month after the fair: Send thank-you letters to health care professionals, sponsors, and agencies, and pay bills associated with the fair.
From Rice CA, Pollard JM: Health fair planning guide, Agri LIFE EXTENSION Texas A&M System, September 16, 2009. Available at http://fcs.
Skills of the Effective Educator The educator needs to understand the basic sequence of instruc- tion. The following steps are useful in planning an educational program. Begin by (1) gaining the attention of the learners and helping them understand that the information being presented is important and helpful to them; (2) tell the learners the objec- tives of the instruction; (3) ask the learners to recall previous knowledge related to this topic of interest so that they link new knowledge with previous knowledge; (4) present the essential material in a clear, organized, and simple manner and in a way consistent with the learners’ strengths, needs, and limitations; (5) help learners apply the information to their lives and situ- ations; (6) encourage learners to demonstrate what they have learned, which will help you correct any errors and improve skills; and (7) provide feedback to help learners improve their knowledge and skills. When you use each of these steps you can help clients increase their learning experiences.
Motivational Interviewing Sometimes clients do not provide all of the information needed to help promote their health. It is important before developing an implementation plan to carefully assess the need. The goal in health education is to engage the clients in wanting to learn ways in which they can change their behavior. Pay attention to the words you use and avoid medical jargon. Instead, use con- versational language. One tool to use in health education is “motivational interviewing” (MI), which is a tool designed to help clients state their motivations to change (Miller and Rose, 2009). It is a collaborative partnership between the teacher and the learner designed to help people make their own choices. It seeks to help clients resolve their ambivalence about change and uses the techniques of elaboration, affirmation, reflection, and summary to engage people in talking about change. MI often is used in conjunction with other communication techniques. MI has four essential steps: engaging, which includes person- centered, empathic listening; guiding, which includes a particu- lar identified target for change; evoking of the client’s own motivations for change; and planning (Motivational Interview- ing Network of Trainers, 2013).
MI was initially designed to treat problem drinkers and is used often with individuals rather than groups. However, the principles can be applied to health education. For example, if a public health nurse determines that she has four women in a
Preparatory Change Talk Implementing Change Talk Desire (I want to change) Ability (I can change) Reason (It’s important to
change) Need (I should change)
Commitment (I will make changes)
Activation (I am ready, prepared, willing to change)
Taking steps (I am taking actions to change)
362 PART 3 Conceptual and Scientific Frameworks
Apply the DARN-CAT mnemonic to the goal you and Anna have for her to learn ways to prepare more nutritious meals. Although MI is a set of skills that requires training to use completely, nurses can incorporate some of the MI techniques into their communication with clients. See the website www.motivationalinterviewing.org for more information on motivational interviewing.
Develop Effective Health Education Programs All programs, including sessions using MI skills, should include a clear message conveyed in a format appropriate to the learners and in an environment that is free from distractions and con- sistent with the message. Emotions such as anxiety, stress, anger, or fear can interfere with the listener actually hearing the message being sent. Also, provide information that is under- standable to the listener. Use plain language and avoid jargon, multisyllable words, slang, and complex medical terms. Use words that the listener will know and recognize. For example, some people are more familiar with terms like high blood pres- sure and high blood sugar levels rather than hypertension and increased glucose levels. On the other hand, be careful not to oversimplify your terms if your audience is knowledgeable about health care. You want to avoid “talking down” or “over the head” of your listeners.
The type of learning format that you select will depend on the learners. If they are young, you will want an interactive format and many of your options will include the use of tech- nology. You could use a game such as developing a bingo game with food groups to teach about healthy eating. The old adage “A picture is worth a 1000 words” still holds true. People tend to remember what they see or hear; a lively format rather than a passive one encourages learning. Most people have a short attention span, so you need to make your point quickly and directly. It may help to provide take-home written materials or a CD for further reminders and follow-up of what is taught. Because people often learn better when they are actively engaged in the learning, small group discussion, role-playing, and question-and-answer sessions may reinforce learning. See Box 16-2 for examples of types of learning formats.
Pontius (2013) offers many useful suggestions for developing both verbal and written messages. Her audience is composed of school nurses; however, her messages fit many areas of health education. For written material, first limit the content and make it relevant; use an active voice and conversational tone so that you engage the learner in the process; make the material easy to read and write the way you talk. You do not want to use a thesaurus to find terms to use, so say what you mean in under- standable words. As has been mentioned, make the content relevant to the age, gender, and culture of the learner. For online and social media messages, send out one message at a time. Use 12-point print size for most people and 14 point for older people. Use bullets or numbers to easily catch the attention of the reader, and put your most important points early in the list. Leave some white space on the page and choose ink that con- trasts clearly with the background of the paper. Use examples to show the desired behavior. Figure 16-1 shows a community
FIG 16-1 Educating a community group about environmental health issues and gathering their concerns. (From Centers for Disease Control and Prevention [2009]; courtesy Dawn Arlotta.)
Presentation: This method can be used when the group is large and you want to be consistent in the message that is delivered to all participants. Remember, people tend to have a short attention span, so what can you do to keep them engaged? You might ask them to spend some time talking with one another in small groups and then have the group respond to questions, or ask attendees to write answers to questions and invite several to share their answers. The presentation can also be a webinar or similar electronic tool, including Skype.
Demonstration: Use the demonstration technique to show attendees how to perform a task. You could demonstrate insulin injection, heart-healthy food preparation, and exercise.
Small Informal Group: Because learners often learn as much from one another as from the instructor, small groups can be valuable. For example, in working with women in a shelter for abused women, participants may share actions they took to remove themselves safely from the violent environment. They might also be able to jointly plan how each might move to the stage of independent living outside the shelter.
Health Fair: See the How To box on ways to plan, implement, and evaluate a health fair. For example, you might offer a health fair in a senior center and have displays such as posters; videos; live demonstrations; handouts on such topics as reducing fat in selected recipes (including samples) and age-appropriate exercises for flexibility; as well as screenings for elevated blood pressure, glucose, or cholesterol or for osteoporosis and vision.
Non-native Language Sessions: You could adapt the health fair approach for a Hispanic group by holding the session in Spanish and providing all of the materials in Spanish. Then ask Spanish-speaking nurses to staff each of the stations for health learning.
BOX 16-2 Examples of Learning Formats
group being educated, and Box 16-3 lists ways to design clear educational programs.
EDUCATIONAL ISSUES There are three important educational issues to consider when you are planning educational programs. First, different populations of learners require different teaching strategies. Second, be prepared to overcome barriers to learning. And
363CHAPTER 16 Changing Health Behavior
Andragogy is a more transactional way of learning than is the pedagogical model. Each model has useful elements (Knowles et al, 2005). For example, when learners are dependent and entering a totally new content area, they may require more pedagogical experiences. In addition to considering the age of the population to be educated, think about the learning needs of the population and use the pedagogical and andragogical principles that will best meet these needs. In educational pro- grams for children, provide information that matches the devel- opmental abilities of the group. The following age-specific strategies may help the nurse tailor educational programs for children. • With younger children use more concrete examples and word
choices. You might tell a group of 3-year-old children that it is good to brush their teeth two times a day. With 10-year- olds, you can explain to them the benefits of brushing their teeth and the risks of not brushing and talk about issues such as the care of their teeth with braces.
• Use objects or devices, rather than just discuss ideas, to increase attention. When teaching a group of children with asthma how to use inhalers, it is better to hand out inhalers to each participant and have them practice proper technique with the inhalers rather than just giving them a handout with instructions or demonstrating how to use an inhaler while they watch you.
• Incorporate repetitive health behaviors into games to help chil- dren retain knowledge and acquire skills. Singing songs while acting out healthy activities such as washing hands before eating helps children get in the habit of washing their hands and makes this health promotion behavior fun. For example, the time a child should wash his or her hands is about the same amount of time it takes to sing “Twinkle, Twinkle Little Star.” In thinking about culture, it is important to know that by
2050 approximately 50% of the U.S. population will consist of ethnic minorities such as Asians, African Americans, Hispanic Americans, Native Americans, and Pacific Islanders. Culture influences family structure and interactions as well as views about health and illness. These demographic changes present new challenges to nurse educators. Nurses need to understand the health belief systems of the ethnic populations being served and be familiar with populations who are prone to develop certain health problems. When presenting seminars or provid- ing written, audio, or visual information, provide information in a culturally competent manner.
For example, in a rural farming area, there might be a large population of Mexican migrant crop workers. Knowing that this Spanish-speaking group is more likely to have tuberculosis than other segments of the community, nurses may visit the migrant worker camp to present information on tuberculosis such as prevention, symptom identification, early diagnosis, and treatment. An interpreter may accompany the nurses and provide oral content in Spanish. Written handouts can be in Spanish and designed to be read and understood on a second- or third-grade reading level.
Think also about the generation of the learner. The genera- tion born between 1980 and the present time have always had
third, consider the appropriateness of using technology in the programs.
Population Considerations Based on Age and on Cultural and Ethnic Backgrounds Nurses are an important source of health education in the com- munity. The increase in populations of varying cultural and ethnic backgrounds and the aging of baby boomers require that community health education cross age and cultural boundaries. In terms of age, children, adults, and older adults have different learning needs and respond to different educational strategies. In each age group, learners vary also in their cognitive ability, personality, and prior knowledge. Some people learn better with more direct instruction, supervision, and encouragement than do other people.
Learning strategies for children and individuals with little knowledge about a health-related topic are characterized as pedagogy. In the pedagogical model of learning, the teacher assumes full responsibility for making decisions about what will be learned, and how and when it will be learned. This form of learning is teacher directed. Learning strategies for adults, older adults, and individuals with some health-related knowledge about a topic are called andragogy. In andragogy, learners play an important role in deciding what they need and want to learn.
1. Develop the content for your message. 2. Identify the most appropriate format and location for the program, taking
into account your budget, location, and other available resources and con- straints. See Box 16-2 for examples of formats.
3. Organize the learning experience to fit the audience; consider how to engage the learners in the process.
4. Plan how you will deliver the material, using the following points: • Limit the number of points that you wish to cover to the most important
ones. • Begin with a strong opening and close with a strong ending; people
remember most what is said first and last. • Fit your use of language to the learners; use an active voice and empha-
size the positive. For example, “Many people are able to lose weight by reducing their intake by 500 calories a day and exercising 45 minutes at least four times a week.”
• Use examples, stories, and other vivid messages. Limit statistics and complex terminology.
• Refer to trustworthy sources. In general, government, educational, or professional association sources are peer reviewed by professionals and dependable. The Centers for Disease Control and Prevention, National Cancer Institute, American Public Health Association, and the American Academy of Pediatrics are four examples of sites that offer useful information.
• Use aids to highlight your message. For example, you might have posters, handouts, or CDs to give to attendees. You might also incorpo- rate a clip from a website such as www.YouTube.com to emphasize your point. Be sure to verify that the content on the site is accurate; not all information is provided by professionals.
5. Don’t forget to plan the evaluation when you are initially planning the program.
BOX 16-3 Ways to Design Clear Educational Programs
364 PART 3 Conceptual and Scientific Frameworks
• Links: Have the links been evaluated according to back-link- ages, content, and selection? The Evidence-Based Practice box below describes the effective use of a smartphone app for health promotion.
digital media and access to the Internet and are called the net generation (Billings and Kowalski, 2004). They are connected and use mobile devices for many purposes including learning. They typically prefer to work in groups or teams, are active learners who seek innovation, want an immediate response to their questions, and are able to multitask. They like simulations and virtual reality forms of learning. Generation X members were born between 1960 and 1980, and they tend to be self- directed, like to work in teams, and may need to develop skills because they may not be as tech savvy as the net generation. Members of this group can tolerate delayed gratification; they want clear information with practical value; and they can engage in games and activities when appropriate. The boomers, born between 1940 and 1960, are accustomed to being depen- dent on the teacher, want to be in charge of their own learning, respond positively to feedback, and want to do a good job. They like to be connected to other people.
Use of Technology in Learning Many kinds of technologies such as computer games and pro- grams, videos, CDs, and Internet resources can increase learn- ing. These technologies may enable the learner to control the pace of instruction, offer flexibility in the time and location of learning, present an appealing form of education, and provide immediate feedback. You may want to use a variety of techno- logical applications in your teaching. It is also important to be aware that people increasingly are using the Internet as a source of health information. Why do people use the Internet? A major benefit is its convenience: It is available 24 hours a day, 7 days a week, and there is no need to drive there, take public trans- portation, or find a parking place.
Educating people through the Internet has been shown to be more effective in fostering treatment adherence than in-person counseling, telephone counseling, or self-directed learning (Dauz et al, 2004). Clients may ask nurses to provide them with information about ways to evaluate the quality and reliability of this information. The following list provides some criteria for assessing the quality of Internet health information (Agency for Healthcare Research and Quality, 1999; VanBiervliet and Edwards-Schafer, 2004): • Authorship: Are the authors and contributors listed with
their credentials and affiliations? • Caveats: Does the site clarify whether its function is to
provide information or to market products? • Content: Is the information accurate and complete, and is an
appropriate disclaimer provided? • Credibility: Does the site include the source, currency, rele-
vance, and editorial review process for the information? • Currency: Are dates listed for when the content was posted
and updated? • Design: Is the site accessible, capable of internal searches, easy
to navigate, and logically organized? • Disclosure: Is the user informed about the purpose of the site
and about any profiling or collection of information associ- ated with using the site?
• Interactivity: Does the site include feedback mechanisms and opportunities for users to exchange information?
Kirwan M, Duncan MJ, et al: Design, development, and formative evaluation of a smartphone application for recording and monitoring physical activity levels: the 10,000 Steps “iStepLog.” Health Educ Behav 40:140–151, 2013.
The authors describe the development and formative evaluation of a smart- phone app that deals with physical activity promotion. They say that physical inactivity is the fourth leading risk factor for global mortality and that self- monitoring of physical activities levels can support a healthier life. Because the Internet is easily accessed by many people, the authors used “10,000 Steps,” which is an online physical activity health program to encourage the use of step-counting pedometers to track daily exercise. Their goal was to evaluate the design and usability of this smartphone app. They used both qualitative (video-taping and having participants “think aloud”) and quantita- tive (a four-item usability questionnaire that used a 5-point Likert-type scale followed by a semistructured interview) measures. During the project they made modifications to the app. The results showed that the design changes significantly reduced the time it took for participants to complete their tasks. The study demonstrates the relevance of testing the design and then modify- ing a smartphone app designed for health promotion.
Nurse Use Smartphones and their apps are an innovative medium for the delivery of health messages and health care interventions. It is a good idea to test the app before launching it to work out any areas that could be improved in terms of ease of use.
EVIDENCE-BASED PRACTICE
Barriers to Learning Barriers to learning fall into two broad categories: one concern- ing the educator and the other concerning the learner.
Educator-Related Barriers Some common educator-related barriers to learning, together with strategies to minimize them, follow (Knowles et al, 2005): • Fear of public speaking: Be well prepared, use icebreakers,
recognize and acknowledge the fear, and practice in front of a mirror or video camera or with a friend.
• Lack of credibility with respect to a certain topic: Increase your confidence by carefully preparing for the talk so that you have included useful information and you understand the information; avoid apologizing for lack of expertise, and instead convey the attitude of an expert by briefly sharing your personal and professional background.
• Limited professional experiences related to a health topic: You may want to describe personal experiences (brief ones), share experiences of others, or use analogies, illustrations, or examples from movies, current news, or famous people.
• Inability to deal with difficult people who need to learn health- related information: One strategy that may help with han- dling difficult learners is to confront the problem learner directly. Other strategies include using humor, using small groups to foster participation of timid people, asking
365CHAPTER 16 Changing Health Behavior
assessment was first conducted in 1992. At that time, out of five levels in the assessment, 50% of American adults were in the top two levels and 50% were in the bottom three levels of lit- eracy. The minimal standard needed to function in the work- place is that of level 3 proficiency. In 2003, the tool measured literacy in four levels: Below Basic, Basic, Intermediate, and Pro- ficient. The literacy scales used in 2003 were as follows: prose literacy, document literacy, and quantitative literacy. Prose examples include searching, comprehending, and using infor- mation from editorials, news stories, brochures, and instruc- tional materials. Document literacy refers to searching, comprehending, and using information from documents such as job applications, payroll forms, transportation schedules, maps, tables, and drug and food labels. Quantitative literacy is the ability to identify and perform computations such as bal- ancing a checkbook, completing an order form, or determining the interest on a loan from an advertisement. The 2003 test is more than just a survey and actually asks the test takers to perform tasks to demonstrate their literacy (Kutner et al, 2006). The 2003 NAAL included information about health literacy, which is an important topic for nurses.
Health literacy is gaining considerable attention for many reasons including the costs of health illiteracy when people are unable to follow directions about health care. Healthy People 2020 defines health literacy as “[t]he degree to which individu- als have the capacity to obtain, process, and understand basic information and services needed to make appropriate health decisions” (USDHHS, 2010). Health literacy includes a range of abilities including being able to “read, comprehend, and analyze information; decode instructions, symbols, charts and dia- grams; weigh risks and benefits; and, ultimately, make decisions and take action” (National Institutes of Health [NIH], 2014). “Literacy skills are a stronger predictor of an individual’s health status than age, income, employment status, education level, or racial/ethnic group” (Weiss, 2007, p. 13). A person with limited literacy may be unable to understand instructions on prescrip- tion bottles, interpret health appointment cards, fill out health insurance forms, and read and understand self-care or hospital discharge instructions. What happens when someone has health illiteracy? A person with limited literacy may: • Have a limited vocabulary and general knowledge and does
not ask for clarification • Focus on details and deal in literal or concrete concepts
versus abstract concepts • Select responses on a survey or questionnaire without neces-
sarily understanding them • Be unable to understand math (which is important in calcu-
lating medications) In the past few years a great deal of federal and local atten-
tion has been paid to health literacy. Box 16-4 summarizes a sample of websites available to guide people in learning more about how to provide information in a way that learners who have varying levels of literacy can understand. The Plain Writing Act of 2010 requires the federal government to write all new publications, forms, and publicly distributed documents in a “clear, concise, well-organized” manner and according to plain writing guides (see Public Law 111-274 at http://www.gpo.gov/
disruptive people to give others a chance to speak, or, if this does not work, asking them to leave.
• Lack of knowledge about how to gain participation: You can foster participation by asking open-ended questions, invit- ing participation, and planning small group activities whereby a person responds based on the group rather than presenting his own information.
• Lack of experience in timing a presentation so that it is neither too long nor too short: Plan ahead and practice the presenta- tion by speaking during the practice at the same pace that you will speak to the group.
• Uncertainty about how to adjust instruction: You can more easily adjust instruction when you know the participants’ needs, request feedback, and redesign the presentation during breaks, based on what you have learned about the participants.
• A sense of discomfort when learners ask questions: Try to antic- ipate questions, concisely paraphrasing questions to be sure that you correctly understood the question, and recognizing that it is appropriate to admit that you do not know the answer to a question.
• Lack of feedback from learners: Solicit informal feedback during the program and at the end with program evaluation.
• Concern about whether media, materials, and facilities will function properly: Test the equipment before the program to make sure it runs and also that you know how to use it. Also, have back-up plans for how to get help if you have a problem.
• Difficulty with openings and closings: Strategies to foster suc- cessful openings and closings include developing several examples of openings and closings, memorizing the opening and closing, concisely summarizing information, and thank- ing participants for attending.
• Overdependence on notes: You may wish to use note cards or visual aids as prompts; also, practicing in advance is a proven way to increase skill at presenting.
Learner-Related Barriers Two of the most important learner-related barriers are low lit- eracy and lack of motivation to learn information and make needed behavioral changes.
Low Literacy Levels. Nurses often deal with individuals and populations who are illiterate or who have low literacy levels. These individuals may be embarrassed to admit this deficit to health care providers and educators and may try to appear to understand when they really do not. Specifically, they may not ask questions to clarify information even when they do not understand it. As society becomes more multicultural, the problem of low literacy can increase due to limited use of the primary language as well as limited education. One of the Core Competencies for Public Health Professionals listed in the 2009 revisions by the Council on Linkages between Academia and Public Health Practice is to “assess the health literacy of popula- tions served” (Council on Linkages, 2010). The next paragraphs describe the significance of this problem and the need for nurses to address health literacy.
The National Assessment of Adult Literacy (NAAL) is the largest literacy assessment study done in the United States. This
366 PART 3 Conceptual and Scientific Frameworks
fdsys/pkg/PLAW-111publ274/pdf/PLAW-111publ274.pdf ). Similarly, the National Institutes of Health has developed mate- rials on health literacy and clear communication and calls atten- tion to the enormous costs associated with health illiteracy and how clear, understandable communication is needed for health care professionals (NIH, 2014). An especially helpful document is Simply Put: A Guide for Creating Easy-to-Understand Materi- als developed by the Centers for Disease Control and Preven- tion (2009). This 43-page guide is filled with information on how to create materials that will increase knowledge or change beliefs, attitudes, and behaviors by sending messages that are clear, relevant, and appropriate for the intended audi- ence. Box 16-5 summarizes key sections in the guide.
Nurses may use pictures including comic books, slides and videos including YouTube presentations, and models in educat- ing clients with low literacy. Some people learn better in a series of educational sessions. For example, at the first session, identify learning capacity and provide a small amount of foundational information. During subsequent sessions, new information that builds on existing knowledge and skills is provided and evalu- ated. Give additional information when you believe that the information has been understood and can be incorporated into learners’ lives. To evaluate whether a person has limited health literacy, listen for the following clues: “I forgot my reading glasses,” “I can read this when I get home,” or “I will talk about this with my family—may I take the instructions home?” These comments may be quite straightforward or be a clue that the person actually cannot read the material.
Some people do not engage in learning because they have low levels of motivation to do so. Although adults respond to some external motivators, the most powerful motivators are internal. People are motivated to learn if they value the infor- mation and feel that they will benefit from the outcome, if they think they can follow through on what is being taught, and if it will improve their situation in life or increase their self-esteem (Ota et al, 2006).
As discussed in Chapter 17, models can be used to structure health education and health promotion plans. One model, the health belief model (HBM), is an individual-level model. This model can be useful in planning programs in which the motiva- tion of learners might be a concern. Specifically, the HBM was one of the first theories of health behavior. As is discussed in Chapter 17, it began in an interesting way when people failed
• Centers for Disease Control and Prevention: Plan and Act: What Is the National Action Plan to Improve Health Literacy? (http://www.cdc.gov/ healthliteracy/planact/index.html)
• Centers for Disease Control and Prevention: Simply Put: A Guide for Creat- ing Easy-to-Understand Materials (http://www.cdc.gov/healthliteracy/pdf/ Simply_Put.pdf)
• National Institutes of Health: Health Literacy (http://www.cdc.gov/ healthliteracy/planact/index.html)
• www.motivational interviewing network of trainers (MINT): Motivational Interviewing at http://www.motivationalinterviewing.org/
BOX 16-4 Examples of Useful Websites for Health Education
to use free chest x-rays in the 1950s. A group of social psycholo- gists were asked to try to explain the failure to use this screening. Specifically, what would motivate people to seek health care?
As discussed in Chapter 17, the HBM includes six compo- nents that attempt to answer the question of what motivates an individual to do something. These components are as follows: (1) perceived susceptibility (“Will something happen to me?”),
Make Your Message Clear 1. Give the most important information first and limit the number of
messages. 2. Tell audiences what they need to do and what they will gain from under-
standing and using material. 3. Choose your words carefully.
Text Appearance Matters 1. Use font sizes between 12 and 14 points; for headings use a font size at
least 2 points larger than that in the main text. 2. Font style: Do not use all caps; limit use of light text on a dark
background.
Visuals Help Tell Your Story 1. Choose the best type of visual for your material. 2. Use visuals to help communicate your messages in a culturally relevant
and sensitive manner. 3. Make visuals easy for your audience to follow and understand and of high
quality. 4. Sometimes drawings can help your audience understand. 5. Use realistic images to illustrate internal body parts or small objects.
Layout and Design 1. Design an effective cover. 2. Organize your messages so they are easy to act on and recall. 3. Organize ideas in the order that your audience will use them. 4. Make the text easy for the eye to follow and invite the audience into the
text.
Consider Culture 1. Use terms that your audience uses and/or is comfortable with. 2. Target messages to each cultural or ethnic group or subgroup.
Translations Take Your Message Further 1. Messages that work well with an English-speaking audience may not work
for audiences who speak another language. 2. Design material for minority populations based on subgroups and geo-
graphic locations. 3. Get advice from community organizations in the areas you wish to reach. 4. Carefully select your translator and avoid literal translations. 5. Use the back-translation method and field-test your materials with
members of the intended audience.
Test for Readability 1. Reduce reading level before using formulas; test a document’s readability
level (CDC, 2010, pp. 5-27).
BOX 16-5 Excerpts from Simply Put A Guide for Creating Easy-to-Understand Materials
Source: Centers for Disease Control and Prevention (CD): Simply Put: A Guide for Creating Easy-to-Understand Materials, ed 3, Atlanta GA, 2010, CDC.
367CHAPTER 16 Changing Health Behavior
Feedback to the educator provides the person an opportu- nity to modify the teaching process and enables the educator to better meet the learner’s needs. The learner’s evaluation of the educator occurs continuously throughout the educa- tional program. The educator may receive written or verbal feedback from learners. Educators can get feedback by using return demonstrations to see what learners have mastered (Palazzo, 2001).
The educator should assume that inadequate learner responses reflect an inadequate program, not an inadequate learner. If the evaluation reveals that the learning objectives are not being met, the nurse must determine why the instruction is not effective. At this point, the educator will want to present the material creatively and meaningfully in new ways that will increase learner retention and the learner’s ability to apply the new knowledge. Ultimately, the educator must assume respon- sibility for the success or failure of the educational process and the development of learner knowledge, skills, and abilities.
Process Evaluation Process evaluation examines the dynamic, ongoing compo- nents of the educational program. It follows and assesses the movements and management of information transfer and attempts to make sure that the objectives are being met. Use process evaluation throughout the educational program to determine whether goals and objectives are being met and the time required for their accomplishment. Ongoing evaluation also allows the teacher to correct misinformation, misinterpre- tation, or confusion (Palazzo, 2001).
Periodically review program goals and objectives, and ask whether the desired health behavior change is really necessary. Such a question inevitably leads back to the original learning objectives and enables the nurse to rethink the practicality and merit of each of the objectives. If teaching seems not to be working, re-examine the factors that influence learner readiness and motivation. Process evaluation uses information gathered from the educator as well as from learner evalua- tions and assesses the dynamics of their interactions (Knowles, 1990).
THE EDUCATIONAL PRODUCT The educational product is the outcome of the educational process, and the product can be measured both qualitatively and quantitatively. For example, a qualitative assessment should answer the question, “How well does the learner appear to understand the content?” A quantitative assessment should answer the question, “How much of the content does the learner retain?” Thus, the quality of the product is measured by improvement and increase, or the lack thereof, in the learner’s knowledge, skills, and abilities related to the content of the educational program. Selected outcomes for the population of interest need to be identified when the educational program is conceived. Measurement of changes in these outcomes deter- mines the effectiveness of the program. In nursing, the educa- tional product is assessed as a measurable change in the health or behavior of the client.
(2) perceived severity (“If something does happen to me, will it be a big problem?”), (3) perceived benefits (“If I do what is suggested, will it really help me?”), (4) perceived barriers (“Assuming I do what is suggested, will there be barriers that will be unpleasant, costly, and so forth?”), (5) cues to action (“What might motivate me to actually do something?”), and (6) self-efficacy (“Can I really do this?”). This model has been applauded and criticized. It does offer guidance in planning health education programs in that it reminds nurses to think carefully about what motivates people to change. To understand motivation, it is important to learn (1) how the people involved feel about the health problem, (2) whether they think it is serious, (3) whether they believe that action on their part will make a difference, and (4) whether they think that they can both manage the barriers and actually perform the action.
Consider the following example of how the HBM might be applied to a person in the community who has recently been diagnosed with diabetes. The person, June, is 25 years old and was diagnosed 2 months ago with diabetes mellitus. She has found it difficult to follow the recommendations of the public health nurse who has seen her in the community clinic. When the nurse asked June what seemed to be getting in the way of her complying, June said that she had asked herself these questions: 1. If I do not follow the nurse’s advice about diet, exercise, and
taking my insulin, will something really happen to me? 2. If I do not follow the advice and something does happen,
will it really be a problem? 3. On the other hand, if I take my medicine, eat a diet that
will keep my diabetes under control, exercise as recom- mended by the nurse, and take my insulin according to the nurse’s directions, will I really reduce the seriousness of my disease?
4. How much will it cost me to purchase the foods in order to follow the diet? How much time will it take each week to exercise as recommended? Will it hurt me to give myself insulin injections?
5. I did see that my friend, Sue, who was diagnosed about 2 years ago with diabetes was careful about what she ate at the party, and she did talk about her exercise program where she walks 50 minutes 5 days a week. Sue did look better than she did when I saw her last year.
6. Is it possible for me to take care of myself like Sue does? Two additional models that are especially useful in health
promotion are discussed in Chapter 17. They are the transtheo- retical model (TTM) and the precaution adoption process model (PAPM). Both models deal with change that occurs in stages and over time.
Further details about health promotion models can be found in Chapter 17.
Evaluation of the Educational Process Evaluation is as important in the educational process as it is in the nursing process. Evaluation provides a systematic and logical method for making decisions to improve the educational program. You will need to evaluate the educator, the process, and the product.
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this percentage to 100%, the nurse tries an educational inter- vention in which radio and television stations make public service announcements (PSAs) about the importance and avail- ability of prenatal services.
After 1 year, the nurse discovers that 80% of all pregnant women now receive prenatal care. The nurse continues to use PSAs the next year because good results are evident. However, the long-term goal of the education program to influence the behavior of 100% of the pregnant women in the community has not yet been met. The nurse enlists volunteers to put infor- mational posters in shopping malls, grocery stores, public trans- portation stops, laundries, and public transportation vehicles. In the second year after implementing the revised educational program, again using the statistics from the health department, the nurse finds that 95% of all pregnant women in the target area now receive prenatal care. The nurse can now evaluate and modify a community educational program over time to increase the rate, range, and consistency of progress made toward meeting the long-term goals of the project. It will be important and often difficult to keep track of clients; e-mail, telephone calls, and text messages may be useful.
Because health education is often conducted in the com- munity in groups rather than provided to one person at a time, the use of groups in health education is discussed.
GROUPS AS A TOOL FOR HEALTH EDUCATION People are part of a variety of groups, and each can influence health behavior and support useful or poor health practices. Groups are an effective and powerful medium by which to initi- ate and implement changes for individuals, families, organiza- tions, and the community. People naturally form groups in the home, and groups in the community dramatically influence the community’s health. They may form for a clearly stated purpose or goal, or they may form naturally as shared values, interests, activities, or personal characteristics attract individu- als to each other.
Community groups represent the collective interests, needs, and values of individuals; they provide a link between the indi- vidual and the larger social system. Throughout life, group membership influences thoughts, choices, behaviors, and values as people socialize and interact. Through groups, people may express personal views and relate them to the views of others. Groups serve as communication networks and can help orga- nize various aspects of communities.
Community groups may be informal or formal. Formal groups have a defined membership and a specific purpose. They may or may not have an official place in the com- munity’s organization. In informal groups, the ties between members are multiple, and the purposes are unwritten yet understood by members. These groups often form spontane- ously when participants have a common interest or need. You can find out about what formal and informal groups exist in a community by reading the local newspaper, listening to public service information on the radio or television, reading items on the Internet, and asking residents about the groups to which they belong. Nurses often serve as a catalyst for
Evaluation of Health and Behavioral Changes Many approaches, methods, and tools are used to evaluate health and behavioral changes. Examples include question- naires, rating scales, surveys, checklists, skills demonstrations, testing, subjective client feedback, and client repeat demonstra- tion. Whether you use qualitative or quantitative strategies depends on the expected educational outcome. Evaluation of outcomes measured includes changes in knowledge, skills, abilities, attitudes, behavior, health status, and quality of life. Approaches to evaluating health education effects will vary, depending on the situation. For example, when considering a client’s ability to perform a psychomotor skill such as changing a dressing, observing the client doing the skill is the most appro- priate means of evaluation.
If evaluation of the educational product shows positive changes in health status and health-related behaviors, the edu- cator can expect good results in similar health educational pro- grams. If evaluation shows no changes or negative changes in health status and health-related behaviors, then re-examine and modify the program to attain better results in the future.
It is important to evaluate short-term health and behavioral effects of health education programs and to determine whether they are really caused by the educational program. Short-term objectives are often easy to evaluate (Babcock and Miller, 1994). For example, a short-term evaluation of whether a client can perform a return demonstration of a process being taught requires minimal energy, expense, or time; skill mastery can be determined within a matter of minutes. If the short-term objec- tive is not met, the nurse determines why and identifies possible solutions so that successful learning can occur. If the short-term objective is met, the nurse can then focus on long-term evalu- ation designed to assess the lasting effects of the education program.
The goal of health education is to help clients make lasting behavioral changes that will improve their overall health status. Long-term follow-up with clients is a challenging task. Long- term evaluation is geared toward following and assessing the status of an individual, family, community, or population over time. The tools of evaluation are designed to assess whether specific goals and objectives were met. Also, monitor the extent and direction of client changes in health status and health behaviors (Kleinpell and Mick, 2001).
Often, for nurse educators, the goal of long-term evaluation is an analysis of the effectiveness of the education program for the entire community, not the health status of a specific client. Nurses track the achievement of community objectives over time, but not that of the individual community members. Thus, in a changing population, long-term evaluation of the results of an education program is still possible. The percentage of objectives and goals met by sampling the target population gives valid statistics for program assessment, even though the population of individuals may have experienced a complete turnover (Kleinpell and Mick, 2001).
For example, a nurse notes that according to annual health department data, 60% of all pregnant women in the nurse’s catchment area received some prenatal care. Wanting to increase
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nurse proposed that a parent group address this community need, and she chose this purpose for the group: dealing with kids for child and parent satisfaction. The purpose indicated both the process (to help parents deal with children) and the desired outcome (satisfaction for parents and children). As potential members were approached, this statement of group purpose helped them decide if they wanted to join.
Cohesion is the attraction between individual members and between each member and the group. Individuals in a highly cohesive group identify themselves as a unit, work toward common goals, endure frustration for the sake of the group, and defend the group against outside criticism. Attraction increases when members feel accepted and liked by others, see similar qualities in one another, and share similar attitudes and values. Group effectiveness also improves as members work together toward group goals while still satisfying the needs of individual members.
Members’ traits that increase group cohesion and productiv- ity include the following: (1) compatible personal and group goals, (2) attraction to group goals, (3) attraction to some members of the group, (4) a mix of leading and following skills, and (5) good problem-solving skills.
Groups have both task and maintenance functions. A task function is anything a member does that deliberately contrib- utes to the group’s purpose. Members with task-directed abili- ties become more attractive to the group. These traits include strong problem-solving skills, access to material resources, and skills in directing. Of equal importance are abilities to affirm and support individuals in the group. These functions are called maintenance functions because they help other members stay with the group and feel accepted. Other maintenance functions are the ability to help people resolve conflicts and create social and environmental comfort. Both task and maintenance func- tions are necessary for group progress. Naturally, those members who provide these functions are attractive, and an abundance of such traits within the membership tends to increase group cohesion.
The following group members’ traits may decrease cohesion and productivity: (1) a sense of conflict between personal and group goals, (2) lack of interest in group goals and activities, (3) poor problem-solving and communication abilities, (4) lack of both leadership and supporter skills, (5) disagreement about types of leadership, (6) aversion to other members, and (7) behaviors and attributes that others do not understand.
Usually, the more alike group members are, the stronger a group’s attraction, whereas differences tend to decrease attrac- tiveness. Members’ perceptions of differences can create marked competition and jealousy. At the same time, personal differ- ences can increase group cohesion if they support complemen- tary functioning or provide contrasting viewpoints necessary for decision making. Cohesive factors are complex and many factors influence member attraction to each other and to the group’s goal. High group cohesion positively affects productiv- ity and member satisfaction. The following example illustrates factors that influence group cohesion. A nurse initiated a group for clients who had been treated for burns. Ten residents, all from one town, had been discharged after a month in the local
forming new groups or by creating linkages among groups that currently exist.
Group support often helps people make needed health changes. Skillful use of group methods can help a person analyze the problem, sustain motivation for change, experience support during vulnerable periods, and receive quick interpersonal feedback. The discomfort associated with change can be reduced through the relationships with others in beneficial groups. Many of the Healthy People 2020 priorities can be addressed in health promotion and disease prevention groups, where indi- viduals learn healthier behaviors and gain support from others in changing from risky to healthy lifestyle choices. For example, groups may support physical activity and fitness, sound nutri- tion, and safe sexual practices. Through group support, individuals may conquer smoking, drug abuse, or abusive rela- tionships. They may identify and reduce exposure to environ- mental hazards and promote safer physical settings for all. Also, one of the core competencies for public health professionals is to “use group processes to advance community involvement” (Council on Linkages, 2010, p. 10).
Group: Definitions and Concepts An understanding of several group concepts facilitates group work in the community. Some of the core concepts answer the following questions: (1) What is a group? (2) What is the purpose of the group? (3) How do groups develop and func- tion? (4) What are their stages? and (5) What roles do members typically play in the group?
Definitions A group is a collection of interacting individuals who have common purposes and are influenced by one another. Groups form for a variety of reasons. Families are an example of a com- munity group. Families share kinship bonds, living space, and economic resources. They have many purposes such as teaching their members as well as providing psychological support and socialization. Groups also form in response to community needs, problems, or opportunities. For example, community residents may form a neighborhood association to protect their health and welfare. Community groups occur spontaneously because of mutual attraction between individuals and obvious and keenly felt personal needs such as those for socialization and recreation. Health-promoting groups may form when people meet to work together to support one another in achiev- ing health goals such as weight loss, exercise, dealing with loss, and giving up smoking, gambling, or drinking.
Concepts Groups need to identify a clear purpose. Having a clear purpose helps in establishing criteria for member selection and deter- mining the action plan. For example, a clear statement of purpose proved valuable in forming a new group in one city’s housing development. The local department of social services had received numerous reports of child abuse and neglect. Routine home visits for well-child care documented high stress between parents and their offspring, and some parents requested teaching and guidance from the nurse in child discipline. The
370 PART 3 Conceptual and Scientific Frameworks
and Kurland, 2001). All groups have norms and mechanisms to accomplish conformity. Group norms serve three functions: (1) to ensure movement toward the group’s purpose or tasks; (2) to maintain the group through various supports to members; and (3) to influence members’ perceptions and interpretations of reality.
Although certain norms keep the group focused on its task, some diversion can be present if members respect goals and feel committed to return to them. The task norm is the commit- ment to return to the central goals of the group, and its strength determines the group’s ability to adhere to its work.
Maintenance norms create group pressures to affirm members and maintain their comfort. Individuals in groups seem most productive and at ease when their psychological and social well-being is nurtured. Maintenance behaviors include identifying the social and psychological tensions of members and taking steps to support those members at high-stress times. For example, maintenance norms often refer to things such as scheduling meetings at convenient times and in an accessible and comfortable space with parking as well as seating, refresh- ments, and toilets.
Groups also have reality norms, where members reinforce or challenge and correct their ideas of what is real. Groups can examine the life situations confronting individuals and help to make sense of them. As individuals gather information, attempt to understand that information, make decisions, and consider the facts and their implications, they can take responsible action, not only in relation to themselves and their group, but also for the community. Group (task, maintenance, and reality) norms combine to form a group culture. Although working with a group does not mean dictating its norms, the nurse can support helpful rules, attitudes, and behaviors. Norms form when these rules, attitudes, and behaviors become part of the life of the group, independent of the nurse. Reality norms influ- ence each member to see relevant situations in the same way the other members see them. For example, suppose a group of individuals with diabetes defines an uncontrolled diet as harmful; members may try to influence one another to main- tain diet control. The nurse’s role in this group is to provide accurate information about diet and the disease process while continually displaying a belief that health through diet control is attainable and desirable.
Group members with similar backgrounds may have a limited scope of knowledge. For example, women in a spouse abuse group may believe that men are exploitive and harmful on the basis of common childhood and marriage experiences. Such a stereotypical view of men could be reinforced by similar percep- tions in other members; this might lead to continuing anger or fear of interactions with men, and a hostile or helpless approach to family affairs. Nurses or group members who have known men in loving, helpful, and collaborative ways can describe their different and positive perceptions of men, thereby adding infor- mation and challenging beliefs. The health and condition of members improve as their perceptions of reality are based on a more complete range of data. Nurses bring an important per- spective to groups in which similar backgrounds limit the understanding and interpretation of personal concerns.
burn unit. The stated purpose for the group was to teach coping skills to assist members in the difficult transition from hospital to home. Each person had been treated for extensive burns in an intensive care treatment center; each had relied heavily on health care workers for physical, social, and emotional rehabili- tation; and each had faced the challenge of resuming work and family roles. Individuals shared some similar experiences and hopes for the future but varied in the amount of trauma and stress experienced. They also differed widely in psychologi- cal readiness for return to ordinary daily routines. One woman in the group was able to return quickly to her job as a cashier in a large supermarket. The strength of her determination to overcome public reaction to her scars, coupled with an ability to “use the right words” and an empathy for others, distin- guished her from others in the group. These differences proved attractive to other members, inspiring them to work toward a return to their own roles in life. These members saw her differ- ences as attainable.
This group’s cohesion was provided by the members’ attrac- tion to the common purpose of returning to successful life patterns and managing relationships with others. Members also believed that interaction with others with similar burn experi- ences could help them reach that goal. This example shows that certain member experiences such as crises or traumas may help individuals identify with each other and may increase member attraction.
Being different from the general population and similar to the other group members can be positive for some members and negative for others. Some members may not want to be identified by an aversive characteristic such as disfigurement. Empathy for another’s pain, learned only through mutual expe- rience, may provide a person with a required perspective for problem solving or affirming another’s view. This group was effective, and the nurse helped members use common experi- ences and learn from their differences.
Members’ attraction to the group is influenced by factors such as the group programs, size, type of organization, and position in the community. Attraction to the group is increased when members view goals clearly and see group activities as effective.
The concept of cohesion helps to explain group productivity. Some cohesion is necessary for people to remain with a group and accomplish the set goals. Attractiveness positively influ- ences members’ motivation and commitment to work on the group task. Group cohesion may be increased as members better understand the experiences of others and identify common ideas and reactions to various issues. Nurses facilitate this process by pointing out similarities, contrasting supportive differences, or helping members redefine differences in ways that make those dissimilarities compatible.
Norms are standards that guide, control, and regulate indi- viduals and communities. Group norms set the standards for group members’ behaviors, attitudes, and perceptions. Norms suggest what a group believes is important, what it finds accept- able or objectionable, or what it perceives as of no consequence. This commonly held view of what ought to be motivates members to use the group for their mutual benefit (Northen
371CHAPTER 16 Changing Health Behavior
paying close attention to communications and interactions, members detect changing group needs, and they can take responsibility and pride in their own involvement. One or more members may lead the group or many may share leadership. Shared leadership may increase productivity, cohesion, and sat- isfying interactions among members.
After initiating or establishing a group, nurses may facilitate leadership within and among members, frequently relinquish- ing central control and encouraging members to determine the ultimate leadership pattern for their group. In some settings and circumstances, a single authority seems necessary (e.g., when members have limited skills or limited time, or when groups claim discomfort with shared responsibility for leading). A lead- ership style that shares leading functions with other group members is effective when there are many alternatives and when issues of values and ethics are involved in the group’s action. Examples of leadership behaviors are shown in Box 16-7. Lead- ership can be described as patriarchal (paternal), or democratic. Each of these styles has a particular effect on members’ interac- tion, satisfaction, and productivity. Groups may reflect one or a combination of styles.
A patriarchal or paternal style is seen when one person has the final authority for group direction and movement. A person using patriarchal leadership may control members through rewards and threats, often keeping them in the dark about the goals and rationale behind prescribed actions. Paternal leaders win the respect and dependence of their followers by parent-like devotion to members’ needs. The leader controls group movement and progress through interpersonal power. Patriarchal and paternal styles of leadership are authoritarian. These styles are effective for groups such as a disaster team in which immediate task accomplishment or high productivity is the goal. Group morale and cohesiveness are typically low
The role structure of a group refers to the expected ways in which members behave toward one another. The role that each person assumes serves a purpose in the group. Examples of roles are leader, follower, task specialist, maintenance specialist, eval- uator, peacemaker, and gatekeeper. Box 16-6 includes descrip- tions of each of these group roles.
Stages of Group Development Tuckman (1965) developed a model of the stages of group development that has remained useful over time. He contended that any group, regardless of its type or setting, went through four stages: forming, storming, norming, and performing. In 1977 Tuckman and Jensen determined that there was actually a fifth stage: adjourning. This model can be used for health- related groups to identify in what stage the group is and what may be the next stage. Specifically, in the “forming” stage, members become acquainted with one another and the leader, become oriented to the group, and try to determine what their behaviors should be in relation to one another and to the goal of the group. In the “storming” stage, members begin to express their own individuality, which may run counter to that of others, and they may express hostility to one another and polar- ize because of interpersonal issues. In the third, or “norming,” stage, members start to accept one another; develop some cohe- sion, norms, and roles; and become comfortable in expressing their opinions and offering ideas. Members begin to trust one another and their interaction takes on more depth. In the fourth stage, “performing,” the group uses its interpersonal structure to accomplish its goals, and group energy is directed toward the tasks. In the fifth stage, “adjourning,” the group engages in sepa- rating from one another.
Leadership is a complex concept. It consists of behaviors that guide or direct members and determine and influence group action. Positive leadership defines or negotiates the group’s purpose, selects and helps implement tasks that accomplish the purpose, maintains an environment that affirms and supports members, and balances efforts between task and maintenance. An effective leader pays attention to communications and inter- actions among the members. Attention is paid to both spoken words and body language, and this information provides con- tinuous feedback about the members and the group process. By
(There are many examples; this is a representative list of the types of roles members assume.) • Follower: Seeks and accepts the authority or direction of others • Gatekeeper: Controls outsiders’ access to the group • Leader: Guides and directs group activity • Maintenance specialist: Provides physical and psychological support for
group members, thereby holding the group together • Peacemaker: Attempts to reconcile conflict between members or takes
action in response to influences that disrupt the group process and threaten its existence
• Task specialist: Focuses or directs movement toward the main work of the group
BOX 16-6 Examples of Group Role Behavior
• Advising: Introducing direction on the basis of knowledgeable opinion • Analyzing: Reviewing what has occurred as encouragement to examine
behavior and its meaning • Clarifying: Verifying the meanings of interaction and communication
through questions and restatement • Confronting: Presenting behavior and its effects to the individual and
group to challenge existing perceptions • Evaluating: Analyzing the effect or outcome of action or the worth of an
idea according to some standard • Initiating: Introducing topics, beginning work, or changing the focus of a group • Questioning: Generating analysis of a view or views by questions that
support examination • Reflecting behavior: Providing feedback on how behavior appears to
others • Reflecting feelings: Naming the feelings that may be behind what is said
or done • Suggesting: Proposing or presenting an idea to a group • Summarizing: Restating discussion or group action in brief form, high-
lighting important points • Supporting: Giving the kind of emotionally comforting feedback that helps
a person or group continue ongoing actions
BOX 16-7 Examples of Leadership Behaviors
372 PART 3 Conceptual and Scientific Frameworks
groups formed for individual health change can be used for groups focused on community health. Such interventions include the following: • Building cohesion through clarifying goals and individual
attraction to groups • Building member commitment and participation • Keeping the group focused on the goal • Maintaining members through recognition and encourage-
ment • Maintaining member self-esteem during conflict and
confrontation • Analyzing forces affecting movement toward the goal • Evaluating progress
When nurses enter established groups, they need to assess the leadership, communications, and normative structures. This facilitates group planning, problem solving, intervention, and evaluation. The following example illustrates working with a community group. A nurse was asked to meet with a neigh- borhood council to help them study and “do something about” the number of homeless living on the streets. Residents knew this nurse from a local clinic and from his consulting work at a shelter for the homeless in an adjacent community. In their invitation to the nurse, council members said “our intent is to be part of the solution rather than part of the problem.” The nurse accepted the invitation to visit. He learned that this council had addressed neighborhood concerns for 20 years— protecting zoning guidelines, setting up a recreational program for teens, organizing an after-school program for latchkey chil- dren, and generally representing the homeowners of the area. The neighborhood was made up of low-income families who took great pride in their homes. After meeting with the council and listening to their description of the situation, the nurse agreed to help and joined the council.
As the first step in addressing the problem, the council con- ducted a comprehensive problem analysis on the homeless situ- ation. All known causes and outcomes of homeless persons on
under sustained authoritarian styles of leadership, and members may not learn how to function independently. Also, issues of authority and control may disrupt productivity if the group members challenge the power of the leader.
Democratic leadership is cooperative in nature and pro- motes and supports members’ involvement in all aspects of decision making and planning. Members influence each other as they explore goals, plan steps toward the goals, implement those steps, and evaluate progress.
Choosing Groups for Health Change Nurses choose the type of group that will be used after studying the overall needs of the community and its people. Such a study is based on client contacts, expressed concerns from various community spokespersons, health statistics for the area, avail- able health resources, and the community’s general well-being. These data point to the community’s strengths and critical needs.
The nurse can identify goals for the community and for various groups through media reports, from community infor- mants, and from colleagues. Goals may include visions for change as perceived by the people living and working in the local community. Data may be organized according to the opin- ions and behaviors of the identified groups. Such information about community groups and assessment data are used with community representatives to plan desired interventions. Alli- ances or coalitions unite diverse interest groups who share a common interest in perceived threats to community health, and nurses may work with groups both for community analysis and vehicles for change.
Deciding whether to work in established groups or to begin new ones is based on the clients’ needs, the purpose of existing groups, and the membership ties in existing groups. There are advantages to using established groups for individual health change. Membership ties already exist, and the existing struc- ture can be used. It is not necessary to find new members because compatible individuals already form a working group. Established groups usually have operating methods that have proved successful; an approach for a new goal is built on this history. Members are aware of each other’s strengths, limita- tions, and preferred styles of interaction and may be comfort- able working with and may be able to influence one another. If you choose to work with an established group, be sure to deter- mine whether the new focus is compatible with the existing group purposes. Figure 16-2 shows a breakout session during a community forum.
Groups can be used during a community assessment for information. Groups such as health-planning groups, better business clubs, women’s action groups, school boards, and neighborhood councils are excellent information resources because part of their purpose is to determine and respond to community needs. In addition, they are already established as part of the community structure. When a group representing one community sector is selected for community health inter- vention, the total community structure is studied. Groups reflect existing community values, strengths, and norms.
How might nurses help established groups to work toward community goals? The same interventions recommended for
FIG 16-2 Breakout session in a community forum on environ- mental health concerns. (From Centers for Disease Control and Prevention [2009]; courtesy Dawn Arlotta.)
373CHAPTER 16 Changing Health Behavior
others who serve in supportive roles; try to have a mix of people with both task and maintenance functions, and others who can develop these skills.
The size of the group influences effectiveness; generally, 8 to 12 is a good number for group work focused on individual health changes. Groups of up to 25 members may be effective when their focus is on community needs. Large groups often divide and assign tasks to subgroups, with the original large groups meeting less frequently for reporting and evaluation. Setting member criteria can facilitate recruitment and selection of the most appropriate members for any group. The criteria usually suggest a mixture of member traits, allowing for balance for the processes of decision making and growth.
Managing the Community Group As soon as the group forms, begin to work on the stated purpose. Help members interact by paying attention to maintenance tasks of attending, eliciting information, clarifying, and recog- nizing contributions of members. Begin by talking about what brought each person to the group. Encourage each one to par- ticipate; recognize and support them as they take on leadership functions. The new group begins to take shape in the early ses- sions as members try out familiar roles and test their individual abilities. The core competency skills for communication recom- mended by the Public Health Foundation (Council on Link- ages, 2010) are useful to nurses working with community groups. Box 16-8 lists these competencies. Subsequent steps are then planned not only according to the nurse’s skill and prefer- ence, but also according to the group composition and the skills brought by members.
Conflict is normal in human relations. People may see con- flict as the opposite of harmony and try to guard against it. This is an unfortunate view because the tensions of difference and potential conflict actually help groups work toward their pur- poses. Conflict occurs when members feel obstructed or irri- tated by one or more other group members (Northen and Kurland, 2001). Conflict signals that antagonistic points of view must be considered and that one must reexamine beliefs and assumptions underlying relationships. Some people are
the street were identified, and the relationships between each factor and the problem were documented from literature and from the local history. The nurse brought expertise in health planning and knowledge of the homeless and their health risks. He suggested negotiation between the council and the local coalition for the homeless, recognizing that planning would be most relevant if homeless individuals participated. The council was cohesive and committed to the purpose, had developed working operations, and did not need help with group process. They made adjustments in their usual group operation to use the knowledge and health-planning skills of the nurse. Inter- ventions for the homeless included establishing temporary shel- ters at homes on a rotating basis, providing daily meals through the city council or churches, and joining the area coalition for the homeless.
This example shows how an established, competent group addressed a new goal successfully by building on existing strengths in partnership with the nurse. Community groups, because of their interactive roles, are logical and natural ways for people who work together for community health change. As the decision-making and problem-solving capabilities of com- munity groups are strengthened, the groups become more able representatives for the whole community. Nurses improve the community’s health by working with groups toward that goal.
How can the nurse enter existing groups and direct their attention to individual health needs? One nurse employed by an industrial firm noted the harmful effect of managerial stress on several individuals. They had elevated blood pressure, stomach pain, and emotional tension. The nurse learned that the employees with stress were all members of a jogging team that met weekly for conversation in addition to regular work- outs. High-level health had been a value shared by all team members, but although jogging was seen as an enjoyable and health-promoting activity, they had never talked about a shared purpose for improved health. The nurse saw a need for stress reduction, thought that the individuals at risk could achieve stress reduction if supported through a group process from valued friends, and proposed that a new purpose be added to the jogging team’s activities. All in the group readily accepted and began to focus more on their stress levels as they jogged.
When it is neither desirable nor possible to use existing groups, the nurse can initiate a selected membership group. Choose members who have common health needs or concerns. For instance, individuals with diabetes can meet to discuss diet management and physical care and to share problem-solving remedies; community residents can meet for social support and rehabilitation after treatment for mental illness; or isolated older adults can meet to socialize, eat nutritious meals, and exercise.
Consider members’ attributes when composing a new group. Members are attracted to others from similar backgrounds, with similar experiences, and with common interests and abili- ties. Members’ behavior is influenced by the membership, purpose, attraction, norms, leadership, and group structure, and by memories of prior groups. Select members so that common ties or interests balance out dissimilar traits. Try to have members with expressive and problem-solving skills and
Communication Skills • Communicates effectively both in writing and orally, including via e-mail • Solicits input from individuals and organizations • Advocates for public health programs and resources • Leads and participates in groups to address specific issues • Uses the media, varied technologies, and community networks to convey
information • Effectively presents accurate demographic, statistical, programmatic, and
scientific information for professional and lay audiences
Attitudes • Listens to others in an unbiased manner • Respects points of view of others • Promotes the expression of diverse opinions and perspectives
BOX 16-8 Core Competencies for Communication Skills of Educators
374 PART 3 Conceptual and Scientific Frameworks
disregard others in the promotion of self. Teams that try to be harmonious and avoid conflict may hinder collaboration and personal growth (Gerow, 2001).
It is important to evaluate individual and group progress toward health goals. Early in the planning, specify the action steps that should be taken to meet the goals. These small steps may be responses to learning objectives (listed as action steps designed to support facilitative forces and deal with resistive forces), or they may reflect the group’s problem-solving plan. The action steps and the indicators of achievement are dis- cussed and written in a group record. Recognition of accom- plishments in the group and of the group is built into the group’s evaluation system. Recognition may include concrete rewards such as special foods and drinks, or it may be the per- sonal expression of joy and member-to-member approval. Cel- ebration for group accomplishments marks progress, rewards members, and motivates each person to continue.
Implementing the Educational Plan Once educational methods have been selected, they should be implemented through management of the educational process. Implementation entails the following: (1) control over starting, sustaining, and stopping each method and strategy in the most effective and appropriate time and manner; (2) coordination and control of environmental factors, the flow of the presentation, and other contributory parts of the program; and (3) keeping the materials logically related to the core theme and overall program goals (Knowles, 1990). Administrative and political support is essential to successful program implementation.
Educators must be flexible and modify educational methods and strategies to meet unexpected challenges that confront both the educator and the learner. External influences (such as time limitations, expense, and administrative and political factors) and learner needs require an ongoing evaluation of their impact on the educational program. Implementation is a dynamic element in the educational process.
concerned about security, control of self and others, respect between parties, and access to limited resources. In groups, members may express frustrations about trust, closeness and separation, and dependence and independence. These themes of interpersonal conflict operate to some extent in all interac- tions and are not unique to groups.
People tend to repeat the same patterns of behavior in con- flicts. Sometimes the pattern works; other times it does not. The best approach is to match the response style to the situation (Sportsman and Hamilton, 2007), which requires personal awareness and awareness of others. Specifically, when you respond with avoidance, forcing with power, capitulation, and exclusion of a member, the behaviors fail to satisfy the concerns of participants. Assertiveness (attempting to satisfy one’s own concerns) and cooperativeness (attempting to satisfy the con- cerns of others) can be positive responses to conflict. Behaviors that reflect either assertiveness or cooperativeness and that may satisfy the frustrated parties include confrontation, competi- tion, compromise, reconciliation, and collaboration. Resolving conflict within groups depends on open communication among all parties, diffusion of negative feelings and perceptions, con- centration on the issues, and use of fair procedures and a struc- tured approach to the process.
Conflict can be overwhelming, especially when members view the expression of controversy as unacceptable or unremit- ting. Conflict suppressed over time tends to build up and finally explode out of proportion to the current frustration. A group that repeatedly avoids expressing conflict becomes fragile, is unable to adapt and helpless to face challenges. Conflict may be destructive if contentious parties fail to respect the rights and beliefs of others.
Approaches for acknowledging conflict and solving prob- lems that respect others and represent self-concerns are first learned in families and other small groups. These lessons teach people to embrace conflict as a natural occurrence that supports growth and change. Other people learn to avoid conflict or to
P R A C T I C E A P P L I C A T I O N During Kristi’s BSN student public health practicum at a local health department, the health department got many calls from people wanting information about H1N1 virus. For Kristi’s com- munity health intervention project, she decided to do an educa- tional piece on this topic. What is her best course of action? A. Develop a poster presentation to have on display at the
health department.
B. Make an educative pamphlet to mail to anyone calling with questions.
C. Work with the health department staff to develop a commu- nity forum presentation and information brochures on H1N1.
D. Develop an in-service program for health department staff on potential spread of the virus and ways to prevent its spread. Answers can be found on the Evolve site.
K E Y P O I N T S • Health education is a vital part of nursing because the pro-
motion, maintenance, and restoration of health rely on clients’ understanding of health care topics.
• Nurse educators identify learning needs, consider how people learn, examine educational issues, design and imple- ment educational programs, and evaluate the effects of the educational program on learning and behavior.
• Nurses often use the Healthy People 2020 educational objec- tives as a guide to identifying community-based learning needs.
• Education and learning are different. Education is the estab- lishment and arrangement of events to facilitate learning. Learning is the process of gaining knowledge and expertise and results in behavioral changes.
375CHAPTER 16 Changing Health Behavior
K E Y P O I N T S — cont’d • Three domains of learning are cognitive, affective, and psy-
chomotor. Depending on the needs of the learner, one or more of these domains may be important for the nurse edu- cator to consider as learning programs are developed.
• Nine principles associated with community health education are gaining attention, informing the learner of the objectives of instruction, stimulating recall of prior learning, present- ing the stimulus, providing learning guidance, eliciting per- formance, providing feedback, assessing performance, and enhancing retention and transfer of knowledge.
• Often theory can guide the development of health education programs. Two useful ones are the health belief model (HBM) and the transtheoretical model (TTM), the latter discussed in connection with the precaution adoption process model (PAPM).
• Principles that guide the effective educator include message, format, environment, experience, participation, and evaluation.
• Educational issues include population considerations, barri- ers to learning, and technological issues.
• Two important learner-related barriers are low literacy, espe- cially health literacy, and lack of motivation to learn infor- mation and make the needed changes.
• The five phases of the educational process are identifying educational needs, establishing educational goals and objec- tives, selecting appropriate educational methods, imple- menting the educational plan, and evaluating the educational process and product.
• Evaluation of the product includes the measurement of short- and long-term goals and objectives related to improv- ing health and promoting behavioral changes.
• Working with groups is an important skill for nurses. Groups are an effective and powerful vehicle for initiating and imple- menting healthful changes.
• A group is a collection of interacting individuals with a common purpose. Each member influences and is influ- enced by other group members to varying degrees.
• Group cohesion is enhanced by commonly shared charac- teristics among members and diminished by differences among members.
• Cohesion is the measure of attraction between members and the group. Cohesion or the lack of it affects the group’s function.
• Norms are standards that guide and regulate individuals and communities. These norms are unwritten and often unspoken and serve to ensure group movement to a goal, to maintain the group, and to influence group members’ perceptions and interpretations of reality.
• Some diversity of member backgrounds is usually a positive influence on a group.
• Groups also go through a set of stages in order to form, operate, and adjourn.
• Leadership is an important and complex group concept. Lead- ership is described as patriarchal (or paternal), or democratic.
• Group structure emerges from various member influences, including members’ understanding and support of the group purpose.
• Conflicts in groups may develop from competition for roles or member disagreement about the roles ascribed to them.
• Health behavior is greatly influenced by the groups to which people belong and for which they value membership.
• An understanding of group concepts provides a basis for identifying community groups and their goals, characteris- tics, and norms. Nurses use their understanding of group principles to work with community groups toward needed health changes.
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Think about an educational interaction that you had with
each type of client (individual, family, community, and pop- ulation) that did not seem to go well. For each type of client and on the basis of how people learn, identify what might have been the problem. Develop a plan for ways in which the interaction could have been improved, based on how people learn.
2. Recall a learning experience in which the message, format, environment, experience, participation, or evaluation was unsatisfactory. Then develop a plan for how the problem could have been overcome and turned from a negative or neutral learning situation into a positive one.
3. Review the phases of the educational process. Apply this process to a population of individuals with hypertension, a community in which tuberculosis is on the rise, and families with a child who has attention deficit disorder.
4. Select one of the Healthy People 2020 educational objectives and design a population-specific education program to meet that objective. Consider how people learn, educational issues,
educational process including teaching strategies, and evalu- ation procedures that you would use.
5. Consider three groups of which you are a member. What is the stated purpose of each group? Are you aware of unstated but clearly understood purposes? What is the nature of member interaction in each group? How do purpose and interaction differ in the three groups?
6. Observe two working groups in session, from the commu- nity, a health care agency, or a school. Notice the attractive- ness of each group through the eyes of its members.
7. List actions that nurses may take to assist groups in various aspects of their work, such as member selection, purpose clarification, arrangements for comfort in participation, and group problem solving.
8. Observe a nurse working with a health promotion group. Does the nurse function in the way you anticipated? What nursing behavior facilitates the group process? List the areas of skill and knowledge that groups consisting of community residents would most likely expect of the nurse.
376 PART 3 Conceptual and Scientific Frameworks
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Building a Culture of Health through Community Health Promotion
Pamela A. Kulbok, DNSc, RN, PHCNS-BC, FAAN Pamela A. Kulbok earned her BS and MS from Boston College and her doctorate at Boston University and did postdoctoral work in psychiatric epi- demiology at Washington University in St. Louis. She was a U.S. Navy nurse; has worked in a visiting nurse service; and has directed a hospital-based home health agency. She is the Theresa A. Thomas Professor of Primary Care Nursing, Professor of Public Health Sciences, and Chair of the Depart- ment of Family, Community, and Mental Health Systems at the University of Virginia, School of Nursing. Dr. Kulbok is a Robert Wood Johnson Foundation, Executive Nurse Fellow (2102-2015). She was the Principal Investigator of an interprofessional, cross-institution, community-based par- ticipatory research project to design a youth substance use prevention program and of a series of studies of youth nonsmoking behavior. She has taught undergraduate and graduate courses in public health nursing, health promotion research, and nursing knowledge development. She was Co-Chair of the American Nurses Association (ANA) workgroup that revised the Public Health Nursing: Scope and Standards of Practice (2013), a member of the American Public Health Association (APHA) PHN Section, Definition Task Force that updated the Definition of Public Health Nursing (2013), President of the Association of Community Health Nursing Educators, and Chair of the Quad Council of Public Health Nursing Organizations. She was a member of the ANA—Congress on Nursing Practice and Economics. She is Fellow in the Center for Health Policy at the University of Virginia.
Nisha Botchwey earned her doctorate degree at the University of Pennsylvania and completed her Masters of Public Health at the University of Virginia. She taught Urban and Environmental Planning and Public Health at the University of Virginia. She is an Associate Professor of City and Regional Planning in the College of Architecture at the Georgia Institute of Technology. Dr. Botchwey specializes in public health and the built environment and community engagement. She teaches Public Health and the Built Environment, Community Engagement and the Citizen Participation and Health Impact Assessment, courses subscribed by community design and public health students from Emory and Georgia State University. Dr. Botchwey is author of Health Impact Assessment in the United States (Springer, 2014). She is also Director of the Built Environment and Public Health Clearinghouse (www.bephc.gatech.edu), an online resource supported by the Centers for Disease Control and Prevention and the National Prevention Strategy, offering training resources and multisector community building for public health, planning, architecture, transportation engineering, and health impact assessment. Dr. Botchwey is co-lead of the Atlanta Dashboard, an interactive tool that collects, analyzes, and displays quality of life and health data at the sub-county level to aid in evidence-based decision making. Dr. Botchwey is Co-Director of the National Academy of Environ- mental Design’s Research Committee, a member of the Centers for Disease Control and Prevention’s Advisory Committee to the Director, and an NSF ADVANCE Woman of Excellence Faculty award recipient.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Describe a culture of health and community health
promotion in the context of the ecologic model and social determinants of health (SDOH).
2. Analyze participatory approaches and the interrelationships among communities, populations, and interprofessional health care providers in the application of community health promotion strategies.
3. Describe evidence-based practice using the integrative model of community health promotion at multiple levels of the client system: individual, family, aggregate, and community.
4. Analyze nursing and interprofessional roles that are essential to build a culture of health through community health promotion.
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks—Of special note see the links for these sites:
• National Prevention Strategy • MAP-IT: A Guide To Using Healthy People 2020 in Your
Community
• Quiz • Case Studies • Glossary • Answers to Practice Application
Nisha Botchwey, PhD, MCRP, MPH
378 PART 3 Conceptual and Scientific Frameworks
INTRODUCTION The Robert Wood Johnson Foundation (RWJF) (2013) recently introduced the idea of a culture of health. Recognizing that health and health care are in the forefront of national debate and dialogue about health reform, nurses and other providers are questioning the foundation of our health care system. There is a significant shift away from acceptance of the status quo, and toward building a culture of health. Such a shift puts emphasis on the pursuit of long, healthy lives for all Americans and is consistent with the national health vision and goals proposed in Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2014a) and the National Prevention Strat- egy (National Prevention Council [NPC], 2011). The RWJF foresees “… a vibrant American culture of health: where good health flourishes across geographic, demographic, and social sectors; where being healthy and staying healthy is an esteemed social value; and everyone has access to affordable, quality health care” (2013). While most people recognize the need to exercise regularly, maintain their weight at recommended levels, and manage stress in their lives, modifiable health behaviors remain the major contributors to deaths in the United States (U.S.) (National Center for Health Statistics [NCHS], 2012). For example, tobacco use remains the leading cause of prema- ture deaths in the United States, with 480,000 deaths annually attributed to cigarette smoking (USDHHS, 2014b). Nurses,
other health professionals, and the public recognize that initiat- ing and maintaining a healthy lifestyle is difficult and requires different approaches directed toward individuals, families, communities, populations, and the environments in which they live.
In this chapter, we describe the historical underpinnings of health and health promotion for communities and populations including the concepts of community and social determinants of health (SDOH). In addition, we describe community health promotion models and frameworks including those specific to public health nursing and health promotion models from the social sciences. These concepts and models and the ways they are related are critical to building a culture of health and deter- mine the nature of nursing practice with communities and populations. We emphasize an ecologic approach to commu- nity health promotion and population health, which integrates multilevel interventions to promote the health of the public. The integrative model of community health promotion (Laffrey and Kulbok, 1999) can help nurses plan care for clients includ- ing communities and populations. The model synthesizes knowledge from public health, nursing, and the social sciences. The chapter describes studies that illustrate community-based participatory research (CBPR) and multilevel interventions. Applications of the integrative model of community health pro- motion show that the way nurses view these concepts is impor- tant in their approach to practice.
K E Y T E R M S built environment, p. 386 client system, p. 387 community, p. 382 community-based participatory research (CBPR), p. 388 community health promotion, p. 383 culture of health, p. 378 disease-oriented perspective, p. 381 ecosocial or social-ecological, p. 379 focus of care, p. 387 health, p. 379 health belief model (HBM), p. 384 health-oriented perspective, p. 381
health promotion, p. 380 illness care, p. 388 multilevel interventions, p. 383 National Prevention Strategy, p. 380 Photovoice, p. 389 population health, p. 380 social cognitive theory (SCT), p. 385 social ecological model, p. 385 social determinants of health, p. 380 transtheoretical model (TTM) or stages of change
(SOC), p. 384 —See Glossary for definitions
C H A P T E R O U T L I N E Introduction Historical Perspectives, Definitions, and Methods
Health and Health Promotion Community
Community Health Promotion Models and Frameworks Public Health Nursing Community Models and
Frameworks Health Promotion Models and Frameworks
The Ecologic Approach to Community Health Promotion Ecologic Perspectives on Population Health The Social Determinants of Health
An Integrative Model for Community Health Promotion Interprofessional Application to Nursing and Public Health
Community-Based Participatory Research (CBPR) Photovoice Method and Projects
Application of the Integrative Model for Community Health Promotion
Obesity and the Built Environment
379CHAPTER 17 Building a Culture of Health through Community Health Promotion
HISTORICAL PERSPECTIVES, DEFINITIONS, AND METHODS Health and Health Promotion Health is the key term in the process of building a culture of health through community health promotion. Beginning with Nightingale’s efforts to discover and use the laws of nature to enhance humanity, nursing has taken an active role in promot- ing the health of communities and populations. The way one defines health shapes the process of nursing and health care, including making decisions about what to assess, with what level of client, and how to evaluate the outcomes of care. For example, health from a medical perspective as alleviating an individual’s illness symptoms, involves assessment of the dura- tion, intensity, and frequency of specific symptoms. Interven- tion focuses on symptom relief and treatment of the cause of symptoms. Evaluation consists of determining the extent of symptom alleviation. On the other hand, health defined from an ecologic or environmental perspective as maximizing a community’s physical recreation opportunities, may involve assessment of existing recreation facilities, accessibility to the population, and beliefs and knowledge related to recreation and land use in the community as resources for healthy living.
The holistic or ecologic view of health is not new. The ancient Greeks viewed health as the influence of environmental forces on human well-being and healing from illness. Scientific medi- cine emerged slowly and in the twentieth century, professional care took precedence over self-care. During the last five decades, the concept of self-care as derived from a positive idea of health has reemerged to compete with professional care. Some propo- nents of self-care emphasize lay diagnosis and self-treatment, whereas others focus on teaching people how to work with their health care providers. As a result, health care system changes include the renegotiation of roles and emphasize collaboration between consumers and providers, as well as recognition of the health impact of the conditions in which people live.
Many health professionals believe that individuals are in a position to produce health. This idea is not new. In 1974, Fuchs suggested that the “greatest potential for improving health lies in what we do and don’t do for and to ourselves” (p. 55). In the political arena, LaLonde introduced a similar idea in A New Perspective on the Health of Canadians (1974). LaLonde identi- fied four major determinants of health: human biology, envi- ronment, lifestyle, and health care. In 1976, policy makers in the United States reinforced these determinants of health and sup- ported efforts to improve health habits and the environment as the best hope of achieving any significant extension of life expectancy (U.S. Department of Health, Education and Welfare [USDHEW], 1976, p. 69). The fundamental ideas of these land- mark documents about the determinants of health emerged during the era of social ecology (Bronfenbrenner, 1977 and 1979). Box 17-1 lists some landmark initiatives in health pro- motion and disease prevention.
The ecosocial or social-ecological perspective, initially presented by Bronfenbrenner in 1977, described human- environment interaction and health outcomes over a life span.
BOX 17-1 Landmark Health Promotion/ Disease Prevention Initiatives 1974—LaLonde’s A New Perspective on the Health of Canadians 1976—Forward Plan for Health, FY 1978-1982 1979—Healthy People: The Surgeon General’s Report on Health Promotion
and Disease Prevention 1989—Guide to Clinical Preventive Services (USPSTF, 1989) 1990—Healthy People 2000 1994—Put Prevention into Practice (PPIP) 2000—Healthy People 2010: Understanding and Improving Health and Objec-
tives for Improving Health, ed 2 (supersedes Jan 2000 conference edition) 2002—Progress reviews of Healthy People 2010 initiated 2005—Guide to Community Preventive Services: What Works to Promote
Health? (TFCPS, 2005) 2009—Healthy People 2020 Framework 2010—Healthy People 2020 Objectives 2012—Guide to Clinical Preventive Services (USPSTF, 2011)
U.S. Preventive Services Task Force: Guide to Clinical Preventive Services, 2012: Recommendations of the U.S. Preventive Services Task Force. October 2011. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://www.ahrq.gov/ professionals/clinicians-providers/guidelines-recommendations/guide/ index.html. Accessed April 26, 2014.
Sources: Task Force on Community Preventive Services: The Guide to Community Preventive Services-What Works to Promote Health, New York, 2005, Oxford University Press. U.S. Preventive Services Task Force: Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force, Baltimore, 1989, Lippincott, Williams & Wilkins.
The environments are described as the micro-, meso-, and macro-system levels. McLeroy et al (1988) translated these levels of the ecologic model to actionable layers of influence that include intrapersonal (characteristics of the individual), inter- personal (formal and informal social networks and social support systems), institutional (social institutions), community (mediating institutions, relationships and power), and public policy (multilevel laws and policies).
The U.S. Public Health Service established the first national objectives involving disease prevention, health protection, and health promotion strategies in the surgeon general’s Healthy People report. Disease prevention strategies focus on services such as family planning and immunizations delivered in clinical settings. Health protection strategies include environmental measures to improve health and quality of life. Health promo- tion strategies focus on achieving well-being through commu- nity and individual lifestyle change measures (USDHEW, 1979).
As described in Chapter 2, the health objectives for the nation outlined in Healthy People 2020 build on initiatives that have been pursued since 1980. Designed for use by individuals, communities, states, and professional organizations, these health objectives provided a guide for community and popula- tion programs to improve health. The release of Healthy People 2020 in 2010 included a national vision, mission, and overarch- ing goals. The four goals emphasized prevention, health equity, environments conducive to health for all, and healthy develop- ment across the life span. Information on Healthy People 2020 objectives and action plans (USDHHS, 2014c) is available at http://www.healthypeople.gov/2020/default.aspx.
380 PART 3 Conceptual and Scientific Frameworks
function,” Terris placed the WHO definition in a realistic context, providing a useful framework for health promotion.
Smith (1981), a nursing scholar, suggested that the “idea of health” directs nursing practice, education, and research. She defined health along a continuum, allowing for “more” or “less” health. Smith proposed four models of health, ordered from narrow and concrete to broad and abstract: clinical health, or absence of disease; role performance health, or ability to perform one’s social roles satisfactorily; adaptive health, or flex- ible adaptation to the environment; and eudaemonistic health, or self-actualization and attainment of one’s human potential.
Population health is a term widely used in several IOM reports and in contemporary health care policy. Recently, the IOM Roundtable on Population Health Improvement defined population health as “the health outcomes of a group of indi- viduals, including the distribution of such outcomes within the group” (Kindig and Stoddart, 2003, p. 381). Though not a part of the definition itself, population health outcomes are the product of multiple determinants of health, including genetics, behaviors, public health, medical care, and environmental and social factors (Adler et al, 2013; IOM, 2014).
It is important for nurses and health care providers to reflect on their own definition of health and recognize how their defi- nition influences the care they provide. Likewise, it is equally important for nurses to assess clients’ personal health defini- tions. Only through knowledge of their own health definition, together with assessment of clients’ health definitions, can nurses create interventions tailored to achieve the clients’ health goals. Nurses and health care providers who emphasize health promotion and population health that is congruent with the beliefs, health definitions, and goals of the population also acknowledge the importance of illness prevention. Nurses must strive to understand health policies and the consequences of these policies on vulnerable populations whose living condi- tions may include few determinants of good health.
Definitions of Health Promotion Health promotion is an aim of nursing and health care, although explicit definition of health promotion and differen- tiation from disease prevention or health maintenance is rare. Leavell and Clark (1965) strongly influenced the evolution of health promotion and disease prevention strategies through their classic definitions of primary, secondary, and tertiary
The National Prevention Strategy (NPS) published through the U.S. Surgeon General’s Office by the National Prevention Council (NPC, 2011) seeks to “improve the health and quality of life for individuals, families, and communities by moving the nation from a focus on sickness and disease to one based on pre- vention and wellness” (NPC, 2011, p. 7). To realize this vision for children, youth, adults and the elderly, the NPS targets interven- tions in multiple settings. These include healthy and safe commu- nity environments, clinical and community preventive services, empowered people, and elimination of health disparities. A focus on safe and healthy communities recognizes the power of the social, economic and environmental factors that have a stronger influence on health and well-being than does the health care setting (see Figure 17-2 for National Prevention Strategy).
This idea that the health of communities and populations is shaped by multiple determinants has been reinforced in the national (Institute of Medicine [IOM], 2003) and international (World Health Organization [WHO], 2014a) health policy litera- ture. The current focus is on determinants of population health (Figure 17-1), which include genes and biology, health behaviors, medical care, total ecology, and social/societal characteristics (Centers for Disease Control and Prevention [CDC], 2014a; IOM, 2006). In Figure 17-1, genes, biology, and health behavioral choices account for 25% of population health; and social determinants of health including medical care, the physical and social environment account for the remaining 75%. Although recent trends reveal improvement in determinants of population health such as health- ier living conditions and a decrease in smoking, these positive trends are associated with persistent socioeconomic disparities worldwide (WHO, 2014a) (see Healthy People 2020 box).
Definitions of Health The WHO (1948) reflected a holistic perspective in its classic definition of health as a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity. Terris expanded the WHO definition: “Health is a state of physical, mental and social well-being and the ability to func- tion and not merely the absence of illness and infirmity” (Terris, 1975, p. 1038). By deleting “complete” and adding “ability to
FIG 17-1 Determinants of Population Health (From Centers for Disease Control and Prevention: Social determinants of health. Available at http://www.cdc.gov/socialdeterminants/faq.html#b. Accessed April 26, 2014.)
Total ecology Medical care
Health behaviors
DETERMINANTS OF POPULATION HEALTH
Genes & biology
Social/societal characteristics
HEALTHY PEOPLE 2020
Selected objectives from Healthy People 2020 that pertain to tobacco use: • TU-1: Reduce tobacco use by adults. • TU-2: Reduce tobacco use by adolescents. • TU-3: Reduce the initiation of tobacco use among children, adolescents,
and young adults. • TU-6: Increase smoking cessation during pregnancies. • TU-7: Increase smoking cessation by adolescent smokers. • TU-11: Reduce the proportion of nonsmokers exposed to secondhand smoke.
Tobacco Use
From U.S. Department of Health and Human Services: Healthy People 2020. Available at http://www.healthypeople.gov/2020/default. aspx. Accessed January 15, 2011.
381CHAPTER 17 Building a Culture of Health through Community Health Promotion
health (WHO, 2014b). According to the 1986 Ottawa Charter, health promotion combines both individual- and community- level strategies to build healthful public policy, create supportive environments, strengthen community action, develop personal skills, and reorient health services. Health is a resource for daily living. For individuals or communities to realize physical, mental, and social well-being, they must become aware of and learn to use the social and personal resources available within their environment.
There is considerable evidence supporting a positive view of health underlying health promotion activities directed toward individuals, communities, and populations. The WHO’s defini- tion of health promotion as a process and the current focus on an ecologic approach to determinants of population health are grounded in the perspective of positive health. These approaches view health promotion in the context of a holistic healthy life- style, as well as involving simultaneous interaction with the social and physical environments. Clearly, health promotion and population health are consistent with the goals of public health nursing.
Disease Oriented versus Process and Environmentally Ori- ented Health and Health Promotion. Nurses have long recog- nized the importance of an emphasis on wellness and health promotion in health care. In public health nursing (PHN) prac- tice, it is clear that many factors, beyond illness, affect the health of individuals, communities, and populations. The biomedical model, in which health is defined as absence of disease, does not explain why some populations exposed to illness-producing stressors remain healthy, whereas others, who appear to be in health-enhancing situations, become ill. Viewing clients from the perspective of the biomedical model alone makes it difficult to identify health potential beyond the absence of disease in the individual. For example, most at-risk populations such as the frail elderly have at least one diagnosed chronic disease. Limit- ing the definition of health potential to the absence of disease, nurses would never perceive this population as healthy. Defin- ing health as the absence of disease is a pessimistic and individual-level definition; nursing actions can help older and chronically ill persons become healthier if a broader definition of health is used.
Laffrey, Loveland-Cherry, and Winkler (1986) describe two perspectives from which the key concepts of nursing science (e.g., person, health, environment) and nursing can be viewed. The first is the disease-oriented perspective that views health objectively, and defines it as the absence of disease as discussed previously. This perspective assumes that humans are com- posed of organ systems and cells; in this instance, health care focuses on identifying what is not working properly with a given system and repairing it. In this context, health behavior begins with patient compliance with health professionals’ recommen- dations. The second perspective defines health subjectively as a process, not as a presence or absence. In this health-oriented perspective, humans are complex and ever-changing systems, and are interconnected with others and the environment. Health behavior within this latter health-oriented perspective involves a holistic view of lifestyle and interaction with the environment and not simply compliance with a prescribed regimen.
levels of prevention that were rooted in the biomedical model of health and epidemiology. The application of preventive mea- sures, according to Leavell and Clark, corresponds to the natural history or stages of disease (see Chapter 12). Primary preventive measures apply to “well” individuals in the prepathogenesis period to promote their health and to provide specific protec- tion from disease. Secondary preventive measures apply to diag- nosis or to treatment of individuals in the period of disease pathogenesis. Tertiary prevention addresses rehabilitation and the return of people with chronic illness to a maximal ability to function (see Levels of Prevention box).
LEVELS OF PREVENTION
Primary Prevention For a person with identified risk factors for diabetes, the goal is to maintain a normal weight, to exercise regularly, and to reduce the intake of carbohydrates.
Secondary Prevention Have regular blood glucose level testing done and be alert for any symptoms of the onset of diabetes. If the blood glucose level indicates that the client has diabetes, begin treatment.
Tertiary Prevention For a person diagnosed with diabetes, monitor blood glucose levels and maintenance of a diabetic diet, regular exercise, and medication.
Diabetes
Even though primary, secondary, and tertiary levels of pre- vention had their origins in the medical model, Leavell and Clark (1965) moved beyond the medical model. They concep- tualized primary prevention as two distinct components: health promotion and specific protection. Health promotion focuses on positive measures such as education for healthy living and promotion of favorable environmental conditions as well as periodic examinations including, for example, well-child devel- opmental assessment and health education. Specific protection includes measures to reduce the threat of specific diseases or injury, such as hygiene, immunizations, use of seat belts, and the elimination of workplace hazards.
Health promotion and specific protection, when used as sub- concepts of primary prevention, stem from a definition of health as the absence of disease. However, health promotion and specific protection strategies are not the same. Some terms used to describe health promotion are linked to a positive view of health (e.g., health habits or health practices), whereas other terms are linked to the negative view of the absence of disease (e.g., disease or illness prevention). Using the terms health promotion, health protection, and disease prevention interchangeably, as indicators of preventive behavior, leads to confusion (Kulbok et al, 1997). Interestingly, similar confusion exists today in the field of health education regarding definition of the terms health behavior, health education, and health promotion (Simons-Morton, 2013). As interprofessional practice opportunities increase, public health nurses need to have clear definitions in mind when they use terms associated with community health promotion.
The WHO described health promotion as a process that enables individuals to increase control over and improve their
382 PART 3 Conceptual and Scientific Frameworks
MAP-IT (USDHHS, 2014e) as a guide to using Healthy People 2020 in your community (see http://healthypeople.gov/2020/ implement/mapit.aspx). MAP-IT stands for Mobilize, Assess, Plan, Implement, and Track; and communities can use the guide to evaluate public health interventions designed to imple- ment the goals of Healthy People 2020.
Nurses and interprofessional health care providers have many opportunities to participate in community-wide health care. To address community problems, these professionals need to integrate concepts of health and illness, individual and popu- lation, public health and health care, health promotion and disease prevention, and ecology and environmental health. This integration means that nurses must consider the complex rela- tionship between personal and environmental forces that affect health. Over 35 years ago, Milio (1976) offered a set of proposi- tions for improving health behavior by considering personal choices in the context of available societal resources. These propositions (Box 17-3) remain relevant today. They constitute
Both perspectives support the aims and processes of population-focused nursing. The disease-oriented approach directs nursing toward illness prevention, risk appraisal, risk reduction, prompt treatment, and disease management of indi- viduals. However, the health-oriented approach directs nursing practice toward promotion of positive health for a larger segment of the population. Defining health broadly as the life process, taking into account the mutual and simultaneous interaction of humans and their environment, views illness as a potential mani- festation of that interaction. Because positive health does not exclude any part of the life process (it includes illness prevention and illness care), it goes beyond the disease perspective to include positive and holistic health (Laffrey and Kulbok, 1999).
Community Another concept essential to building a culture of health through community health promotion is community. The emphasis on community as the target of practice gained increased attention since the mid-1970s when the U.S. and Canadian governments and health researchers attributed declining mortality and morbidity rates to better standards of living, such as sanitation, clean air and water, and wider avail- ability of healthy foods. Again, these approaches were consistent with emerging ideas about social ecology during the same period. The IOM’s seminal report on the future of public health highlighted the importance of community in its statement that the “mission of public health is to assure conditions in which people can be healthy by generating organized community effort to prevent disease and promote health” (National Research Council [NRC], 1988, p. 7). (See Chapter 18 for more on the concept of community.)
As discussed previously, national health goals emphasize that environment and community are central to achieving health. Healthy People in Healthy Communities: A Community Planning Guide Based on Healthy People 2010 (USDHHS, 2001) (Box 17-2), outlines practical recommendations for coalition build- ing, creating a vision, and measuring outcomes to improve the health of communities. Communities can tailor these recom- mendations to their own local needs, and health professionals in public and private organizations can work together with com- munity members to develop programs that fit the needs and resources of their own communities. The National Prevention Strategy also offers recommendations on what can be done to improve population health in specified contexts and across goal areas (NPC, 2011). Nurses participate in this collaborative and interprofessional process through community assessments, community development activities, and identification of key persons in the community with whom to build partnerships for health programs. Nurses working with nonprofit hospitals can also directly engage in improving health of communities through completion of a Community Health Needs Assessment (CHNA) as required under the Affordable Care Act (Rosenbaum, 2013).
One of the four overarching goals of the Healthy People 2020 Framework is to create social and physical environments that promote good health for all (USDHHS, 2014d). Community- wide program planning provides a strategy to achieve this goal. Healthy People 2020 highlighted a community framework called
• Health status of populations is a function of the lack or excess of health- sustaining resources.
• Behavior patterns of populations are related to habits of choice from actual or perceived limited resources and related attitudes.
• Organizational decisions determine the range of personal resources available.
• Individual health-related decisions are influenced by efforts to maximize valued resources in both the personal and societal domains.
• Social change is reflective of a change in population behavior patterns. • Health education will impact behavior patterns minimally without new
health-promoting options for investing personal resources.
BOX 17-3 Milio’s Propositions for Improving Health Behavior
Modified from Milio N: A framework for prevention: changing health damaging to health-generating life patterns, Am J Public Health 66:435, 1976.
To achieve the goal of improving health, a community must develop a strategy supported by many individuals who are working together. The MAP-IT tech- nique helps you to map out the path toward the change you want to see in your community. This guide recommends that you MAP-IT—that is, mobilize, assess, plan, implement, and t rack.
Mobilize individuals and organizations that care about the health of your community into a coalition.
Assess the areas of greatest need in your community, as well as the resources and other strengths that you can tap into to address those areas.
Plan your approach: start with a vision of where you want to be as a community; then add strategies and action steps to help you achieve that vision.
Implement your plan using concrete action steps that can be monitored and will make a difference.
Track your progress over time.
BOX 17-2 Healthy People 2010: A Strategy for Creating a Healthy Community
From U.S. Department of Health and Human Services: A strategy for creating a healthy community: MAP-IT. In Healthy people in healthy communities: A community planning guide using Healthy People 2010, Washington, DC, 2001, U.S. Government Printing Office.
383CHAPTER 17 Building a Culture of Health through Community Health Promotion
responsibilities to assure environmental health protection, community assessment, and health improvement planning” (Bekemeier and Jones, 2010, p. E16).
Anderson and McFarlane (2000, 2010) and Salmon (1993, 2009) developed system models based on the assumption that assessing the various components of the system (i.e., individual, family, community, and society) facilitates a healthy commu- nity. Anderson and McFarlane’s community-as-partner model includes eight major community subsystems. The basic core of the community, according to these authors, is its people, described by their demographic characteristics and their values, beliefs, culture, religion, laws, and more. Within the community system, the people interact with the other subsystems. A com- munity health assessment must include information about the subsystems and the pattern of interactions among the subsystems and of the total community with the systems external to it.
Salmon’s model (1993, 2009) focused on the public health mission of organized efforts to protect, promote, and restore health. It embraces multiple determinants of health and is consistent with the IOM’s perspective on population health (IOM, 2014). According to Salmon’s model, nursing includes health promotion, illness prevention, and health protection strategies. Systems models provide important guidance for assessing communities and populations and indicate that system-level interventions require participation with relevant subsystems. However, systems models may not provide the guidance needed for intervention development.
Keller et al (1998, 2004) proposed a population-based inter- vention model based on the scope of PHN practice that crosses multiple levels of care; this model defines the population- focused underpinning of PHN practice and provides guidance for PHN interventions at the individual, community, and system levels. The model was later termed the “Intervention Wheel” (Keller et al, 2004, p. 453). The Intervention Wheel includes community, systems, and individual/family levels of practice. (See Chapter 9 for more information on the Interven- tion Wheel.) It is population based and identifies 17 public health interventions. The models proposed by Anderson and McFarlane (2000, 2010), Salmon (1993, 2009), and Keller et al (1998, 2004) focus on stability and equilibrium. They empha- size protecting the community from specific disease risks; less attention is directed toward factors that promote an optimally healthy community. A few of the classic community-wide epi- demiologic studies focused on multilevel interventions or community health promotion are described next.
Influential Multilevel Community Studies Two significant community studies of health risks, morbidity, and mortality are the Framingham Heart Study, initiated in 1949, and the Human Population Laboratory’s longitudinal survey in Alameda County, California, initiated in the early 1970s. The Framingham Heart Study followed 5209 adults over their life span to identify factors contributing to coronary heart disease (CHD). Collecting periodic health assessments and morbidity and mortality data, major risk factors associated with CHD mortality were identified (e.g., elevated systolic blood
a fitting model for health promotion that addresses both per- sonal and societal resources for this and future decades.
COMMUNITY HEALTH PROMOTION MODELS AND FRAMEWORKS Numerous models and frameworks have community health promotion as the goal. The following sections provide brief descriptions of models specific to community and/or health promotion that are useful to public health nurses practicing at a basic or advanced level.
Public Health Nursing Community Models and Frameworks Although theoretical frameworks developed within nursing and other health disciplines are traditionally oriented toward indi- viduals, there is increasing recognition of the importance of community and person–environment interactions that go beyond social cognitive theory and other interpersonal frame- works (USDHHS, 2005) in promoting health. PHN defined community as “… persons in interaction, being and experienc- ing together, who may or may not share a sense of common purpose” (ANA, 2013, p. 65). Nurses realize that the community is more than the sum of the individuals, families, aggregates, and organizations within it and that interaction is essential for any real change to occur. The following are examples of public health nursing models focused on interventions with commu- nities or populations.
Chopoorian (1986) was among the first to acknowledge that nurses could strengthen their position with communities by focusing on the social, economic, and political structures that make up the community, as well as the social relations and pat- terns of everyday life in the community. Within this perspective, interventions targeted to public health policy can have far- reaching health benefits. Shuster and Goeppinger (2012) asserted that definitions of community vary widely and that nurses working with communities learn quickly that there are many different types. Shuster and Goeppinger highlighted the importance of person, place, and function, as well as interaction among systems within a community. Nurses must examine the complexity and dynamic nature inherent in the process of com- munity building, rather than viewing the community as a geo- graphic, racial, or cultural group that is static.
Despite the ideal, it is not easy to integrate the concept of the community as client into practice. Consequently, the provision of care to individuals in the community may still overshadow nursing practice and health promotion directed to the commu- nity. Bekemeier and Jones (2010), in a study of local public health agency (LPHA) functions, leadership, and staffing, reported that the proportion of nursing staff in an LPHA related strongly to provision of services involving individual-level care. They found that the staff nurses were most likely to perform individual-family interventions, and that both the staff nurses and the managers rated individual-family interventions as more important than community- or system-level interventions. These findings suggest that there is an ongoing need to expand “… education and outreach to nurses regarding their roles and
384 PART 3 Conceptual and Scientific Frameworks
provide support. The third level is community, which includes institutional structures and policies that may enhance or inhibit health behavior. Brief descriptions of selected models and frameworks are provided in the following sections.
Individual Health Promotion Models There are several intrapersonal or individual level models including the health belief model, the theory of reasoned action and the theory of planned behavior, the stages of change or transtheoretical model, and the precaution adoption process model (Edberg, 2013). The health belief model (HBM) can be used to plan programs to increase an individual’s motivation to take a positive health action. Specifically, the HBM was one of the first theories of health behavior. It began in the 1950s, when the U.S. Public Health Service sent mobile units to communities to provide chest x-rays as a way to screen for tuberculosis (Rosenstock, 1974). The chest X-rays were free, convenient, and painless, yet people did not take advantage of the service. A group of social psychologists tried to explain the failure to use this screening, or more specifically, to determine what would motivate people to seek health care.
The HBM includes six components that attempt to deter- mine what motivates an individual to adopt a health behavior. These components are (1) perceived susceptibility (“Will some- thing happen to me?”); (2) perceived severity (“If something does happen to me, will it be a big problem?”); (3) perceived benefits (“If I do what is suggested, will it really help me?”); (4) perceived barriers (“If I do what is suggested, will there be barriers that will be unpleasant or costly?”); (5) cues to action (“What might motivate me to take the recommended action?”); and (6) self-efficacy (“Can I really do this?”). This model has been praised and criticized. It provides guidance in planning health promotion programs because it reminds nurses to think carefully about what motivates people to change. To understand motivation, it is important to learn (1) how people involved feel about the health problem, (2) whether they think the problem is serious, (3) whether they think that action on their part will make a difference, and (4) whether they think they can both manage the barriers and actually perform the action (Edberg, 2013; USDHHS, 2005).
The transtheoretical model (TTM) or stages of change (SOC), and the precaution adoption process model (PAPM) are discussed together because they both deal with the process of change that occurs in stages and over time. The TTM or SOC has six stages: 1. Precontemplation, in which the person does not plan to
change; this may be because the person does not know there is a problem or does not want to do anything about it. For example, a person may not know that potential exposure to radon, a cancer-causing radioactive gas that he cannot see, smell or taste in his home, is a health risk.
2. Contemplation, in which the person begins thinking about making a change in the future and examines the pros and cons of doing so. The person may have heard about home radon exposure on the local news and is considering whether his home may have unsafe levels of radon and whether he should test for radon.
pressure, elevated serum cholesterol level, and cigarette smoking). The investigators used health risk appraisals to relate the risk factors in well individuals to the probability of future cardiovascular disease (Lieb et al, 2009). The Framingham study continues today (see http://www.framinghamheartstudy .org/).
The Alameda County study measured the relationships of health and social behaviors to mortality in a community sample of 6928 individuals over 4 years. The behaviors included eating three meals daily, eating breakfast, sleeping 7 to 8 hours a night, using alcohol moderately, exercising regularly, not smoking, maintaining a desirable weight-to-height ratio, and maintain- ing social networks. There was a positive relationship between smoking and excessive alcohol use and mortality. There was an inverse relationship between physical exercise, 7 to 8 hours of sleep, optimal weight in relation to height, and social networks and mortality (Berkman and Breslow, 1983). These findings led to the emphasis on social and environmental variables, in addi- tion to personal behaviors, in strategies for community health promotion.
Findings from these early large-scale surveys prompted a number of public health multilevel intervention programs. Examples include the Stanford Five-City Heart Disease Preven- tion program (Farquhar et al, 1990), the North Karelia study (Puska et al, 1983), the Pawtucket Heart Health program (Lasater et al, 1984), the Minnesota Heart Health program (Luepker et al, 1994), and the Dutch Heart Health Community Intervention (Ronda et al, 2005). These programs provided beginning scientific evidence for the implementation of community-level risk reduction programs, although the results were modest and often not statistically significant. However, these studies made major contributions to theory and practice in building community partnerships, establishing social mar- keting, developing behavior change strategies, and evaluating health programs. Results of these studies make it clear that multiple levels of intervention are necessary to reach the com- munity in a meaningful way. Nurses have close relationships with individuals, families, high-risk groups, organizations such as schools, congregations and workplaces, and other health care professionals. They can contribute to health promotion by par- ticipating in community projects such as the ones described here. It is important that nurses develop health programs and document improved outcomes for high-risk groups with whom they interact.
Health Promotion Models and Frameworks There are a variety of theoretical approaches that can be used to help public health nurses design and implement health promotion programs for individuals and communities. The National Cancer Institute’s seminal document, Theory at a Glance (USDHHS, 2005), organized these health promotion models and frameworks into three levels, which are consistent with the ecologic perspective used in this chapter. The first level is intrapersonal or individual, including models focused on knowledge, attitudes, personal beliefs and values. The second level is interpersonal, including models that emphasize pro- cesses and groups such as family, friends, and peers who may
385CHAPTER 17 Building a Culture of Health through Community Health Promotion
Community Health Promotion Models The social ecological model is another model used to guide public health nursing interventions for community health pro- motion (USDHHS, 2005; Edberg, 2013). The social ecological model (SEM) guides health promotion as well as illness preven- tion interventions. According to this model, health care and health-related behavior are a function of individual, inter- personal, organizational, community, and population factors. Thus, interventions are specific to each of these levels. In one of the first comprehensive studies using the SEM to assess factors related to the uptake of influenza vaccine, researchers examined vaccine uptake during the 2009 H1N1 pandemic. Of the 2079 adults surveyed, only 18.4% reported that they received the 2009 H1N1 vaccine. The results indicated that variables at all SEM levels influenced acquiring the vaccination: intraper- sonal level explained 53%; interpersonal explained 47%; insti- tutional level explained 34%; and, the policy and community levels each explained 8% of the variance related to influenza vaccine uptake. Together the SEM levels explained 65% of the variance in vaccine uptake. This data indicated that interven- tions aimed at multiple levels might be more effective than those targeting a single level (Kumar et al, 2013) (see Evidence- Based Practice box).
3. Preparation, in which the person intends to do something. In the example about radon exposure, the person might contact the environmental office of the local health depart- ment for advice about radon testing.
4. Action occurs when the person actually buys a radon-testing kit and uses it in his home.
5. Maintenance is when the person decides to test for radon and to take measures to reduce radon to acceptable levels.
6. Termination is when the person has adopted and sustained the behavior change process. For most behaviors, this stage is rarely accomplished and individuals stay in the mainte- nance stage (Edberg, 2013; USDHHS, 2005). Although the terms used are slightly different, the intent of
the PAPM is much like that of the TTM or SOC. The stages are (1) unaware of the issue, (2) unengaged by the issue, (3) decid- ing about acting, (4) deciding not to act, (5) deciding to act, (6) acting, and (7) maintenance. You can apply the cooking example later in this chapter to these stages, as well (Edberg, 2013).
Interpersonal Health Promotion Models Interpersonal-level models generally involve interaction between individuals and the social environment. These models focus on the reciprocal or mutual nature of interaction; that is, the person’s thoughts, feelings or actions are influenced by and also exert influence on his or her immediate environment. The social environment typically involves family, friends, peers, co-workers, health providers and others (USDHHS, 2005). Social learning theory, social cognitive theory, social network theory, and social support (Edberg, 2013) are examples of interpersonal-level frameworks that are useful for health pro- motion. Social cognitive theory (SCT) is one of the commonly used interpersonal theories. It evolved from Bandura’s social learning theory (SLT), which proposed that individuals learned from their own behaviors and from observations of the behav- iors of others and the benefits of those behaviors. Bandura expanded SLT by adding the construct of self-efficacy, which addresses the degree of confidence individuals have in their ability to perform a behavior (Edberg, 2013; USDHHS, 2005).
Continuing with the example of radon exposure, an indi- vidual would need to believe that he was capable of obtaining a radon test kit, understanding the directions for radon testing, and using it properly to test radon levels in his home. Note that there are incremental, small steps involved in a behavior seem- ingly as simple as using a radon testing kit. Bandura stressed the importance of understanding the target behavior in order to plan potential strategies to assist an individual in the process of behavior change. In addition to understanding the target behavior, change strategies based on SCT include (1) verbal persuasion, (2) role modeling, (3) positive affective response, and (4) positive reinforcement of the behavior. Strategies that public health nurses can use to change behavior include (1) communication skills to persuade a person to test his home for radon, (2) modeling the radon testing behavior, (3) emphasiz- ing the positive emotional response associated with reducing the health risk for his family, and (4) providing positive encour- agement and affirmation when the person has completed the radon testing in his home.
A study of leisure time physical activity (LTPA) in black adults, which used the social ecological model, helped to clarify relationships between LTPA and social-ecological factors such as self-efficacy, self-regulation, social support, outcome expectations, and policy beliefs (Li et al, 2012). The results sug- gested that self-regulation and intention to organize personal time for routine PA may yield successful results and that a PA intervention may succeed if participants in the intervention include people in their close network who support each other. In addition, the results suggested that planning policies to enhance the built environment and satisfy the community have the potential for wide-reaching effect on PA levels of African Americans. Several other major community-wide studies have drawn on concepts such as those pre- sented in these models.
EVIDENCE-BASED PRACTICE
Li K, Seo DC, Torabi MR, et al: Social-ecological factors of leisure-time physical activity in black adults. Am J Health Behav 36:797–810, 2012.
THE ECOLOGIC APPROACH TO COMMUNITY HEALTH PROMOTION Ecologic Perspectives on Population Health Because individuals ultimately make decisions to engage in healthy or risky behaviors, lifestyle improvement efforts have focused typically on the individual as the target of care. Follow- ing the health belief model (Rosenstock, 1974), individuals gen- erally concentrate on immediate personal rewards or threats when deciding whether to engage in specific behaviors; in this context, they may convince themselves that their immediate personal risks from certain behaviors such as smoking are low, or that the immediate rewards outweigh the risks. However, from a public health perspective, smoking in the United States has resulted in more than 480,000 deaths annually in the United
386 PART 3 Conceptual and Scientific Frameworks
(Navarro et al, 2007). More studies are needed to design and test these ecologic, multilevel community health interventions.
Farley and Cohen (2005) introduced the curve-shifting prin- ciple. This principle complements the ecologic model and calls for targeting health interventions at the population level. They built on representations of the relationship between individual and group behavior (Rose, 1992), with individual behavior being the foundation of the total population distribution. The median of this normal distribution represents prevailing social norms that govern health behavior. Traditional approaches to health behavior interventions for public health problems like obesity focus on the intrapersonal and interpersonal levels for high-risk populations—people at the extremes of the popula- tion curve. Although treating high-risk populations may be effective for selected individuals and may move them closer to the center or the prevailing social norm, this approach does little to prevent others from becoming the extremes of the dis- tribution. Therefore, a focus on the total population, not just the high-risk group, with efforts to change the social norm so that everyone is consuming less sugar or participating in more hours of moderate to vigorous physical activity, exemplifies the curve-shifting principle.
Consider another example of the curve-shifting principle that involves the built environment. The built environment includes the physical parts of the environment where we live and work (e.g., homes, buildings, streets, open spaces, and infrastructure) (CDC, 2013). Prentice and Jebb (1995) were among the first to report the association between obesity and the built environment by measuring inactivity, car ownership, and television viewing.
States, approximately 20% of all deaths (USDHHS, 2014b). Though still alarming, the percent of American adults who smoke today is 18%, down from 43% in 1964. However, we continue to increase spending on smoking-related medical care for adults, $132 billion in 2014, and lose more money in worker productivity costs, $157 billion, a 50% increase from just six years ago (CDC, 2008; USDHHS 2014b). Therefore, it is clear that health behaviors extend beyond the individual or the intra- personal and the interpersonal levels, having multiple determi- nants both internal and external to individuals and communities, as well as determinants within the society.
For example, adolescents’ decisions not to smoke are associ- ated with their individual attributes (e.g., positive self-image), family characteristics (e.g., parent–child connectedness), aggre- gate characteristics (e.g., peer influence), and community factors (e.g., living in a tobacco-growing region) (Kulbok et al, 2008a). As a result, interventions to initiate or maintain healthy behaviors have greater potential for success when directed sys- tematically toward the multiple targets of the individual, family, group, community, and society—that is, when they use an eco- logic approach to community health promotion.
The Social Determinants of Health Current trends in public health and health promotion empha- size the ecologic perspective on interaction between individuals and the environment. The ecologic approach also addresses the SDOH (McQueen, 2009) through social networks, organiza- tions, neighborhoods, and communities (Navarro et al, 2007). According to the World Health Organization (WHO), SDOH “are the conditions in which people are born, grow up, live, work and age, including their health. These circumstances are in turn shaped by a wider set of forces: economics, social poli- cies, and politics” (2010, p. 1). The WHO is an important con- tributor to defining and developing strategies to address the SDOH, and has outlined ten components of SDOH. (Box 17-4 lists the 10 components.)
There is increasing awareness that to achieve lasting gains in population health, assessments and interventions must be directed to multiple levels of the client system like those outlined in the SDOH. For example, a multilevel analysis of depressive symptoms in a national sample of 18,473 adolescents in the United States (Wight et al, 2005) showed that individual, family, aggregate, and community characteristics accounted for signifi- cant differences in adolescent depression. The American Academy of Pediatrics (2005) issued a statement urging pedia- tricians to increase their partnerships with communities in developing programs to improve child health. Examples of pediatrician–community partnerships (Sanders et al, 2005) include establishing a child health consultant program, working with a community to repair and fund sites to facilitate safe physi- cal activity for children, developing dance programs for over- weight and obese adolescent girls, and arranging a program for community leaders to learn about the Medicaid enrollment process. Traditional interventions that target only an individu- al’s risk or illness are not as effective as interventions and pro- grams developed using an ecologic approach that can affect all levels of the client system that contribute to good or ill health
1. The Social Gradient: Life expectancy is shorter and most diseases are more common further down the social ladder in each society.
2. Stress: Stressful circumstances—making people feel worried, anxious, and unable to cope—are damaging to health and may lead to premature death.
3. Early Life: The health impact of early development and education lasts a lifetime.
4. Social Exclusion: Hardship and resentment, poverty, social exclusion, and discrimination cost lives.
5. Work: Stress in the workplace increases the risk of disease. People who have more control over their work have better health.
6. Unemployment: Job security increases health, well-being, and job satisfac- tion. Higher rates of unemployment cause more illness and premature death.
7. Social support: Friendship, good social relations, and strong supportive networks improve health at home, at work, and in the community.
8. Addiction: Individuals turn to alcohol, drugs, and tobacco and suffer from their use, but use is influenced by the wider social setting.
9. Food: Because global market forces control the food supply, healthy food is a political issue.
10. Transport: Healthy transport means less driving and more walking and cycling, backed up by better public transport.
BOX 17-4 The Social Determinants of Health
From World Health Organization: Social Determinants of Health, Geneva, 2010. Available at http://www.who.int/socialdeterminants/ thecommission/finalreport/keyconcepts/en/index.html. Accessed January 2, 2010.
387CHAPTER 17 Building a Culture of Health through Community Health Promotion
providers, and the population. Each of these collaborators brings expertise to the client system. Important assumptions underlying the model include the need for integration of care in the complex health care system; the inseparable nature of individuals, families, aggregates, and community systems; and the maximization of health potential through health promotion interventions. In addition, the model builds upon complementary health and disease perspectives described previously (Figure 17-2). The health perspective focuses on promoting health as a dynamic and positive quality of life and includes the promotion of physical, mental, emotional, functional, spiritual, and social well-being considered in the context of ecologic and environmental factors. The disease perspective includes both the care and prevention of illness (disease and disability) and focuses on reducing risks and threats to health. Although some clinical strategies may be similar in the two perspectives, their ultimate goals differ fundamentally. The difference in these two perspectives is seen in the specific purpose of nursing and health care, as it is applied to health promotion, illness prevention, or illness care.
The integrative model (Laffrey and Kulbok, 1999) includes two dimensions: client system and focus of care. The client system is multidimensional with nursing and health care target- ing the multiple levels of clients. The simplest level of the client system is its most delimited target, the individual. When the individual is the client, the environment includes the family, the broader aggregate, and the community of which the individual is a part. The nurse and health care provider are concerned with how these environments affect the individual’s health.
Instead of simply teaching children the importance of walking and biking to school, the Safe Routes to Schools initia- tive improved the environment and the walkability of areas near schools, which correlates with increased local resident walking (Owen et al, 2004). Increased walking among local adult resi- dents is evidence that “… increasing neighborhood walkability may affect people in the larger community, not just schoolchil- dren” (Watson et al, 2008, p. 5). As a result, the population living nearest to walkable areas will walk more, thereby shifting the population social norms about walking and biking, includ- ing to school. People’s behavior will change based on targeted interventions to the environment in which they live, a concept advanced by B.F. Skinner (1978), a behavioral psychologist in the 1950s. In following this curve-shifting principle in health promotion and illness prevention, the ecologic model works at the population level to shift social norms governing health behavior and ultimately health outcomes.
AN INTEGRATIVE MODEL FOR COMMUNITY HEALTH PROMOTION Laffrey and Kulbok (1999) developed an integrative model for community health promotion to guide nursing and health care. The intent of the model was threefold. First, the model assists nurses to see the continuity of care at multiple levels. Second, it helps nurses describe their own areas of expertise within the complex health care system. Third, the model provides a basis for collaboration and partnership among nurses, other health care
FIG 17-2 National Prevention Strategy (From National Prevention Council, National Prevention Strategy, Washington, DC, 2011, U.S. Department of Health and Human Services, Office of the Surgeon General. Available at http://www.surgeongeneral.gov/initiatives/prevention/strategy/. Accessed on May 16, 2014.)
Healthy & Safe Community
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Elimination of Health Disparities
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388 PART 3 Conceptual and Scientific Frameworks
Community-Based Participatory Research (CBPR) The aim of PHN is to create partnerships with individuals, families, groups, and communities to promote their health. Community-based participatory research, grounded in epis- temology and critical social theories (Minkler and Wallerstein, 2008), provides the philosophical and theoretical basis for forming partnerships and for collaboration with the commu- nity. Researchers have used CBPR to conduct ecologic, com- munity, and environmental assessments. This approach to community assessment allows understanding of sociocultural contexts, systems, and meaning through a collaborative research process. In CBPR, partnerships are active and community members are involved in assessing, planning, implementing, and evaluating change. Both professionals and community residents determine health needs and plan interventions. As residents increase their awareness, they are better able to determine what they want for themselves, their families, and their community and they are more likely to take leadership roles in program development, using health professionals as consultants.
Just as early PHN roles extended beyond disease prevention and illness care to encompass advocacy, community organizing, health education, political and social reform (Kulbok and Glick, 2014), contemporary PHN roles emphasize collaboration with community organizations and community members. Recently, Kulbok, Thatcher, Parks, and Meszaros (2012) examined emerg- ing PHN roles that address complex, multicausal, community problems. They utilized a community participatory and ethno- graphic community assessment model and provided a PHN exemplar from their CBPR project, Youth Substance Use Pre- vention in a Rural County. The project involved an interprofes- sional team (i.e., the community participatory research team [CPRT]), including an advanced practice public health nurse, a human development specialist, a psychologist, an architecture and urban planning specialist, a nurse anthropologist, graduate students, and youths, parents, and leaders from the rural com- munity. The CPRT used community participatory strategies, Geographic Information Systems (GIS) mapping, and Photo- voice to design a substance use prevention program in a rural tobacco-growing county in the South. The CPRT completed a comprehensive community and environmental assessment of the county, its rural ecology, context, and culture, and reviewed evidence-based prevention programs as the foundation for designing and implementing a youth substance use prevention program that was acceptable, effective, relevant, and sustainable by the rural county.
In another example of a CBPR project, the community resi- dents of the East Side Village Health Worker Partnership (ESVHWP) on Detroit’s East Side developed a community- based program titled Healthy Eating and Exercising to Reduce Diabetes (HEED) (Schulz et al, 2005). The purpose was to increase community awareness about diabetes and prevention. Community groups and individuals with expertise in diabetes served as the project steering committee. They developed train- ing protocols and recruited and trained community advocates. After training completion, the HEED advocates developed activities to promote healthy diets and physical activity. The
Each succeeding level of the client system is more complex, since the client can also be the family, an aggregate, or the community. The aggregate and community make up the envi- ronment for the family, and the community is the environ- ment for the aggregate. Examples of different types of assessments and interventions appropriate at each level of client within the system are discussed later in this chapter. It is important to remember that community-oriented care is holistic in nature and is population focused in that it addresses multiple levels of clients and multiple levels of care within the total system. The integrative model of community health promotion is consistent with the ecologic approach described earlier, which addresses SDOH through social networks, organizations, neighborhoods, and communities (Navarro et al, 2007).
Focus of care in the integrative model includes health pro- motion, illness (disease or disability) prevention, and illness care. Each focus is appropriate for some aspects of nursing and health care. It is even more important to remember that the goal of health care is a healthier community, achieved through health promotion interventions. No matter where care begins, it ulti- mately leads to health promotion of the community. It under- scores the need for nurses and health care providers to have a good understanding of care requirements at all client levels. The individual, family, aggregate, and community each have char- acteristics, strengths, and health needs that are unique and that differ from those at the other levels.
INTERPROFESSIONAL APPLICATION TO NURSING AND PUBLIC HEALTH The integrative community health promotion model reflects the basic beliefs and values of holistic nursing and health care practice and is consistent with the current emphasis on build- ing a culture of health (RWJF, 2013) and the ecologic per- spective on multiple determinants of health (IOM, 2014; WHO, 2014a). The model depicts continuity and expansive- ness of the client systems and foci of care. Health promotion is the central axis, or core, of the model. At its narrowest focus, individuals receive illness care. According to the model, at the broadest level of care, nurses work with community leaders, other community residents, and health professionals to plan programs to promote optimal health for the community and its people. The goals of nursing and health care actions in the integrative model, at any client level from the individual to the community, are to identify health potential and achieve maximal health. To achieve these goals it is essential to have an active partnership between the nurse, health care providers, and the client system. By facilitating an active partnership with the client system, whether the focus of care is health promo- tion, illness prevention, or illness care, nurses involve clients in each step of the process of managing care from the assessment of their health needs and resources to implementation and evaluation of outcomes. In the following sections, strategies such as community-based participatory research and Photo- voice that are useful in interprofessional community health promotion interventions are discussed.
389CHAPTER 17 Building a Culture of Health through Community Health Promotion
modified Photovoice method would enhance the contribution of male adolescent participants and parents in individual and group interviews. Photovoice is a qualitative approach that uses images to promote effective ways of sharing beliefs about a specific topic. Researchers have used Photovoice to facilitate group conversations and to encourage participants to share their thoughts among themselves. In this study, Photovoice was a concrete way for youth and parents to express their percep- tions about being tobacco-free, amplified through photographs that respond to questions about this topic. This approach was particularly effective with the male adolescents, who were hesi- tant to share their thoughts and feelings, and had a hard time articulating their thoughts.
The Ngudo Nga Zwinepe (NNZ) Learning through Photos projects use Photovoice to understand water perceptions and innovations as well as health in the Limpopo Province of rural South Africa where water resources are scarce and frequently con- taminated (Cunningham et al, 2009). In one Photovoice project, community members took pictures documenting their perception of water and their water system. In contrast to the researchers’ expectations, there was little mention of the deleterious health effects of contaminated water. Instead, the participants listed infrastructure/storage, community, money, and food as their top priorities; health/hygiene ranked fifth overall. Photovoice pro- vided data to characterize the water priorities of this community and to implement an intervention that meets the community’s primary concerns in the shorter term while developing educa- tional strategies regarding the health risks of contaminated water.
The projects described in the previous paragraphs show the importance of multiple approaches to reaching the population. In multilevel intervention approach to community-oriented programs, it is important to pay attention to all client levels (i.e., individual, family, aggregate, and community). For example, in nutritional programs, it is important to address the individual, the household, grocery store accessibility and environment, the community, and the food environment. No one individual can address all of these levels, but there is increasing emphasis on working in teams and in developing partnerships consisting of residents, health providers, and other professionals outside the health field as specified through the National Prevention Strat- egy. In addition, it is important to frame and initiate interven- tions based on participants’ priorities, not the priorities of experts. This approach promotes increased buy-in to projects and the necessary compliance by community participants to adhere to healthy behaviors. Nurses have many opportunities to work with and to lead these multidisciplinary teams to conduct assessments, develop strategies with the community and its populations, and facilitate the empowerment of com- munity residents and recommended change. It is increasingly important that nurses integrate these intervention strategies with the epidemiologic evidence base for practice.
APPLICATION OF THE INTEGRATIVE MODEL FOR COMMUNITY HEALTH PROMOTION In the previous sections we described the importance of multiple levels of nursing and health care aimed at health promotion and
advocates and other community residents identified important barriers to healthy dietary choices, such as lack of access to grocery stores and fresh produce. Members of the HEED project established a monthly mini-market at a community site with a few retail outlets carrying high-quality produce. The project was successful in fostering a strong interest among participants in healthy cooking demonstrations and cooking techniques. Subsequently, the HEED project joined forces with another community initiative to obtain funding to expand the mini- markets and food demonstrations.
The Physical Activity and Neighborhood Resources in High School Girls study (Pate et al, 2008) followed an ecologic model based on the social cognitive theory for adolescent females in urban, suburban, and rural communities. Research- ers hypothesized that physical activity is influenced by a com- prehensive set of personal, social, and physical environmental factors. Using GIS mapping, mixed regression models on BMI, and environmental variables, as well as 3-day physical activity recall, they found that the physical environment explained less than 5% of the variance in physical activity among adolescent girls. However, after adjusting for race, BMI, socioeconomic status (SES), and household income, there was an association between churches and vigorous physical activity. An additional study by Botchwey (2007) showed that up to 80% of congregations and faith-based organizations offer health services to their community, with a greater variety of services than secular non-profit organizations. Therefore, as nurses work with communities, it is important to consider the social and physical components of the environment, especially those actively engaged in health promotion.
Photovoice Method and Projects Photovoice is a novel method used in CBPR projects that inte- grates the strengths of social support and engagement, building local capacity to identify and address community concerns. Wang and Burris (1997) developed this methodology in 1997 by expanding the use of “photo novella” (Wang and Burris, 1994) as a means to empower communities while gathering qualitative data. It is a grassroots community method of gather- ing information by using photography. By using Photovoice participants photograph, contemplate, and then verbalize stories or simple descriptions about their photo(s) taken in response to a particular prompt, thereby allowing their voices to be heard. This process prevents written text from hindering communication and is effective in a society that uses oral tradi- tion to preserve its culture (Riley et al, 2004). Health care researchers have used Photovoice as an assessment tool (Lacson, 2007; Strecher, 2004; Thompson et al, 2008).
This study by Kulbok et al (2008b) addressed gaps in the youth tobacco prevention literature. The purpose was to iden- tify attitudes, beliefs, values, strategies, and shared meanings associated with tobacco-free behaviors of rural-dwelling male adolescents and their parents. The study examined differences in the meaning attached to nonsmoking and nonuse of smoke- less tobacco among groups of African American and white male adolescents and their parents from two tobacco-growing coun- ties in Virginia. In addition, the study assessed whether a
390 PART 3 Conceptual and Scientific Frameworks
illness prevention of individuals, families, aggregates, and the total community. In the remainder of this chapter, we present an example using the integrative model to apply these concepts.
Obesity and the Built Environment Illness Care In this case example (Table 17-1), a young woman recently diagnosed with obesity is referred for care. The nurse’s immedi- ate goal is to provide care that will help this client resolve her illness. Obesity rates have doubled over the last 20 years, with 16.9% of children ages 2 to 19 years and 34.9% of U.S. adults considered obese (Ogden et al, 2014). These rates are the result of a built environment that promotes increased unhealthy food consumption and decreased physical activity. Our built environ- ment includes all of the places we live, work, learn, worship, and play and that are created or modified by people. According to the CDC, in order for people to make healthy choices to combat obesity, both policy and environmental changes are needed to assure affordable healthy food and safe places for activities (CDC, 2014b). Therefore, teaching the client about the effects and side effects of her medications, and how to monitor her weight, nutrition, and physical activity at home, are important interventions. Since predisposing genetic, lifestyle, and environ- mental factors related to obesity exist, it is important to give family members information about this illness, including early recognition of signs and symptoms for themselves. Other important aspects of illness care include assessing the prevalence of obesity among high-risk aggregates in the community and teaching obesity prevention and treatment classes in commu- nity-wide settings that high-risk groups frequent. An example is providing cooking classes in churches to at-risk women in the community. At the community level, it is important to assess whether there are adequate and available providers and resources for healthy food and safe physical activity in the community.
Illness/Disease Prevention Prevention care is also addressed at the individual level by teaching measures such as healthy nutrition, progressive
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Teamwork and Collaboration Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality client interventions and outcomes. Important aspects of teamwork and collaboration include: • Knowledge: Know the scopes of practice of teammates and support them
in practicing to their fullest level. • Skills: Clarify roles when necessary to avoid duplication of efforts and to
gain the most comprehensive approach to client care. • Attitudes: Respect the unique perspectives and contributions of team
members.
Teamwork and Collaboration Question Consider the role of partnerships with the community to reduce childhood and adult obesity in the community in collaboration with school health, public health, occupational health, and home health. Are other team members needed to launch a community program to focus on obesity? If so, who would you include and what is your rationale?
CLIENT SYSTEM
Focus of Care Individual Family Aggregate Community
Illness care Administer medications Monitor weight as well as
adherence to nutrition and physical activity recommendations of individual client in the home setting
Teach family members about nutrition and physical activity practices to lose weight and prevent the onset of obesity-related diseases
Assess prevalence of obesity in the community
Teach obesity classes community-wide in settings that high-risk groups frequent
Assess community for accessibility and adequacy of healthy food and safe physical activity venues in the local environment
Illness/disease prevention
Teach nutrition, progressive exercise, and lifestyle techniques to prevent additional weight gain
Teach nutrition and importance of regular exercise to all family members to prevent additional cases of obesity
Develop classes about obesity risk reduction for targeted high-risk groups and their community
Participate in community- wide multimedia education for obesity risk reduction
Health promotion Empower individual to adopt a less sedentary and more active health promotion lifestyle
Plan with family to incorporate health promotion activities into lifestyle
Provide group education (classes) regarding benefits of regular exercise and healthy eating
Work with community leaders and citizens to establish safe physical activity space and healthy food options
TABLE 17-1 Community Health Levels of Care: Obesity and the Built Environment
exercise, and lifestyle techniques to prevent additional weight gain. Healthy nutrition and regular moderate to vigorous exer- cise are important preventive measures for all family members. Aggregate-level preventive interventions include providing showers at workplaces to encourage exercise before or during the workday. Community intervention examples include year- long multimedia campaigns to provide intensive education to the community about prevention of obesity.
Health Promotion Health promotion can motivate a person to adopt a less seden- tary and more active lifestyle. Health promotion includes encouraging individuals to adopt a health-promoting lifestyle and helping them to become aware of their own power and self-efficacy to do so. Nurses can encourage families to make health-promoting activities a part of their daily lives. This might include taking walks, swimming together, or joining an
391CHAPTER 17 Building a Culture of Health through Community Health Promotion
intergenerational baseball or bowling team in which families compete with other families. Aggregates can also benefit from heart-healthy classes or activities that are culturally specific to particular subgroups, such as older Hispanic women or African American teenage girls. These activities can include stress management, well-balanced nutrition, exercise, dance classes, sports, or any other topic that can promote heart health. When looking at the total community, an example of a health promo- tion intervention is participating in a coalition to plan for supermarkets and community gardens, as well as parks or rec- reation areas within the community that are safe and accessible to the population.
LINKING CONTENT TO PRACTICE
In this chapter, we describe the origins of the integrative model of community health promotion (Laffrey and Kulbok, 1999) and its application in public health nursing practice. The integrative model addresses the multiple determinants of population health and is consistent with the ecologic framework (IOM, 2014) and social determinants of health (SDOH) (Commission on Social Determinants of Health [CSDH], 2008; WHO, 2014a). The ecologic approach provides a basis for understanding population health and the challenges of building a culture of health (RWJF, 2013). It emphasizes that multiple social determinants of health influence the conditions that promote health on multiple levels
(i.e., individual, family, aggregate, community, and society). The central focus of public health nursing practice is health promotion. Health promotion is also central and dominant in the integrative model of community health promotion. Public health nurses strive to improve the health status of communi- ties and populations. Whether the client system is the family or a vulnerable population, and the focus of care is illness prevention or illness care, health promotion remains the central goal. No matter where public health nursing care begins, it ultimately leads to health promotion of the community and population health.
K E Y P O I N T S • The goals of a culture of health for America are for good
health across geographic, demographic, and social sectors; for being healthy and staying healthy as a social value; and for everyone to have access to affordable, quality health care.
• The idea of health shapes the process of population-focused nursing practice, from assessment of health-related needs of individuals, families, aggregates, and communities to evalu- ation of health outcomes.
In summary, the concepts of health, health promotion, and community are inextricably linked; it is difficult to discuss one without including the others. It is also important that nurses examine their definitions and beliefs about each concept as the basis for their practice. The essence of public health is the ability to see the totality of community while addressing its compo- nent parts and, at the same time, to see the total needs for health promotion, health protection, illness and disease prevention, and illness care and management. The integrative relationship among these components distinguishes public health nursing from nursing in more circumscribed settings, such as hospitals and clinics.
P R A C T I C E A P P L I C A T I O N A rural health outreach program serves migrant workers, their families, and other vulnerable populations in the local commu- nity. The program’s goals include increased knowledge about risk factors, services, and self-care; improved community health; increased access and affordability of individual- and community- level health promotion services; and reduced barriers to health services. The program offers health promotion and disease pre- vention educational materials and classes in English and Spanish throughout the region in churches, schools, community centers, fire departments, and migrant camps. In addition, clinics in eight local sites across the county provide services. Clinic ser- vices include health risk assessments, disease screening, immu- nizations, health education, counseling, and referral. The program staff trained community health workers (CHWs) from the migrant community to deliver basic health education and resource information. Funding from a variety of public and private sources supports the program. It is essential that the program show effective outcomes if it is to sustain funding.
Mary Ann Jones, a nurse with a bachelor of science in nursing degree, works for the outreach program. She is a member of a group asked to evaluate whether the outreach program (includ- ing the eight clinics) is effective in meeting the stated objectives.
A. Using the integrative model for community health promo- tion as a guide, how might you organize a comprehensive approach to assessment and data collection?
B. What are sources of data you might use for assessing indi- vidual, aggregate, and community health indicators?
C. What is the value of interviewing rural residents, migrant workers, and clinic participants about their perceptions of health and the value of health services?
D. Who else can you interview to elicit important information about the usefulness of the outreach program?
E. How can you best use CHWs to increase participation and partnership among concerned health professionals, community residents, and migrant families and to sustain the program? Be creative and comprehensive in your approach, and con-
sider how you might build a culture of health using the ecologic perspective, the social determinants of health, and cultural factors associated with rural and migrant populations in the United States. Current spending limits on federal and state pro- grams for health promotion and disease prevention require that nurses deal effectively with issues of outreach, sustainability, and success of community health programs.
Answers can be found on the Evolve site.
392 PART 3 Conceptual and Scientific Frameworks
K E Y P O I N T S — cont’d • The National Prevention Strategy foresees a prevention-
oriented society where public and private sectors value health for individuals, families, and society and work together to achieve better health for Americans.
• The greatest benefits in public health are likely to come from efforts to improve individual and family lifestyles through community and population interventions that address the social determinants of health including social conditions and the built environment.
• Public health nurses have a history of commitment to primary health care and to enhancing levels of wellness in communities and populations.
• When nurses examine their own definition of health, they recognize how this health definition directs the nursing care they provide.
• When nurses examine the client’s definition of health, they are more likely to tailor care to the client’s culture, needs, lifestyle, and social and physical environment.
• The Framingham Heart Study has provided more than 50 years of research about risk factors and lifestyle habits; Fram- ingham researchers are currently studying how genes con- tribute to common disorders such as obesity, hypertension, and diabetes.
• The Stanford Heart Disease Prevention program, the North Karelia Project, the Pawtucket Heart Health program, and the Minnesota Heart Health program contributed to the scientific knowledge base for the design, implementation, and evaluation of community- and population-level risk- appraisal and risk-reduction programs.
• Public health nurses function beyond resolving a specific illness to preventing the illness and promoting optimal health for the individual, the family, the aggregate, and the total community. All of these levels are important to promote the health of the community and populations.
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C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Write your own definition of health, and interview a nurse,
client, and physician about their definitions of health. How are these definitions similar or different? How do they “fit” with your understanding of what nurses and health care providers need to do to build a culture of health?
2. What are some challenges encountered when you consider different definitions of health and health promotion from a disease oriented versus an environmental or social-ecologically oriented perspective? Illustrate these challenges and opportu- nities with examples of strategies that are health promoting and will contribute to building a culture of health.
3. Discuss the importance of the built environment in commu- nity health promotion, and provide examples of environmen- tal health promotion indicators for a specified community.
4. Develop a nursing care plan for addressing childhood obesity using the propositions of Milio (1976) as a frame of reference.
5. Use the integrative model for community health promotion and social determinants of health to identify the most important strategies in a community-wide plan for child- hood obesity.
6. Illustrate community health levels of care including the client system and the focus of care: A. For teenage pregnancy: begin with community-level
health promotion B. For childhood obesity: start with community-level illness
prevention
393CHAPTER 17 Building a Culture of Health through Community Health Promotion
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In the report brief, “For the Public’s Health: Investing in a Healthier Future,” The Institute of Medicine says “In 1914, New York City Commissioner Herman M. Biggs remarked that ‘public health is purchasable’, adding that within natural limitations, a community can determine its own death rate” (Committee on Public Health Strategies, 2012, p. 1). It is embarrassing that over a century later, the United States has not done a good job of determining its own death rate. We spend huge amounts of money on clinical care and too often neglect public health and population-based efforts to improve health care. The primary orientation of health care delivery has been toward care and cure of the individual. There is increasing evidence that lifestyle and personal health habits influence the health of individuals, families, populations, aggregates, and communities.
Although it is necessary to identify health risk factors among individuals and groups in the community, nurses should also identify and work with health problems of a defined population or the total community. Healthy communities provide greater resources for growth and nurturing of individuals and families than do the communities that ignore the need for an emphasis on the health of their populations.
Certainly, nurses can use a public health approach to work with individuals and families in promoting health, intervening in disease onset or progression, and assisting with rehabilitation. Likewise, nurses often find that strategies used to introduce health behaviors directed at illness prevention and lifestyle changes are applicable to groups in the community and the community at large. Concepts for promoting health behaviors through groups, identifying community groups and their contributions to community life, and helping groups work toward community health goals are essential to population-centered nursing practice.
Healthy communities/healthy cities is an approach to helping communities organize and strive to provide environments for healthful living for their populations. In this approach, health is described as encompassing the physical and mental health of individuals and families plus the social, political, economic, educational, cultural, and environmental settings of the total community.
Nurses can help communities attain their health goals by understanding the organization of communities, the effects of rural versus urban settings on health issues, how and why programs are managed, and how to evaluate programs for quality and effectiveness. A community assessment provides the basis for helping com- munities establish their goals. The use of a nurse-managed clinic is one approach nurses have found to be successful in meeting the needs of aggregates, or vulnerable at-risk populations. These needs must be consid- ered when trying to improve the health of a community. Case management is an approach that has been used by nurses since its inception to match the most appropriate services and health care delivery interventions to population needs.
Although all communities strive to protect their populations and provide a safe living environment, natural and man-made disasters may occur; nurses can play a significant role in helping a community through crises. However, as the Institute of Medicine report points out “to improve health outcomes in the United States, we will need to transform the way the nation invests in health to pay more attention to population-based preven- tion efforts, remedy the dysfunctional manner in which public health funding is allocated, structured, and used; and ensure stable funding for public health departments” (Committee on Public Health Strategies, 2012, p. 4).
P A R T 4
Committee on Public Health Strategies to Improve Health and Board on Population Health and Public Health Practices: “For the public’s health: investing in a healthier future,” Washington DC, The National Academies Press, 2012.
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18
Mary E. Gibson, PhD, RN Dr. Mary E. Gibson was a public health nurse in Albemarle County, Virginia, early in her career. Since that time she has practiced in a variety of Maternal Child Health settings. Mary was involved in the Virginia Department of Health’s early initiative to regionalize high risk pregnancies and has worked as an outpatient nurse, childbirth educator, Perinatal Outreach nurse including systems work with regional hospitals and nurses, and outreach education; and as a labor and delivery and perinatal nurse. Her master’s degree concentration was community health. Her doctoral work at University of Pennsylvania focused on nursing history, and this continues to be her research focus. At the University of Virginia, Mary’s teaching experience includes graduate level Community Assessment, undergraduate Obstetric and Neonatal Nursing and clinical undergraduate Community Health Nursing. She currently leads a local nonprofit’s board that serves at-risk, underserved children and families.
As a BSN nursing student, Esther volunteered in El Salvador several times with a group called Nursing Students Without Borders. After graduating, she continued to work with Latinos as a migrant farmworker outreach nurse in rural Virginia. She then worked in adult Internal Medicine settings, where she became interested in preventing chronic diseases in underserved populations. Later, as a public health nurse, Esther reignited her interest in how community environments affect health outcomes. Her PhD research at the University of Virginia was to describe community influences on healthy food access in rural Appalachia. She is currently a postdoctoral fellow at University of North Carolina—Chapel Hill.
K E Y T E R M S active participation, p. 400 aggregate, p. 398 coalitions, p. 399 community, p. 398
community as client, p. 398 community as partner, p. 407 community health, p. 399 community health workers, p. 401
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • Centers for Disease Control and Prevention (provides
numerous .pdf files for download) • Behavior Risk Factor Surveillance System (BRFSS) data • American Public Health Association: The Guide to
Implementing Model Standards • The Community Guide
• Quiz • Case Studies • Glossary • Answers to Practice Application
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Analyze the importance of community assessment in
nursing practice. 2. Select and utilize a method and model for assessment of a
community. 3. Appraise various online data sources for reliability and
accuracy of information.
4. Utilize the nursing process to create a community assessment for a selected community.
5. Interpret concepts basic to community nursing practice: community, community client, community health and partnership for health.
6. Develop a prioritized community problem list and nursing diagnosis, and a care plan for a community.
Esther J. Thatcher, PhD, RN, APHN-BC *
*With gracious thanks to Elayne Kornblatt Phillips, MPH, PhD, RN, FAAN for careful reading and critique. A special thanks to George Shuster for his contributions to this chapter through many editions of this text.
397CHAPTER 18 Community As Client: Assessment and Analysis
C H A P T E R O U T L I N E Introduction Community Defined Community As Client
Nursing Care of the Community As Client Community As Client Community Health Community Partnerships for Assessment The Nurse’s Role in the Community
Community Assessment Why Community Assessment? Data Sources Community Health Assessment Models
Community As Partner How to Conduct a Community Assessment
Getting Started Windshield Survey Community “Place” and “People” Identified The 7 “A’s” Data Analysis Nursing Diagnosis Program Planning, Implementation, and Evaluation
K E Y T E R M S — cont’d core public health functions, p. 399 demographic data, p. 415 distributive justice, p. 399 focus group, p. 406 gatekeepers, p. 401 geographic information systems (GIS), p. 407 health indicators, p. 403 key informant, p. 404 Mobilizing for Action through Planning and Partnerships
(MAPP), p. 399 morbidity, p. 415 mortality, p. 415 NANDA, p. 418 Omaha system, p. 418
participant observation, p. 404 partnership, p. 400 passive participation, p. 400 Photovoice, p. 406 population-centered practice, p. 399 primary data, p. 401 Public Health Nursing Competencies, p. 401 secondary data, p. 401 social justice, p. 399 socio-ecological model, p. 399 spatial data, p. 407 stakeholders, p. 404 utilitarianism, p. 399 windshield surveys, p. 408
“I believe that the community—in the fullest sense: a place and all its creatures—is the smallest unit of health and that to speak of the health of an isolated individual is a contra- diction in terms.”
Wendell Berry
INTRODUCTION Communities are the environments where we live and work. Naturally, the community’s ability to serve the needs of its members defines key aspects in the health of the community. The public health nurse (PHN) is in an ideal position to view the “community as client,” and to begin to identify and work with the strengths present in the community and to help harness these strengths to meet the challenges faced by the community. Health is a broadly defined and interdependent concept. As defined by the World Health Organization, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948). Therefore, the health of the community involves many aspects besides the absence of disease. The influence of environment, public
services and policies along with economics play a large role in the health of the community.
We use the nursing process from assessment through evalu- ation to promote a community’s health. This process begins with community assessment (sometimes called community needs assessment)—one of the core functions of public health nursing—which involves getting to know the community inside and out. It is a logical, systematic approach to identifying com- munity needs, clarifying problems, and identifying community strengths and resources. In this chapter we will clarify specific community concepts including community as client, provide a snapshot of the nurse’s role in communities, and outline the process for undertaking a comprehensive community assess- ment using a hybrid of the nursing process.
COMMUNITY DEFINED “Boston Strong” was a phrase that spread quickly after the 2013 Boston Marathon bombing. Like many communities in the immediate aftermath of a major disaster, residents of Boston and beyond rallied together in a declaration of solidarity and shared community identity. The community spirit and hope
398 PART 4 Issues and Approaches in Population-Centered Nursing
FIG 18-1 Health on a population continuum. Health
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implied in “Boston Strong” is an example of the comfort and reassurance that a strong community identity can provide to individuals (Lin, 2014). But what do we mean by community, and how might being part of a community influence a person’s health?
There are many definitions of community. At its simplest, a community is a group of people that share something in common, such as geographic location, interests, or values (Obst & White, 2005, p. 127). The World Health Organization defines community as “a group of people, often living in a defined geographical area, who may share a common culture, values and norms, and are arranged in a social structure according to relationships which the community has developed over a period of time” (World Health Organization, 2004, p. 16). One study that aimed to define community among a diverse U.S. popula- tion reached the consensus definition of “a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographi- cal locations or settings” (MacQueen et al, 2001).
A community is a system, not just the sum of the character- istics of its inhabitants. In most definitions, the community includes three factors: people, place, and function. People are the community members or residents. An aggregate is a popu- lation or group of individuals who share common personal or environmental characteristics. Place can be a geographic loca- tion or other shared spaces such as the Internet. Function refers to the aims and activities of the community.
Community is a concept rather than simply a specific place, and individuals living in the same place may describe their community differently. When an organization asks a nurse to perform a community assessment, community usually refers to a specific population, an aggregate with specific characteristics that lives within the area that an organization serves, such as a school district, or a geographic area such as a county. However, it is important to remember that individuals within this defined area could view the community through a different lens. Under- standing the many identities of community is part of the community assessment and is best done through talking with residents and stakeholders.
COMMUNITY AS CLIENT Nursing Care of the Community As Client Population-focused health care is highly relevant in our current health care environment, and the community as client is impor- tant to nursing practice for several reasons. The community is the client when the nursing focus is on the collective or common good of the population, instead of on individual health. When focusing on the community as client, direct clinical care can be a part of population-focused community health practice (Radzyminski, 2007). For example, sometimes direct nursing care is provided to individuals and family members because their health needs are common community-related problems. Changes in individual health will ultimately affect the health of the community (O’Donnell et al, 2009).
Improved health of the community remains the overall goal of nursing intervention. This is often accomplished through
individual treatment; for example, addressing intimate partner violence, child or elder abuse is intended primarily to impact the effects of abuse on society and ultimately on the population as a whole. Similarly, treating a client for tuberculosis reduces the risk to other community members, thereby reducing the risk of an epidemic in the community. Since 1965, large-scale campaigns to encourage smoking reduction or cessation among groups and individuals, and laws that prohibit smoking in spe- cific public spaces have resulted in significantly lower smoking rates in the adult population (42% in 1965 compared to 19% in 2011) (CDC, Trends in Current Cigarette Smoking Among High School Students and Adults, United States, 1965-2011).
Focusing on the community client highlights the complexity of the change process. Change for the benefit of the community client must often occur at several levels, ranging from the indi- vidual to society as a whole. For example, health problems caused by lifestyle, such as lack of exercise, overeating, and speeding, cannot be solved simply by asking individuals to choose health-promoting habits. Society must also provide healthy choices. Most individuals find changing their habits independently extremely difficult; indeed, sometimes impossi- ble. The support of family members, friends, community health care systems and relevant social policies are necessary for success. Individuals who have lifestyle health problems are often blamed for their illness because of their choices (e.g., to smoke), often referred to as “blaming the victim.” In his classic work, Ryan (1976) points out that the “victim” cannot always be blamed and expected to correct the problem without changes also being made in the helping professions and public policy. Figure 18-1 illustrates the continuum of care from the indi- vidual to global health.
Commitment to the health of the community client requires a process of change at each appropriate level on the continuum. One nursing role emphasizes individual and direct personal care skills, another nursing role focuses on the family as the unit of service, and a third centers on the community. The most successful change processes often arise from collaborative prac- tice models that involve the community and nurses in joint decision making. (Bencivenga et al, 2008). Nurses must remem- ber that collaboration means shared roles and a cooperative effort in which participants want to work together (Ndirangu et al, 2008). Participants must see themselves as part of a group effort and share in the process, beginning with planning and including decision making. This means sharing not only the power but also the responsibility for the outcomes of the inter- vention. Viewing the community as client and thus as the target of service means a commitment to two key concepts: (1) com- munity health and (2) partnership. These two concepts form not only the goal (community health), but also the means of population-centered practice (partnership).
399CHAPTER 18 Community As Client: Assessment and Analysis
the community as a system to support healthy individuals. The socio-ecological model views individuals as having dynamic interactions with social and environmental features of com- munities, for example social networks, organizations such as schools and businesses, media, government policies, and natural and built environments (Richard, Gauvin, & Raine, 2011). Nurses caring for the community as the client identify effects that these complex community parts have on individuals’ health; they work with all parts of a community to achieve the goal of a healthy community. Betty Neuman’s Health Care Systems Model illustrates this system well (Neuman, 1980).
Neuman’s model views systems as greater than the sum of their parts; the strength of each part of a community and the synergy between these parts contribute to the ability of its resi- dents to be healthy. Community systems provide stability and protection from chronic or sudden stressors such as homeless- ness, health declines, disease outbreaks, or disasters. Another community model, Community-As-Partner, identifies major community systems as physical environment, health and social services, economy, transportation and safety, politics and gov- ernment, communication, education, and recreation (Anderson & McFarlane, 2011).
The World Health Organization’s (WHO) Healthy Cities program is an international leader in promoting health through community systems. It defines a healthy community as “one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in per- forming all the functions of life and developing to their maximum potential” (World Health Organization, 2014). The WHO describes four aims of healthy communities as (1) sup- porting individual health, (2) promoting quality of life, (3) distributing the resources needed for basic sanitation and hygiene, and (4) creating accessible health care services.
Community Partnerships for Assessment Partnering with community members is a key element of a suc- cessful community health program or intervention. Involving community members not only in the data collection process, but in all phases of the assessment, ensures that the data collected are more accurate and more relevant to the concerns of the community. Partnerships also promote community members’ investment in the success of the assessment and in the resulting projects to improve community health. Therefore, successful strategies for improving community health must include community partnerships as the basic means or key for improvement. Some community assessment models feature community partnerships as a central activity, such as Mobiliz- ing for Action through Planning and Partnerships (MAPP) (NACCHO, 2014).
Nurse-community partnerships can take many forms. A suc- cessful democratic partnership requires hard work from all parties and is usually achieved only through a long-term com- mitment to the process, wherein diverse community members and health care professionals share all resources and work equi- tably (D’Alonzo, 2010). Coalitions are formal partnerships in which individuals and organizations serve in defined capacities
Community As Client Population-centered practice seeks healthful change for the whole community’s benefit (Radzyminski, 2007). Although the nurse may work with individuals, families or other groups, aggregates, or institutions, the resulting changes are intended to affect the whole community. For example, an occupational health nurse’s target typically includes preventing illness and injury and maintaining or promoting the health of an entire company workforce. Because of this focus, the nurse might help an individual disabled worker become independent in activities of daily living. The nurse could also take action to make the whole community better able to support persons with disabili- ties. These actions might include promoting vocational reha- bilitation services in the community and advocating for local policies that improve equal opportunities for disabled workers.
Community health nurses join professionals from many other fields in fulfilling the core public health functions: assess- ment, assurance, and policy development (National Research Council, 1988). The community assessment process described in this chapter is a key role of PHNs. The findings of the assess- ment process guide actions of assurance, or ensuring that all community members have access to high-quality health ser- vices. Policy development includes informing and mobilizing community members to advocate for business and government policies that improve health.
The community as client perspective guides decisions about allocation of resources and services to create the greatest benefit for the community. Sometimes this means spreading the benefit to as many people as possible in the community. For example, clean air and water are resources needed by everyone in a com- munity. At other times, the community will experience the greatest benefit if resources are prioritized for groups within the community who are in high-risk categories. For example, sup- plies of vaccine for the 2009 H1N1 influenza pandemic were limited at first. Population groups at highest risk for complica- tions from the disease were vaccinated before making the vaccine available to the general population (Shim, Meyers, & Galvani, 2011).
Two main ethical concepts that guide the community as client perspective are utilitarianism and justice. Utilitarianism means doing the greatest good for the greatest number of people. Distributive justice means treating people fairly, and distributing resources and burdens equitably among the members of a society. Social justice means ensuring that vulnerable groups are included in equitable distribution of resources. The outcome of social justice should be a reduction in health disparities between privileged and marginalized social groups. Nurses can use these concepts to carefully consider how to best allocate scarce resources, such as health services and funding, in ways that benefit the whole community. More information on ethics in community practice is found in other chapters of this book.
Community Health Community health is reflected in the health behaviors and subsequent outcomes of its residents and also by the ability of
400 PART 4 Issues and Approaches in Population-Centered Nursing
on existing community strengths. Nurses working with com- munity groups and organizations can fulfill many different roles including media advocacy, political action, community- based health communication, social marketing, and outreach facilitation. Regardless of what roles nurses fulfill as their con- tribution to the partnership, they must remember to “start where the people are” (Severance & Zinnah, 2009).
Shoultz et al (2006) looked at the challenges and possible solutions in developing partnerships with communities. Com- munity partnerships involve both influence and power. Nurses must focus on where and how health professionals and the com- munity can work together, respecting voices of all community members. This approach requires nurses to do with rather than to the partner, while the partner’s role throughout the process is active and empowered, not passive. Mutually determined goals and plans of action, and the assignment of roles and responsi- bilities, are negotiated. Through this model, community part- ners become more effective at working independently to solve their own problems and make their own decisions.
Prioritizing the problems through the lens of the partici- pants may not match the identified priorities defined by other sources of data. In the language of community empower- ment advocates, community participants must have an active role in the change process. The PHNs must work hard to include members of a setting, neighborhood, or organization while developing trust and providing the community with a central role throughout the process (Christopher et al, 2008; Hanks, 2006).
One historical example of a nurse-community partnership remains an inspiring story of this important work. Nancy Milio was a young, white PHN when she began working with an inner-city African American community in Detroit during the 1960s. Together, she and community members identified needs and designed a program to meet them. Milio’s painstaking process of working with the community to create a Mom’s and Tot’s Center where mothers and children could access primary health care and child care is a sentinel example of community partnership. The true value of this partnership was demon- strated when the Detroit riots occurred in 1967, and the store- front where the clinic was located remained intact while surrounding structures burned; the local rioters had spared the clinic because it “belonged to the people” (Milio, 2000; DeGuzman & Keeling, 2012). Thus, working within the com- munity to develop priorities and to create programs promotes longstanding ownership and at the same time assures the prob- ability for sustainability.
The Nurse’s Role in the Community The nurse’s ability to establish credibility and trust in the com- munity is important in doing a thorough community assess- ment. The nurse may be considered to be an insider if he or she grew up in the community, has personal ties to the people there or comes from a similar cultural or ethnic background. This insider status may increase community members’ willingness to speak openly and partner with the nurse. However, sometimes this insider status can be a disadvantage if it compromises the nurse’s impartiality or objectivity (Ochieng, 2010). Nurses who
such as steering committees, advisory committees, and work groups. Coalitions are active partnerships, in which all partici- pants share leadership and decision making to some degree. Unfortunately, some community health efforts view commu- nity residents only as sources of information and receivers of interventions; this limits residents to passive participation. Passive participation is the antithesis of the partnership approach most valued in nurse-community partnerships, in which all partners are actively involved in and share power in assessing, planning, and implementing needed community changes (Ndirangu et al, 2008; Timmerman, 2007).
Community members who are recognized as community leaders (whether professionals, pastors, government officials or interested citizens) possess credibility and skills that health pro- fessionals often lack. The community member–professional partnership approach specifically emphasizes active participa- tion. O’Donnell (2009) wrote that partnership means the active participation and involvement of the community or its representatives in healthy change. For example, a partnership between Native American community members and academic researchers ensured the development of an effective ongoing program to address breast cancer disparities in this community (Christopher et al, 2008) (Box 18-1).
Partnership, as defined here, is an essential concept for nurses to know and use, as are the concepts of community, community as client, and community health. Experienced nurses know that partnership is important because health is not a static reality but is continuously generated through new and increasingly effective means of community member– professional collaboration. Other active professional service providers such as school teachers, public safety officers, and agricultural extension agents play a large part in the overall health of the community. Partnership in identifying strengths and problems and in setting goals is especially important because it brings commitment from all persons involved, an essential component of successful change (Biel et al, 2009).
Partnerships involving nurses working with community organizations offer one of the most effective means for inter- ventions because they actively involve the community and build
Data from Jackson EJ, Parks CP: Recruitment and training issues from selected lay health advisor programs among African Americans: a 20-year perspective [review], Health Educ Behav 24:418–431, 1997.
The three main characteristics of a successful partnership are the following: 1. Being informed. Community member and professional partners must be
aware of their own and others’ perceptions, rights, and responsibilities. 2. Flexibility and acceptance. Community member and professional partners
must recognize the unique contributions that each can make to a given situation. For example, professionals often contribute important knowledge and skills that laypersons lack. On the other hand, laypersons’ definitions of community health problems are often more accurate than those of professionals.
3. Negotiation. Because contributions vary and each situation is different, the distribution of power must be negotiated at every stage of the change process.
BOX 18-1 Partnerships
401CHAPTER 18 Community As Client: Assessment and Analysis
Why Community Assessment? Community assessments may be done for various reasons. For example, a PHN in a community may want to conduct an assessment to learn more about community needs or strengths, or may want to locate confirmation data to address a recognized community problem. Recently a new directive resulting from the Affordable Care Act requires charitable hospitals to perform a community needs assessment of their catchment area every three years and plan an implementation strategy to address any identified needs (Barnett, 2012).
In some cases administrators will perform these assessments, but PHNs are ideal choices to lead the community in this required activity. Public health personnel are the recognized experts in this arena. The recent formation of the Public Health Department Accreditation Board placed responsibility to implement standards for uniform performance with health departments in the United States. These standards include enhanced surveillance of community health services through regularly conducted community assessments (Riley, Bender, & Lownik, 2012).
Assessment is one of the three core functions of public health (CDC Core Functions, 2011). Public health nursing places assessment at the forefront of PHN competencies. The Quad Council of Public Health Nursing Organizations is a coalition that includes the Association of Community Health Nursing Educators (ACHNE), the Association of Public Health Nurses (APHN), the American Public Health Association—Public Health Nursing Section (APHA), and the American Nurses Association’s Congress on Nursing Practice and Economics (ANA). In 2011, the Quad Council revised the core competen- cies for public health nursing and adopted a three-tiered struc- ture describing the skills expected of nurses as the generalist, specialist, and executive levels of public health nursing practice (Swider et al, 2013). The Public Health Nursing Competencies include eight major domains: analytic and assessment skills, policy development/program planning skills, communication skills, cultural competency skills, community dimensions of practice skills, public health sciences skills, financial manage- ment and planning skills, and leadership and systems thinking skills. The domain of analytic and assessment skills (Table 18-1), details the competencies specific to community assess- ment across all tiers of public health nursing practice.
are new to the community or have few insider connections can increase their familiarity with the community and its residents through taking part in informal community activities, such as shopping, attending church, or participating in organizations. They can also partner with trusted insiders in the community, such as gatekeepers and community health workers.
Gatekeepers refer to formal or informal community leaders who create opportunities for nurses to meet diverse members of the community (Sixsmith, Boneham, & Goldring, 2003). Gatekeepers can confer credibility to the nurse. For example, a church pastor may act as a gatekeeper by introducing a nurse to the congregation, thus increasing the likelihood that the church members will trust the nurse enough to provide infor- mation or to serve as partners in the assessment and throughout any program planning, intervention, and evaluation.
Community health workers (CHW) are not professional or licensed health care providers but are community members from diverse backgrounds who receive training to do health outreach work. CHWs can assist nurses in doing community health assessments in several ways. They extend the reach of the nurse by being able to do many activities that are part of the community assessment process. They can also serve as gate- keepers, using their own insider status to engage community members in the assessment process.
COMMUNITY ASSESSMENT Community assessment put quite simply is taking detailed stock of a community both from the outside in and from the inside out for the purpose of identifying and analyzing condi- tions therein. Community assessment, sometimes called com- munity needs assessment, is one of three core functions of public health. This process requires clinical judgment and criti- cal appraisal of multiple types of data from a variety of sources, and it requires a clear knowledge and understanding of the community as client. People, place, and function are the foun- dational dimensions of a community and need to be defined as part of the assessment process. These dimensions guide the gathering of data. Data can be primary or secondary. Primary data are collected directly through interaction with community members, which may include community leaders or interested stakeholders. Secondary data are obtained through existing reports on the community including census, vital statistics, and numerical reports (e.g., morbidity and mortality information) or information from reference books.
There might be many reasons for conducting a community assessment but for public health nursing the purpose is usually to identify community health needs and to develop strategies to address them. The purpose of this section is to provide a clear method for completing a comprehensive community assessment, using the tools of the nursing process adapted to communities. CDC (2013) offers a clear set of common elements that constitute a community assessment (see Box 18-2). An example of Santa Cruz’s very comprehensive and ongoing community assessment (2009) can be accessed at http://www.appliedsurveyresearch .org/projects_database/quality-of-life/santa-cruz-county -community-assessment-project-cap.html.
Source: CDC Assessment and Planning Models, Frameworks and Tools 2014A, www.cdc.gov/stltpublichealth/ch/assessment.html.
1. Organize and plan 2. Engage the community 3. Develop a goal or vision 4. Conduct community health assessment(s) 5. Prioritize health issues 6. Develop community health improvement plan [in this case Nursing
Diagnosis] 7. Implement and monitor community health improvement plan 8. Evaluate process and outcomes
BOX 18-2 Common Elements of Assessment and Planning Frameworks
402 PART 4 Issues and Approaches in Population-Centered Nursing
Tier 1: Generalist Tier 2: Specialist/Mid-Level Tier 3: Executive/Senior-Level
1. Identifies the determinants of health and illness of individuals and families, using multiple sources of data.
1. Assesses the health status of populations and their related determinants of health and illness. Partners with populations, health professionals, and other stakeholders to attach meaning to collected data.
1. Conducts comprehensive, in-depth system/ organizational assessment as it relates to population health.
2. Uses epidemiologic data and the ecological perspective to identify the health risks for a population. Identifies individual and family assets and needs, values and beliefs, resources, and relevant environmental factors.
2. Develops public health nursing diagnoses for individuals, families, communities, and populations. Uses a synthesis of nursing, public health, and system science/theory when characterizing population-level health risks. Assures that assessments identify population assets and needs, values and beliefs, resources, and relevant environmental factors. Derives population diagnoses and priorities based on assessment data, including input from populations.
2. Uses organizational and other theories to guide development of system-wide approaches to reduce population-level health risks. Designs systems that identify population assets and needs, values and beliefs, resources, and relevant environmental factors.
3. Identifies variables that measure health and public health conditions.
3. Utilizes a wide variety of relevant variables to measure health conditions for a community or population.
3. Utilizes a comprehensive set of relevant variables within and across systems to measure health conditions.
4. Uses valid and reliable methods and instruments for collecting qualitative and quantitative data from multiple sources. Develops a data collection plan using appropriate technology to collect data to inform the care of individuals, families, and groups.
4. Develops a data collection plan using models and principles of epidemiology, demography, and biostatistics, as well as social, behavioral, and natural sciences to collect quantitative and qualitative data on a community or population. Uses methods and instruments for collecting valid and reliable quantitative and qualitative data.
4. Develops systems that support the collection of valid and reliable quantitative and qualitative data on individuals, families, and populations.
5. Identifies sources of public health data and information. Collects, interprets, and documents data in terms that are understandable to all who were involved in the process, including communities.
5. Uses multiple methods and sources when collecting and analyzing data for a comprehensive community/population assessment. Assures that assessments are documented and interpreted in terms that are understandable to all who were involved in the process, including communities.
5. Designs systems that assure that assessments are documented and interpreted in terms that are understandable to all who are involved in the process, including individuals, communities, and populations. Designs data collection system that uses multiple methods and sources when collecting and analyzing data to ensure a comprehensive assessment process.
6. Uses valid and reliable data sources to make comparisons for assessment.
6. Critiques the validity, reliability, and comparability of data collected for communities/populations.
6. Designs systems to assure the validity, reliability, and comparability of data. Revises systems to assure optimal validity, reliability, and comparability of data.
7. Identifies gaps and redundancies in data sources in a community assessment through work with individuals, families, and communities.
7. Identifies gaps and redundancies in data sources used in a comprehensive community/population assessment. Examines the effect of gaps in data on PH practice/program planning.
7. Identifies gaps and redundancies in sources of data used in a comprehensive organizational assessment. Strategizes with relevant others to address data gaps.
8. Applies ethical, legal, and policy guidelines and principles in the collection, maintenance, use, and dissemination of data and information.
8. Assures the application of ethical, legal, and policy principles in the collection, maintenance, use, and dissemination of data and information.
8. Ensures information disseminated is understandable to the community and stakeholders. Establishes systems that incorporate ethical, legal, and policy principles into the collection, maintenance, use, and dissemination of data and information.
9. Describes the public health nursing applications of quantitative and qualitative data.
9. Synthesizes qualitative and quantitative data during data analysis for a comprehensive community/population assessment. Uses various data collection methods and qualitative and quantitative data sources to conduct a comprehensive, community/population assessment.
9. Synthesizes qualitative and quantitative data during data analysis for a comprehensive organizational assessment. Uses multiple methods and qualitative and quantitative data sources for a comprehensive system/ organizational assessment.
TABLE 18-1 Public Health Nursing Competencies, Domain 1: Analytic and Assessment Skills
403CHAPTER 18 Community As Client: Assessment and Analysis
From Swider SM, Krothe J, Ryes D, and Cravetz M (working group for the QUAD Council): The QUAD Council practice competencies for public health nursing, Public Health Nursing 30(6):519-526, 2013.
Tier 1: Generalist Tier 2: Specialist/Mid-Level Tier 3: Executive/Senior-Level
10. Collects quantitative and qualitative data that can be used in the community health assessment process. Assesses data collected as part of the community assessment process to make inferences about individuals, families, and groups.
10. Incorporates an ecological perspective when analyzing data from a comprehensive community/ population assessment. Partners with groups, communities, populations, health professionals, and stakeholders to review and evaluate data collected.
10. Incorporates ecological perspective when analyzing data from a comprehensive, system/ organizational assessment as it relates to population health.
11. Utilizes information technology to collect, analyze, store, and retrieve data related to public health nursing care of individuals, families, and groups.
11. Utilizes information technology effectively to collect, analyze, store, and retrieve data related to care of communities and populations.
11. Collaborates with others in the design of data collection processes and applications that facilitate the collection, use, storage, and retrieval of data.
12. Practices evidence-based public health nursing to promote the health of individuals, families, and groups.
12. Practices evidence-based public health nursing to promote the health of communities and populations.
12. Practices evidence-based public health nursing to create and/or modify systems of care. Utilizes data to address scientific, political, ethical, and social public health issues.
13. Uses available data and resources related to the social determinants of health when planning care for individuals, families, and groups.
13. Collects data related to social determinants of health and community resources to plan for community-oriented and population-level programs. Analyzes those data. Incorporates the results of those analyses into program planning.
13. Evaluates organization/system capacity to analyze the health status of the community/ population effectively. Allocates organization/ system resources to support the effective analysis of the health status of the community/ population.
TABLE 18-1 Public Health Nursing Competencies, Domain 1: Analytic and Assessment Skills—cont’d
Assessing the health of the community requires a broad defi- nition of health, including consideration of the economic, social, physical, and mental health of the population. Access to resources that provide for these broad needs and services will be part of the assessment process.
The PHN should place the assessment of community strengths as high on the list as recognized problems in the development of an assessment plan. It is important to value both in the assessment, planning, implementation, and evalua- tion process.
…Healthy Communities initiatives are better served by assets-oriented methods than by standard “problem-focused” or “needs-based” approaches. An assets orientation allows community members to identify, support and mobilize exist- ing community resources to create a shared vision of change, and encourages greater creativity when community members do address problems and obstacles (Sharpe et al, 2000).
Communities have both resources and needs. We recom- mend a balanced approach to the assessment, highlighting com- munity assets as well as problems to identify the community vehicles already present for positive change. Community strengths can later be called upon in the planning and interven- tion phases of the process to address the challenges the com- munity faces. This strength-based approach may be better received by communities and funders, and promotes the inclu- sion of key informants and interested stakeholders; it can make strategic planning a part of the process.
Data Sources Health Status Indicators Measures of health status take more than one form. Numerical data put out by a recognized agency (such as the U.S. Census Bureau or Centers for Disease Control and Prevention, or Robert Woods Johnson Foundation) are referred to as secondary data (collected by someone else). Information that is gleaned from telephone surveys, personal interviews, or focus groups con- ducted by those who are assessing the community—any data derived from personal connections or key informants—are con- sidered primary data (collected by the assessor[s]). Both types of data are required for the community assessment and both types of data will be included when analyzing the assessment data.
Secondary Sources of Data Even before setting foot in the community it is possible to learn a great deal about its residents’ health status. Health indicators are numerical measures of health outcomes, such as morbidity and mortality, as well as determinants of health and population characteristics. Generally, these data are from secondary sources such as websites or printed materials. Table 18-2 lists several of these sources.
Creation of a set of health indicator data during a commu- nity health assessment serves several purposes. First, it creates a “snapshot” of health conditions that can guide the assessment team during the analysis and problem prioritization phases. Second, it is an important and easily comprehensible means of communicating the results of the assessment to the larger
404 PART 4 Issues and Approaches in Population-Centered Nursing
Behavioral Risk Factors Surveillance Survey (BRFSS)
http://www.cdc.gov/brfss/ Wide variety of data on individuals’ health status, health behaviors, and preventive health services
CDC Wonder http://wonder.cdc.gov/ Public health data on births, mortality, infectious diseases, cancer, and environment
County Health Rankings http://www.countyhealthrankings.org/ Collates county-level data on a wide range of health outcomes and health determinants
Dartmouth Atlas of Health Care http://www.dartmouthatlas.org/data/region/ Distribution and outcomes of health care services, in chart and map formats
Health Indicators Warehouse http://www.healthindicators.gov/ U.S. government website that gathers data from multiple sources and provides a search engine by topic, geography, and program
Local advocacy organizations Organizations that specialize in social issues such as homelessness, child abuse, or domestic violence
Robert Woods Johnson Foundation (RWJF) Data Hub
www.rwjf.org/en/research-publications/ research-features/rwjf-datahub.html#
Provides access to data about health statistics by demographic breakdown. Statistics can be compared state to state.
State Cancer Profile http://statecancerprofiles.cancer.gov/ incidencerates/index.php
Incidence of cancer types by race/ethnicity, sex, and geography
U.S. Census http://www.census.gov Demographic and economic data
TABLE 18-2 Frequently Used Secondary Sources for Health Indicator Data
SECONDARY SOURCE DATA Questions to ask about data from secondary sources: 1. How current is the reported information? 2. When was the site last updated? 3. How credible is the data source? 4. Is an author identified? 5. Are demographic data reported about the people? 6. Are data reported about different community systems? 7. Is there any obvious bias in the reporting of data? 8. Are community voices represented?
Shuster, G: Community as client” assessment and analysis. In Stanhope and Lancaster (editors), Public Health Nursing, Population-centered health care in the community, ed 8, 2012 Elsevier, St. Louis, Mo.
community. Third, it is an effective way to compare the current health status in the community with the same community at different time points, with other communities, or with larger populations such as state or national data. Table 18-3 lists health indicators that are frequently included in community health assessments.
There are two important considerations for selecting which indicators to include in an assessment: the priorities of the com- munity, and comparability to other data. Ideally, diverse com- munity stakeholders should participate in identifying health indicators that address their interests or concerns. Stakeholders include anyone with a personal or occupational interest or concern in a community’s life. If the health indicators will be compared with other assessments, then use similar measures when possible. For example, the total number of deaths in a community is different from the annual rate of deaths per 100,000 population. The box below gives additional tips on obtaining high-quality data.
Healthy People 2020 and County Health Rankings are useful resources for health indicators. Healthy People 2020 identifies national health priorities, providing baseline data as well as
health indicator goals. For example, the baseline rate of injury- related mortality was 59.7 deaths per 100,000 population and the Healthy People 2014 goal rate is 53.7 deaths per 100,000 population (www.healthypeople.gov). The County Health Rankings report is updated annually, and provides county-level data for a wide variety of health indicators and also compares county rankings within and across states (www.countyhealth rankings.org).
Primary Sources of Data Primary data involve the researcher or community members at the community level. Various methods can be used to collect the data, such as participant observation, key informant interviews, surveys, town hall meetings, focus groups, Photovoice, spatial data, or windshield surveys. The researcher or the community members experience the events or interact directly with the com- munity as a group, with individuals, or by observation.
Participant observation refers to the deliberate sharing in the life of a community, for example, participating in a local fair or festival or attending a political or social event. Just as you would assess a hospital patient’s room upon entering and note details about the environment (family members, emotional tone, patient’s level of consciousness, IV access or vital signs, cleanliness, organization), visiting or attending an event can be a window through which to view the community. In addition, participant observation can be a fun way to experience com- munity events.
Key informants can be identified through formal or infor- mal channels in the community. They might be leaders in a sector of the community such as a church congregation, civic club, governmental body or neighborhood. They need not hold any formal title, but are generally viewed as community leaders by other community members and often have a long history in the community. Meeting with key informants and identifying local issues, strengths, and concerns from their viewpoint con- stitutes an important component of the overall assessment. See How To box for more information.
405CHAPTER 18 Community As Client: Assessment and Analysis
Adapted from CDC. (2013). Community health assessment for population health improvement: resource of most frequently recommended health outcomes and determinants. Retrieved May 3, 2014 from http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/CrossCuttingI/ FinalCHAforPHI508.pdf
HEALTH OUTCOME METRICS HEALTH DETERMINANT AND CORRELATE METRICS
Mortality Morbidity Health Care (Access & Quality)
Health Behaviors
Demographics & Social Environment
Physical Environment
SUGGESTED DATA SOURCES
• CDC Wonder • Health
Indicators Warehouse
• BRFSS • County Health Rankings • State Cancer Profiles • BRFSS • CDC Wonder
• County Health Rankings
• Health Indicators Warehouse
• U.S. Census • Dartmouth Atlas • RWJF DataHub
• BRFSS • County Health
Rankings • Health
Indicators Warehouse
• RWJF DataHub
• U.S. Census • County Health Rankings • Local advocacy
organization • Health Indicators
Warehouse • RWJF DataHub
• County Health Rankings
• U.S. Census • CDC Wonder
Mortality: Leading Causes of Death
Obesity Health Insurance Coverage
Tobacco Use/ Smoking
Age Air Quality
Infant Mortality Low Birth Weight Provider Rates (PCPs, Dentists)
Physical Activity Sex Water Quality
Injury-related Mortality
Hospital Utilization Asthma-Related Hospitalization
Nutrition Race/Ethnicity Housing
Motor Vehicle Mortality
Cancer Rates Unsafe Sex Income
Suicide Motor Vehicle Injury Alcohol Use Poverty Level Homicide Overall Health Status Seatbelt Use Educational Attainment
STDs (chlamydia, gonorrhea, syphilis)
Immunizations and Screenings
Employment Status Foreign-Born
AIDS Homelessness Tuberculosis Language Spoken at Home
Marital Status Domestic Violence and Child
Abuse Violence and Crime Social Capital/Social Support
TABLE 18-3 Health Status Indicators: Frequently Recommended Health Metrics
Shuster, G: Community as client” assessment and analysis. In Stanhope and Lancaster (editors), Public Health Nursing, Population- centered health care in the community, ed 8, 2012 Elsevier, St. Louis, Mo.
HOW TO Identify a Key Informant • Talking to key informants is a critical part of the community
assessment. • Key informants are not always people who have a formal title or
position. • Key informants often have an informal role within the
community. • County health department nurses and church leaders are often
key informants. They also know many community members and can identify other key informants.
Town hall meetings are opportunities for local constituents to come together, usually to discuss a particular issue or proposal that influences all members of the community. Many town hall meetings have been held recently, for example,
to address the issue of health care reform. The following photo represents one town hall meeting held for that purpose in Hart- ford, Connecticut, in 2009. Political rallies and delegate forums are often held in this format.
406 PART 4 Issues and Approaches in Population-Centered Nursing
The basic process to incorporate Photovoice into a commu- nity assessment is as follows: 1. Train participants: Participants receive training in Photo-
voice methods, including the topic of interest, basic photog- raphy techniques, and ethical and safety issues. Participants may need to learn how to obtain written consent before photographing people, businesses, or other identifiable sub- jects. Training is especially important when the topic of interest is sensitive or illegal, such as substance abuse.
2. Take photos: Participants take the cameras into their com- munities and take photographs that reflect the topic. Equip- ment should be modified to fit the participants. For example, adolescents may be very comfortable with a variety of mobile devices, whereas older adults may prefer simpler cameras with modifications for low vision or manual dexterity (Novek et al, 2012).
3. Display photos: The photos are collected from the partici- pants, and then printed or digitally projected for group participants, and sometimes members of the public, to view them.
4. Discuss photos: Viewing the photos is meant to spark dis- cussions that provide additional information about the topic of interest. These discussions may take place as focus groups with the Photovoice participants. If the photos are displayed in public, the aim may be to raise awareness and to start conversations among diverse stakeholders.
5. Analyze and report results: The information gathered through these discussions, as well as the photos themselves, can be included in the data analysis phase. The photos can also be part of the report to the community about the findings of the community assessment (Catalani & Minkler, 2010). Photovoice can be useful at different stages of a community
assessment, but may be especially useful in the early stages of data collection. The “insider” knowledge gained through this type of activity can guide subsequent community assessment activities. For example, if the Photovoice topic is “barriers to healthy lifestyles” and the majority of photos focus on places that make pedestrian or bike travel difficult, then the later stages of the assessment should give additional attention to walkability and transportation.
Spatial Data Everything is related to everything else, but near things are more related than distant things.
Tobler’s First Law of Geography (Sui, 2004)
Most of the information gathered in a community assessment has a spatial component: it is located somewhere in the com- munity. The location of places like health care services, food stores, schools, bus routes, factories, highways, bodies of water, and parks can affect residents’ access to health benefits or expo- sure to health threats. Demographic data can also be spatial. We can look at a neighborhood or other area and learn about its residents, such as age, racial or ethnic background, health char- acteristics, income, home value, and crime rates. Having this information can be very helpful for assessing health resources
A focus group is similar to an interview, in that it collects data mainly through asking open-ended questions to partici- pants but to a small group rather than an individual. Focus groups are useful for situations where the interaction between participants is likely to prompt discussions or generate ideas that individual interviews might not. Focus groups work well when the topic is not a sensitive one and participants feel com- fortable speaking out about the issue with the group. For example, an assessment of the role of a parks and recreation department used focus groups to prompt discussions about individual experiences as well as perceptions about the larger community (Henderson et al, 2001).
Focus groups should be structured to balance a diversity of perspectives with opportunities for in-depth understanding of the chosen topics. The design of the question guide should address the goals for the data: for example, do you want to generate a free-flowing discussion of ideas or obtain specific information from each participant? Participants should be recruited through community channels such as churches, asso- ciations, and other places where people gather. An ideal number of participants is between six and eight, though smaller or larger groups can work in different circumstances (Rabiee, 2004).
Each focus group should be organized so that its participants are fairly homogenous in key characteristics. For example, in an assessment to compare different neighborhoods, each focus group might contain residents from one neighborhood. In an assessment of community barriers and resources for physical activity, focus groups might be divided among participants who identify themselves as exercisers, and non-exercisers (Lees et al, 2005). A typical format for a focus group is that one moderator leads the discussion, while an assistant takes written notes, and the session is often audio recorded. The recording is then tran- scribed and included in the analysis.
Photovoice Photovoice, also called photo elicitation, is a community assess- ment technique in which community members take photos to represent a topic or theme about community health. For example, a study on childhood obesity asked rural youth to take photos on the theme of assets and barriers to healthy diets and physical activity (Findholt, Michael, & Davis, 2010). Photovoice has been used with many types of community participants, but can be especially useful in working with groups that may be marginalized or have little power such as youths, the elderly, individuals living in poverty, or those involved in substance abuse. Photovoice is a way for participants to communicate powerful messages about their experiences, without the need for words.
Photography is a relatively easy group activity because devices to take photos are relatively common and inexpensive. Disposable cameras and the participants’ cell phones are exam- ples of devices with minimal added cost. Video, sound record- ing, and other forms of media can also be used in ways similar to Photovoice. For example, a group of New Orleans residents used Videovoice to create their own documentary to advocate for housing, education, and economic development after Hurricane Katrina (Catalani et al, 2013).
407CHAPTER 18 Community As Client: Assessment and Analysis
Contradictions within the data collected are common. If there are disconnects or the two types of data do not match, this is important information to consider for your assessment and program planning. Reports from different members of a community may not agree. Information from primary data should be compared to secondary data which can provide context about a community’s assets and needs. What is impor- tant is that the voice of the informant or group is heard and that the assessor in the community takes all information into account at the time of data analysis. In addition, the priorities of the community members must be included in any planning or implementation of interventions.
Community Health Assessment Models There are many existing models of community health assess- ment, making it possible to conduct an assessment without the need to design the process from scratch. Table 18-4 provides examples of commonly used models that assess for a broad array of community health concerns. The WHO’s Healthy Cities initiative offers another approach to population-centered health assessment. An example of the assessment data that support this approach is found at http://www.healthycity.org. For additional information on Healthy Cities see Chapter 20.
Other assessment models focus on specific topics. For example, the CDC (2014b) developed the Community Assessment for Public Health Emergency Response (CASPER) toolkit for rapid needs assessment of communities affected by disasters or other emergencies (retrieved from http://www.cdc.gov/nceh/hsb/ disaster/casper.htm). The Community Food Security Assessment Toolkit profiles food availability and accessibility by collecting data from focus groups, food stores, and secondary data sources (Cohen, Andrews, & Kantor, 2002). Another example is the Neighborhood Environment Walkability Survey (NEWS), a toolkit to assess the physical and social aspects of a community related to walking and bicycling (Saelens & Sallis, 2002).
The selection of an assessment model and whether to use an existing model or design your own can be guided by several criteria (Ervin, 2002). What are your goals for the assessment? What are the resources available for the assessment project, such as time, people, budget, and access to the community? Is there an existing model that aligns with your goals, and is feasible in terms of your available resources?
COMMUNITY AS PARTNER The community-as-partner model is based on nursing pro- cesses and theories, and emphasizes the dynamic nature of com- munity systems as integral to the health of residents (Anderson & McFarlane, 2011). A key feature of this model is its division of the community structure into subsystems that can serve as an organizational structure for community health assessments. The subsystems of the community structure consist of physical environment, health and social services, economy, transporta- tion and safety, politics and government, communication, edu- cation, and recreation. Each of these subsystems represents distinct functions and organizations within the community that can be assessed separately. However, they also interact to create
and risks for specific neighborhoods. By assessing the spatial distribution of health resources and disparities, we can place programs in neighborhoods where the impact will be greatest.
Maps have several uses in community assessments. Maps are a place to compile spatial data from primary or secondary sources. During the problem analysis and prioritization phases, these maps can support decision making about community health priorities. Later, maps can be used to plan programs and interventions. Like the idea that “a picture is worth a thousand words,” a map can also be an effective means of communicating the findings of a community health assessment to a wide range of stakeholders, and encouraging their participation in discus- sions about the findings.
Map-making is very flexible, depending on the resources that are available. A map can be as simple as a hand-drawn sketch of features in a community or neighborhood. Drawings or graphics can be added to commercially produced paper or online maps. Geographic information systems (GIS) is a set of software and technology that can create maps electronically. The amount of training to use GIS software varies. Some free websites allow users to build GIS maps without any prior train- ing. For example, www.communitycommons.org has demo- graphic, health, and economic data that can be used to build a map of a specific place. More powerful software, such as ESRI ArcGIS, can analyze spatial data and display it using a variety of visual options. This type of software is sometimes expensive and time-consuming to learn, but is very useful for those who want to use maps regularly in their work.
During a community assessment spatial data can be col- lected in several ways. One low-tech approach is to note the address or nearest street intersection of a place and later draw it onto a map. A higher-tech approach can involve a smart phone or other mobile device that has global positioning system (GPS) capabilities. While walking around a community, these devices can be used to note locations by recording the latitude and longitude coordinates. Some smart phones and other devices can take photographs that store the GPS location. These photos can later be incorporated into GIS maps as images or hotlinks.
GIS can pull together multiple types of assessment data that, when viewed on a map, can identify areas of a community with a particular set of characteristics. For example, nurses used GIS to look for patterns between traffic pollution and childhood asthma (Newcomb & Li, 2008). They found that children living near a major roadway were much more likely to experience hospital admissions for asthma.
Using Primary Data Informant interviews, focus groups, and participant observa- tion are good ways to generate information about a commu- nity’s unique beliefs, norms, values, power and influence structures, and problem-solving processes. These primary data can be time-consuming and challenging to collate and interpret. However, it is worthwhile to make the effort to sys- tematically collect primary data in the community and to avoid drawing conclusions from limited observations or unconfirmed intuitions.
408 PART 4 Issues and Approaches in Population-Centered Nursing
Assessment Model Example
Health Impact Assessment (HIA) is a process to predict the effects on health from projects or policies such as land use, community design, transportation, or industrial facilities. The outcome of an HIA is to provide recommendations to minimize negative health impacts, and monitor results. Learn more at http://www.naccho.org/topics/environmental/health-impact- assessment/
An interdisciplinary group of public health experts, health care professionals, and community planners used an HIA to estimate the impact of a proposed multibillion-dollar project in Atlanta, GA, to redevelop a 22-mile loop into transit, parks, and improved neighborhoods. One HIA recommendation was to develop parks and green spaces first, in order to maximize health benefits (Ross et al, 2012).
Mobilizing for Action through Planning and Partnerships (MAPP) is a strategic planning process to select high-priority public health issues and to match them with resources. Public health agencies lead the MAPP, but participation of community members and agencies is a major focus. Learn more at http://www.naccho.org/topics/infrastructure/mapp/
A public health department in Virginia assessed the 5 counties and independent city in its district to identify top health issues needing action. Through partnerships with 61 agencies and gathering data from more than 2,000 residents, the MAPP process selected top priorities as obesity, mental health and substance abuse, pregnancy outcomes, and tobacco use (Thomas Jefferson Health District, 2012).
Community Health Assessment and Group Evaluation (CHANGE) is a tool to help communities annually gather and organize data about community health, plan programs, and monitor changes over time. Five community sectors are assessed: community at large, community institution/organization, health care, school, and work site. Learn more at www.cdc.gov/Healthy CommunitiesProgram (CDC 2010)
Researchers in a rural Missouri county used the CHANGE tool to assess why rates of chronic disease were high. Through interviews with representatives from each of the 5 sectors, they identified challenges, assets, and potential partnerships for addressing chronic disease (Stewart, Visker, & Cox, 2013).
Community Health Needs Assessment (CHNA) is a set of guidelines for nonprofit hospitals to assess the communities they serve, and is a requirement under the Patient Protection and Affordable Care Act (ACA). Community input and other sources provide data on priority health problems, barriers to health care access, and vulnerable populations. Learn more at http:// www.cdc.gov/policy/chna/ (Rosenbaum 2013)
Nursing students partnered with a hospital in rural Minnesota to complete the CHNA. They gathered data through surveys and interviews with residents and organizational leaders. They identified 3 priority health problems, and differentiated assets and barriers to addressing these problems in different community institutions serving vulnerable populations (Madelia Community Hospital & Clinic, 2013).
TABLE 18-4 Interprofessional Community Health Assessment Models
the complex community environment in which people live and function. Each subsystem may protect the health of community members by addressing a particular need. Understanding the relative success of each of these subsystems in promoting health and safety can provide important insights about the commu- nity’s ability to respond to health problems
HOW TO CONDUCT A COMMUNITY ASSESSMENT Getting Started In the previous section several models of community assess- ment are outlined. This section will offer a step-by-step method to complete a community assessment. In beginning the assess- ment the nurse should identify one model that will guide the assessment. We incorporate the steps for the assessment in Figure 18-2, but this process can be adapted to any model used.
The community assessor(s) should plan to visit and interact in the community and collect data about people, place, and func- tion over a month or more to get a feel for the community and create as full a picture as possible. A “feet on the ground” approach will yield rich data and visiting the community and interacting with its members is essential to the process. Very comprehensive assessments will require community coalitions and inclusion of key stakeholders, such as those included in MAPP assessments; expanding the participant group may extend this stage over many months or years (NACCHO, 2014:
www.naccho.org). See Box 18-3 for information on personal safety while assessing communities.
Windshield Survey Windshield surveys are a method of simple observation. They provide a quick overview of a community and can be used along with photographs and interviews to get a general overall sense of the community (Table 18-5). This can be the first step in the process of generating data that help to identify the community, trends, stability, and changes that all serve to define the health of the community (Stanhope & Knollmueller, 2000). The nurse riding in a vehicle can observe many dimensions of a commu- nity’s life and environment through the windshield, but walking the streets can also provide similar information. Under those circumstances, one can readily observe common characteristics of people in the community, neighborhood gathering places, the rhythm of community life, housing quality, and geographic boundaries (see How To box and Table 18-5). A windshield survey can be used by itself for a short and simple assessment. However, it is used here as one part of the longer, more complex comprehensive community assessment.
Community “Place” and “People” Identified Using Figure 18-2, the first step of the community assessment is to define the community. To do this, geographic boundaries, the population within the boundaries, the purpose of the assess- ment, and a data collection plan will be identified. Census
409CHAPTER 18 Community As Client: Assessment and Analysis
FIG 18-2 Community assessment model.
Community Assessment
Model
Begin Here
Organize Data
Community Nursing
Diagnosis Program
Implementation
Data Gathering — People Health Statistics and Health Status Indicators • Identify morbidity and mortality statistics and health indicators for the community
Data Gathering — Function Systems in Place 1. Safety and transportation 2. Government and politics 3. Economics (employment, industry) 4. Education 5. Recreation 6. Health and social services 7. Communication 8. Physical environment (A&M 2011)
Data Analysis • Strengths • Areas for improvement - problems
Planning Programs • Prioritize problems and place in context of community strengths and priorities • Establish goals and objectives for work with the community • Establish criteria for evaluation • Consider intervention activites
Evaluation Evaluate Program Interventions using established measures • Is intervention successful? • Community partnership objectives met? • Community moved towards health? • Community partners satisfied? • Community strengths developed?
If any answers are NO or new issues
arise, return to Data Gathering and reassess with updated data
Define the Community • Place (geographic) • People (demographic) • Function (common/special interests)
Create Problem List Set priorities based on primary and secondary community data
Data Gathering — People • Demographics and vital statistics; population density, age, ethnicity, gender distribution, income, values and beliefs
Shuster, G: “Community as client” assessment and analysis. In Stanhope and Lancaster (editors), Public Health Nursing, Population-centered health care in the community, ed 8, 2012 Elsevier, St. Louis, Mo.
Effective nursing practice starts with personal safety, and this remains important throughout the process. An awareness of the community and common sense are the two best guidelines for judgment. For example, common sense suggests not leaving anything valuable on a car seat and not leaving your car unlocked. Similar guidelines apply to the use of public transportation. Calling ahead to clients to schedule meetings will help prevent delays or confusion, and it gives the nurse an opportunity to lay the groundwork for the meeting. If there is no telephone and no access to a neighbor’s telephone, plan to establish a time for any future meetings during the initial visit. Regardless of whether there has been telephone contact, there are rare situations when a meeting is postponed because the nurse arrives at a location where people are unexpectedly loitering by the entrance and the nurse has concerns about personal safety.
For nurses who either are just beginning their careers in the community or are just starting a new position, three clear sources of information will help answer many questions about personal safety:
1. Other nurses, social workers, or health care providers who are familiar with the dynamics of a given community: They can provide valuable insights into when to visit, how to get there, and what to expect, because they function in the community themselves.
2. Community members: The best sources of information about the community are the community members themselves, and one benefit of developing an active partnership with community members is their willingness to share their insight about day-to-day community life.
3. The nurse’s own observations: Knowledge gained during the data collection phase of the process should provide a solid basis for an awareness of day- to-day community activity. Nurses with experience practicing in the com- munity generally agree that if they feel uncomfortable in a situation, they should trust their instincts and leave.
BOX 18-3 Personal Safety in Community Practice
410 PART 4 Issues and Approaches in Population-Centered Nursing
HOW TO Obtain a Quick Assessment of a Community • One way to get a quick, initial sense of the community is to do
a windshield assessment using a format like the example pro- vided in Table 18-5.
• Nurses interested in conducting a windshield assessment need to take public transportation, have someone else drive while they take notes, or plan to stop frequently to write down what they see.
• The windshield survey example is organized into 15 elements with specific questions related to each element.
• Nurses who use this approach will have an initial descriptive assessment of the community when they are finished.
• If interventions are planned, the more thorough and more comprehensive process described in this chapter will be necessary.
Shuster, G: Community as client” assessment and analysis. In Stanhope and Lancaster (editors), Public Health Nursing, Population- centered health care in the community, ed 8, 2012 Elsevier, St. Louis, Mo.
Adapted and revised by J. Lancaster from: Mizrahi TM: School of Social Work, Virginia Commonwealth University, Richmond VA, September 2008; Stanhope MS, Knollmueller RN: Public and Community Health Nurse’s Consultant: A Health Promotion Guide, St. Louis, 1997, Mosby.
Each community has its own characteristics. These characteristics along with demographic data provide valuable information in understanding the population that lives within the community and the health status, strengths/limitations, risks and vulnerabilities unique to the “population of interest.” Once you have defined a “community of interest” to assess, a windshield survey is the equivalent of a community head-to-toe assessment. The best way to conduct a windshield survey is with more than one person, allowing for one to observe and take notes. Having one pair of eyes on the road, you can benefit from having other individuals notice the unique characteristics of the community; a shared experience provides additional insight. As you analyze your findings, it may be necessary to make a second tour to fill in any blanks. Many of us take these characteristics for granted in our own community, but they provide a rich context for understanding communities and populations and often have significant impact on the health status of the community in general.
Elements Description
Boundaries What defines the boundary? Roads, water, railroads? Does the area have a name? A nickname? Housing and zoning What is the age of the houses? What kind of materials are used in the construction? Describe the housing including space
between them, general appearance and condition, and presence of central heating, air conditioning, and modern plumbing. Open space Describe the amount, condition, use of open space. How is the space used? Is it safe? Attractive? Commons Where do people in the neighborhood hang out? Who hangs out there and at what hours during the day? Transportation How do people get from one place to another? If they use public transportation, what kind and how effective is it: How
timely? Personal autos? Bikes, etc? Are there pedestrians? Does the area appear to be safe? Social service centers Do you see evidence of recreation centers, parks, social services, offices of doctors, dentists, pharmacies? Stores Where do residents shop? How do they get to the shops? Do they have groceries or sources of fresh produce? Is this a
“food desert”? Street people and animals Who do you see on the streets during the day? Besides the people, do you see animals? Are they loose or contained? Condition of the area Is the area well kept or is there evidence of trash, abandoned cars or houses? What kind of information is provided on the
signs in the area? Race and ethnicity What is the race of the people you see? What do you see about indices of ethnicity? Places of worship, food stores,
restaurants? Are signs in English or other languages? (If the latter, which ones)? Religion What indications do you see about the types of religion residents practice? Health indicators Do you see evidence of clinics, hospitals, mental illness, and/or substance abuse? Politics What indicators do you see about politics? Posters, headquarters? Media Do you see indicators of what people read? If they watch television? Listen to the radio? Business & industry What type of business climate exists? Manufacturers? Light or heavy industry? Large employers? Small business owners?
Retail? Hospitality industry? Military installation? Do people have to seek employment elsewhere?
TABLE 18-5 Windshield Survey Guidelines
blocks or tracts and geopolitical boundaries such as city or county lines will allow for collection of consistent data about the region under study. Included in “place” is the type of terrain or environment, the climate, the history of the area, and its size. The population is the next identifier. How does your assessment define those within the community? Are they members of a specific group or the population in general? What data are avail- able for the assessment and where will you seek your sources? In essence, the identification of the community’s members comprise the “client” within these boundaries.
What is the local history? Who were the original settlers and how has the community developed over time? Is it an area of growth or decline? Are original families still living in the area or has the early population been replaced? History can reveal a lot about customs and mores that could influence the health of the community.
• Boundaries • Environment • Size
• Climate • History • Population
PLACE
411CHAPTER 18 Community As Client: Assessment and Analysis
People Those inhabiting the community are a primary focus of the assessment. Various strategies can be used to identify this central core of the community. The first step often involves the use of secondary data. Using census data clarifies the population density and the demographics of the population under study. Suggested websites for the collection of these data are provided in Table 18-2. Some demographic measures include the popula- tion composition—racial and ethnic groups present, ages, socioeconomic status and poverty rates as related to geographi- cal area; educational attainment; and the distribution of the population over census areas. Next, review this information in the context of previous census data (e.g., look back 20 years) to demonstrate how age groups are shifting. For example, if par- ticular age groups are increasing in numbers, that can help to predict needs; if the area is shrinking or growing in population, that will predict different needs.
For quick information estimates on a specific area, consult American FactFinder (http://factfinder2.census.gov). Perhaps one racial or ethnic group inhabits a particular area of the com- munity. Census data will help identify this information. That may be important later in the PHN’s assessment process for under- standing morbidity and mortality data. Many states have websites that can help to predict population projections for localities. In Virginia, for example, one can visit www.virginialmi.com to see projections and historical census data for each county or inde- pendent city, helping to visualize trends.
As a next step, the PHN will identify formal and informal structures within the community. What formal and informal groups exist in the community? What structures are present that unite or separate people in the society? This will require interviews and delving into the community. For example, local government, schools, churches, and health care organizations may represent formal structures. Clubs (e.g., Rotary Club, garden clubs, country club, YWCA or libraries) may reflect informal groups that could form in neighborhoods, where an informal leader could be the advisor to that group on matters of all kinds, including housing, health or legal matters. These informal leaders can be identified through interaction with the community members and by visiting community agencies. There are likely crossovers between formal and informal groups. Pay attention to advocacy groups and those that have goals of improving the community or some subset of the community in some way. This can help to identify community assets.
Carefully examine the formal and informal structures that exist and consider if they unite the population of the community or support only a specific portion of the population. Who are the leaders? For example, a private school might support only a more prosperous portion of the community or the school might reach out into the community to offer scholarships for those in differ- ent socioeconomic strata. Public schools might have broad support and funding or garner limited resources from local coffers. Some of this information may be evident but some may require deeper investigation and interviews with key informants. Leaders of formal groups may be key informants, but leaders of informal groups should be considered key informants as well.
The assessment would not be complete without an inventory of the community belief systems in place, including identifying places of worship. This could be accomplished through both primary and secondary data, by speaking to community members or by looking in the phone book. Traditions and values of the community may be classified according to portions of the community if it is heterogeneous, or in general if it is more homogenous. How the religious climate in the town might influ- ence other goods or services should be investigated. For example, a community may have a religiously conservative population that could influence the availability or access to abortion coun- seling or certain birth control services for residents.
• Size and density of population • Demographic structure of population (e.g., race, ethnic groups, gender, and
age) currently and in historical context • Educational attainment • Informal groups • Formal groups • Linking structures
• Schools • Neighborhood associations • Civic clubs
• Values and beliefs • Churches • Synagogues • Mosques • Political affiliations
PEOPLE
Community Systems in Place Using a systems approach, the PHN can explore the organizing structures in place within the community that may serve the needs of the people. Community systems contributing to com- munity function or dysfunction include safety and transporta- tion; politics and government; economics (including industry, employment, and commerce); education; recreation; health and social services; communication; and physical environment (Anderson & MacFarlane, 2011). Each of these functional systems influences the health of the community and requires full assessment.
Source: Anderson and MacFarlane (2011), Community as partner, Philadelphia, Lippincott Williams & Wilkins.
• Safety and transportation • Politics and government • Economics (employment, industry) • Education • Recreation • Health and social services • Communication • Physical environment
COMMUNITY SYSTEMS IN PLACE
412 PART 4 Issues and Approaches in Population-Centered Nursing
all important. Identify the average income and wages for types of jobs available and identify the industries that operate within the community and what percentages of skilled and unskilled jobs exist.
In an optimal community, the jobs that are available and the educational level needed for those jobs should mesh. Frequently, community colleges identify community employment needs and promote educational programs to meet the needs of the local job market. Virginia’s Labor Market Information (www.virginialmi.com) website, for example, provides detailed data on unemployment and economic indicators for each county. Data availability will relate directly to where your assess- ment is taking place.
The state of the job markets in the community could influ- ence the availability of health insurance associated with employ- ment, and the need for assistance in registering for health insurance through Affordable Care Act–created exchanges. If there are migrant workers in the community you are assessing, the issue of immigration is likely to be present. If so, what local programs or services are available for these legal or illegal immi- grant workers within the community?
Education. When considering the educational systems in the community, the PHN should first identify all the schools in the area, including preschools, school readiness programs, primary and secondary schools and, if possible, visit some or all of them to observe the condition of the buildings and the children at recess or at the end of the day. What resources for nutrition, physical activity, and health care do the schools have? What percentage of the children receive free or reduced cost meals? Are there Head Start or sponsored preschool programs available for lower income families? Are there measures in place to identify school readiness? If different ethnic groups are part of the community, what is the language literacy? Coordinating this information with government spending on education in the locality will help to clarify the value that the community places on education.
The educational attainment of the population is relevant to the type of educational programs that are present in the com- munity. Examining the high school dropout rates, standardized testing results, and the pupil/teacher ratios within the locality will help to evaluate the quality of the schools within the dis- trict. General educational development (G.E.D.) classes for stu- dents who need a high school diploma and adult literacy programs in place would indicate that the community places a high value on the education of its citizens. Higher education institutions, such as community colleges, four-year colleges, professional and technical schools, and universities will also influence the overall educational level of the community, which ultimately influences the economic prosperity of the citizens.
Recreation. Safe indoor or outdoor recreation areas for children and adults can provide the community access to healthy exercise. State, city or county parks, their condition and use, along with organized sports teams, bike paths or public gymnasiums would be indicators of public promotion of physi- cal activities, and the importance of those to the community. If the community has hiking trails, are they well maintained? Are swimming pools open to the public? If there are lakes or rivers
Safety and Transportation. Safety requires a broad assess- ment. Road maintenance and presence of interstate highways or curvy mountain roads will influence the safety of the com- munity. The PHN should identify statistics on highway safety and find information about motor vehicle fatalities and moving violations, seatbelt use, and child safety seat use in the area. For example, in Virginia one can go to the state Division of Motor Vehicles site and locate the sites of most frequent motor vehicle accidents according to cause and location (http://www .dmv.state.va.us/safety/#crash_data/). Likewise, many county websites have information about motor vehicle accidents or fatalities in their jurisdictions. Safety also includes crime rates, issues such as sidewalks or guard rails along roadsides, crosswalks in intersections, safe playgrounds, and bike paths. Police, fire protection, and emergency services also fall under the umbrella of safety, as do laws requiring helmets for motorcyclists.
Following the crime statistics for the area or individual neighborhoods in your community can provide good evidence of the effectiveness of the police force and an overall measure of citizen safety. In addition, qualitative information gained from speaking to locals and service providers can add valuable perspectives about their experience with community safety.
Community residents frequently depend on public trans- portation to access community services. When doing a com- munity assessment, the PHN should survey the availability of affordable community transportation for all income levels. To do this, one should look at whether transportation options such as buses, commuter trains or cabs are present to allow access to central places in the community. What percent of the population have cars? It is also helpful to know if there are railroads and airlines available to connect to more regional or national sites. This can provide insight on poten- tial community permeability to outside influences or commu- nity isolation.
Politics and Government. The PHN will need to identify the type of government structures in place in the geographic area. Many communities have websites that will help clarify this com- munity governance. Is there a mayor or board of supervisors? Who are the identified formal leaders in the government? A visit to the community’s office building will provide a perspective on the accessibility of the governing body. Political affiliation in the community may be relevant to certain priorities, so identifying the mix of party allegiance in past presidential, state, or local elections is a useful measure to obtain.
Government buy-in to community needs is essential for health progress to occur. For example, what dollar amount does the community spend on child health or elderly care? Take a look at the most recent budget of the community. How does that compare with other regions of the state or United States? For example, are government-supported programs in place to enhance early childhood education? There may be overlaps with economic systems of the area as well, which affect taxation and community wealth.
Economics. Regional economic prosperity frequently influ- ences all citizens in the population. The existing jobs, the unem- ployment rates, and the types of industry in the community are
413CHAPTER 18 Community As Client: Assessment and Analysis
Physical Environment. The climate and overall geographic description of the community contributes to health and well- being. Tendencies toward flooding, drought or hurricanes, and mountainous, ocean or riverside locations will carry concurrent health consequences. The availability of good water and air supplies and locally produced food are positive indicators for health, and should be explored within your community. Indus- tries with poorly managed runoff of chemicals, unsafe dams or chemical waste would provide negative health indicators. Envi- ronmental pollution of any kind requires further assessment. The Environmental Protection Agency (EPA) lists information about Superfund sites throughout the country on its web- site (http://www.epa.gov/superfund/sites/index.htm). Score- card (http://scorecard.goodguide.com/) compares localities in terms of pollutants.
The built environment, including housing and neighbor- hoods, provides a potential health indicator. What is the condi- tion and age of local housing? Does the area seem prosperous? While new and energy efficient housing, including housing for low income families, can imply a positive indicator of health, older, less efficient homes appearing run down may be an indi- cator of less positive neighborhood conditions. For example, houses built before 1978 can contain lead paint, which repre- sents a significant health risk for young children (Figure 18-3).
An additional important element related to housing is the average cost of owning or renting a home in the area. This information can identify housing availability and affordability for community members.
Communication. Communication in the United States has become intricately tied to Internet availability. Identifying the methods of communication within the community you are assessing will help to articulate the information available to the public and how they receive it. At which sites within the com- munity is Internet available? Local libraries often provide free Internet access. Are there Internet providers for the commu- nity? Rural areas can sometimes have limited Internet access, thereby restricting communication with those inside or outside their locality through e-mail or Internet-based social media.
The cell phone has become a primary source of communica- tion. Once again, looking at the availability of cell phone coverage in the community may help reveal access to those outside and within the community. While landlines are almost
nearby, do they provide guarded beaches or lifeguards? Part of the assessment of recreation addresses for whom it is available.
Identifying how the residents spend their leisure time will help to clarify recreational opportunities. Local youth and adult sports teams, movie theaters, availability of cable TV, bowling alleys, prevalence of X-rated book stores, and local statistics on drug use will contribute to the information obtained on the community.
Health and Social Services. Location of and population access to health services in the form of health care providers, emergency services, hospitals, and hospice programs are key elements in the assessment of community health. The propor- tion of providers who accept Medicaid or Medicare, or propor- tion of services available to immigrants influences the access of certain populations to services. Number and type of medical practices available can identify gaps or gluts in services for the population when compared with age groups in the community. For example, the proportions of pediatricians, obstetricians, and geriatricians should somewhat mirror the related popula- tion’s age groups. Private versus nonprofit hospitals, insurance coverage, sliding scale payments, and means to reach services (proximity and transportation) all influence how health ser- vices might be used in a community. While in some communi- ties abundant resources may be present, access to the services may be inhibited by hours of operation or limited provision of services through insurance or payment restrictions.
Number of hospitals, clinics, offices, and mental health facili- ties are important, but how the community uses them is a criti- cal element in the success of health care delivery. Health care in vulnerable populations often requires care coordination, which may include home visiting, appointment arranging and transportation, development of a medical home, and the introduction of vulnerable families to resources including early childhood education, child or elder abuse prevention, and family support services. Social services in the form of commu- nity programs and state or local agencies such as community action coalitions or social service departments should be assessed. The presence of these types of services in a community would reflect positive inclinations toward holistic health for that community. Gaps in certain services represent an oppor- tunity for program development.
FIG 18-3 Older homes are more likely to contain lead-based paint. 0% 10% 20%
Y e a r
H o m
e W
a s
B u ilt
30% 40% 50%
Older Homes are More Likely to Contain Lead-Based Paint
60% 70% 80% 90% 100%
24%
69%
87%
Between 1960–1977
Between 1940–1959
Before 1940
414 PART 4 Issues and Approaches in Population-Centered Nursing
different political viewpoints, or may target certain subsystems or aggregates in the community. They may be issued on a daily or weekly basis.
Informal methods of communication, such as signs and bul- letin boards, may offer some means of transferring information at central locations in communities. Churches, local stores, and government offices such as the post office or town hall, may continue to be relevant communication hubs in small or rural communities. U.S. Postal Service, Fed Ex, and other carriers are common links to outside sources of goods and services for communities.
When these systems are robust, they afford degrees of pro- tection for the community and its health. Weaknesses in the systems may permit health threats to enter the community. For example, a lack of sidewalks on a main street could result in pedestrian injuries or fatalities. The stronger and more focused the services/systems in place are toward individual community needs, the stronger the community resilience will be against outside threats to optimal health (Figure 18-5). Assessing the strength of systems can be a measure of the strengths of the community. When the systems are not intact or are insufficient to meet the needs of the community, the possibility of poorer overall health of the community increases. The systems in place may act as protective factors against negative outside forces that could threaten the community. For example, a strong school immunization program could offset a measles epidemic. Table 18-6 provides more information on assessing these systems.
The Seven “A’s” Once the PHN has identified and cataloged the systems of the community, then it is most helpful to measure their effective- ness. One method that can be used to evaluate adequacy of services or systems in a community is the “7 A’s.” A series of queries about a service or system’s effectiveness in reaching the community can be used with any of the above listed com- munity components. The 7 “A’s” are awareness, access, availabil- ity, affordability, acceptability, appropriateness, and adequacy (Truglio-Londrigan & Gallagher, 2003). Asking questions about an agency or service using the 7 “A’s” can help to identify how well the service or system is meeting the needs of the community. Box 18-4 explains how to use the 7 “A’s” to craft questions to assist in gauging the value of existing services, or in identifying assets in the community or opportunities for improvement.
universally available and can provide communication within and outside of communities, young members of the commu- nity rely heavily on social media and texting for communication with their peers. Those sources of communication require both Internet and cell phone coverage in many cases. Today one can hardly imagine limitations on these methods, yet there are rural areas that still do not have good access to them.
Cell phones and mobile devices such as tablets, iPads, and laptops are increasingly becoming vehicles for health messages, advertising, and political messages. While ten years ago only 66% of adults had cell phones, now the number is 91%. In addition, many homes in areas of good cell coverage have dis- connected their landlines and use cell coverage for all phone communication (Rainie, 2013). See Figure 18-4, which illus- trates rates of cell phone ownership in the United States during the past 10 years.
In areas where tornadoes or hurricanes are prevalent, indi- vidual communities may have systems in place for communi- cating early warning of weather events. Such systems usually include a siren that is tested at a regular time each week and otherwise sounds only when the threat is imminent. If your community is in a high risk weather or topographic area, knowing the disaster plan can be helpful in understanding the community.
Radio or television can also provide information about imminent events. Radio or television also may provide news and advertise events to the local community. Local news can clue the community assessor into pertinent current events or community issues that are at the forefront. Newspapers can also provide interesting insights into the community’s current events or issues. Some communities have numerous papers reflecting
FIG 18-4 Cell phone ownership.
2005 2006 2007 2008 2009 2010 2011 2012
65% Nov 2004
Cellphone Ownership, 2004–2013 Percentage of American Adults Who Own a Cell Phone
91% May 2013100%
80
60
40
20
0
Source: Pew Research Center’s Internet & American Life Project, April 17-May 19, 2013 Tracking Survey. Interviews were conducted in English and Spanish and on landline and cell phones. Margin of error is �/� �2.3 percentage points based on all adults (n�2,252).
1. Is the community aware of its needs and of the service? 2. Is it accessible to community members? 3. Is the service available when the community needs it? 4. Can the community members afford the service? 5. Does the community find the service acceptable? 6. Is the service adequate to meet the needs of the community? 7. Are the services appropriate to meet the needs of the community?
BOX 18-4 Using the 7 “A’s”
415CHAPTER 18 Community As Client: Assessment and Analysis
Morbidity and mortality data should be tabulated identify- ing the top three causes of morbidity and mortality and also comparing the local data to the state, national, and previous years’ local data. Are there conditions in the causes of illness or death that are rising or declining? Looking at this information and linking with the information derived from primary data
Data Analysis Once the data are assembled, you will have stacks of papers and multiple computer files. One systematic way to organize your data is to follow a pattern of collating the information according to the section of the assessment and the systems. Follow the model that you have chosen to order your information. You can create tables of census and demographic data, indicating a comparison of your community’s data to state data and national data. Identify ages, gender, marital information, births and infant deaths, race or ethnicity, and density of the population and assemble the information into a table. This helps you to see the information at a glance. Identify whether the population in your community is on the rise or declining and which age and ethnic/racial groups are increasing or decreasing. How many families live below the poverty level? These items of information can pinpoint areas where needs may be increasing. Census data provide rich information about how many people live in your community and historic data about population size, composi- tion, and income. Be sure that your data are the most recent and that when you compare data that you are comparing data reported in the same format and from a reliable source.
Next, organize all data, primary and secondary, related to each of the systems. You may decide to make tables about these data as well and make a report on the data available for each system. Be sure to include the community assets you have iden- tified for each system, as well as any observed deficiencies. Do the perceived issues of the community match your secondary data? Synthesize the data into a coherent report based on each system (See QSEN box).
FIG 18-5 Optimal community systems in place to protect the public. (Data from Anderson ET and MacFarlane J: Community as Partner: Theory and Practice in Nursing, ed 6, Philadelphia, 2011, Lippincott Williams & Wilkins.)
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FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Client-centered Care Recognizes the client or designee as the source of control and as a full partner in providing compassionate and coordinated care that is based on the prefer- ences, values and needs of the client
Knowledge: understanding of multiple dimensions of client-centered care Skill: for individual, family, aggregate, or community elicits values, prefer-
ences, and expressed needs as part of clinical interview Attitude: support care for each client level whose values differ from one’s
own
Question The Quad Council core competency of analytic and assessment skills indicates the beginning PHN should collect data, both quantitative and qualitative, to be used in community assessment. The PHN then assesses data collected as part of the community assessment process to make inferences about clients (values, culture, preferences for health care)
In order to develop, revise, or even improve community health care delivery, how would the PHN use the outcomes of the community assessment? What steps would the nurse take to make change based on client choice?
416 PART 4 Issues and Approaches in Population-Centered Nursing
Safety and Transportation • Crime rates and trends • Traffic accidents and fatalities • Fire stations and emergency responders and response times;
publicly paid or volunteer? • Police protection and public perception thereof • Highway system and road conditions • Availability of public transportation in, out of, and around
the community • Commuters to and from the community and methods
of commute • Child car seat assistance
Politics and Government • Type of local government • Budgets for public services/systems • Diversity in government offices match to community diversity (e.g.,
mayor, board of supervisors, etc.) • Local tax base and taxes levied • Party affiliation of county majority
Economics • Average income • Percentage of families who own their homes • Automobile ownership • Number of children eligible for free lunches • Unemployment figures/types of jobs available • Families on unemployment compensation • Percentage of food stamp recipients • Poverty statistics • Industries in place/largest employers/size of most businesses • Available child care
Education • Number and types of primary and secondary schools (public vs.
private) • Number and access to community and four-year colleges
or universities • Preschool classes available • Early intervention home visiting programs • Average educational achievement of population • Primary and additional languages of community
Recreation • Local parks and park management • Safe playgrounds • Type of recreational businesses (bowling alleys, adult bookstores, movie
theaters) • Sports teams, youth and adult; sports arenas/fields • Biking trails/lanes • Track or running trails, tennis courts • Activity clubs (garden, hiking) • Senior center(s) • Local festivals/fairs
Health and Social Services • Hospitals, health clinics/medical offices, specialists • Health department and programs • Free clinic • Social service department • In home care provision (i.e., hospice, maternal child programs) • Statistics on child and elder abuse, sexual assault • Immunization status of community members • Home health care team • Percentage of Medicaid families in community • Percentage of population on disability and ages of those disabled • Obesity rate: adults and children • Mental health clinic(s)
Communication • Newspapers • Cell phone carriers and availability of service • Internet connections • Radio and TV stations • Community bulletin boards (check post offices and central places) • Informal sources of information and communication
Physical Environment • Age and condition of housing • Physical terrain and potential for environmental disaster (hurricanes,
tornadoes, etc.) • Proximity to Superfund sites (pollution) • Water and air quality • Industrial pollution • Natural environment
TABLE 18-6 Community Systems: Potential Measures
will help focus priorities. Identifying health indicators such as obesity rates, smoking rates, and causes of morbidity and mor- tality can clarify the needs of the community.
Identification of Health Assets and Challenges Once you have pulled together your data into an organized format, the community problems and strengths should emerge. Using a targeted form like Santa Cruz County’s “snapshot” (see Figure 18-6) will help you to see these in a clear way. While the “snapshot” addresses six systems, you can expand this to the size needed to reference your community. With the resulting “list” of identified problems and assets, you will be ready to prioritize your results.
Prioritizing Once the data are collated and clarified on paper, the themes can be placed in the context of the earlier identified community priorities reflected in your primary data. In this way, commu- nity involvement and input in the assessment process will make your assessment and planning relevant to the community, and create the opportunity to meet the community’s identified needs. At the same time, try to identify within your secondary data a rationale for the community’s identified need. In other words, you might compromise. Attempting to implement pro- grams that are not recognized as most relevant by the commu- nity can result in lack of community buy-in and ultimate program failure.
417CHAPTER 18 Community As Client: Assessment and Analysis
FIG 18-6 Snapshot of Santa Cruz County. (http://www.appliedsurveyresearch.org/storage/ database/quality-of-life/santacruzcap/cap15_2009/CAP15_Full_Report.pdf).
June 2009
June 2009
33
2009 44
2008 133
STOP
33STOP
STOP
STOP
STOP
STOP
!
!
!
Unemployment Rate
Santa Cruz County
Watsonville
Affordable Housing Median sale price, all home types – Santa Cruz/Watsonville area
Foreclosures Number of notices of default – Santa Cruz County
1,537 2008 50
Health Insurance Percent of children ages 0‐17 with health insurance – Santa Cruz County
97.9% 2007 111
High School Dropout Rates
Adjusted four‐year derived dropout rate – Santa Cruz County
14.0% 2007/08 83
!Test Scores Percent of 3rd grade students scoring proficient or above in the English‐ Language Arts subject area on the California Standards Test – Santa Cruz County
40% 2009 62
Elder Abuse Rate of reported cases of elder abuse – Santa Cruz County (per 1,000 elders ages 65 and older)
21.0 2008 176
Adult Crime Property crime rate – Santa Cruz County (per 1,000 residents)
29.9 2008 158
Obesity Percent of children ages 5‐19 who are overweight or obese – Santa Cruz County
Quality of Life
Percent of telephone survey respondents who reported being “very satisfied” with their overall quality of life
72.0% 2009 211
!Concern for Natural Environment Percent of telephone survey respondents who said water availability most concerned them about the natural environment
18.1% 2009 218
Food Insecurity Number of people served by the Second Harvest Food Bank – Santa Cruz County
48,161 2008 199
Health of Waterways Number of bodies of water added to the 303(d) impairment list – Santa Cruz County
6 2008 227
IndicatorSection
Economy
Education
Health
Public Safety
Social Environment
Natural Environment
Measurement Data Year Trend Direction Page
10.6%
22.2%
$347,000
25.9%
Shuster, G: Community as client” assessment and analysis. In Stanhope and Lancaster (editors), Public Health Nursing, Population- centered health care in the community, ed 8, 2012 Elsevier, St. Louis, Mo.
Criteria that have been helpful in ranking identified problems include the following: 1. Community awareness of the problem 2. Community motivation to resolve or better manage the problem 3. Nurse’s ability to influence problem solution 4. Availability of expertise to solve the problem 5. Severity of the outcomes if the problem is unresolved 6. Speed with which the problem can be solved
BOX 18-5 Problem Priority CriteriaFor example, though secondary data may document that increased mortality due to heart disease should be the commu- nity’s highest priority, as evidenced by higher than average mor- tality from heart disease, the community might see a different need, such as elder care or child care, as the highest priority. There is no clear guide in this prioritizing process, but testing ideas about perceived need and actual data-driven information with community stakeholders and key informants helps the PHN come to an optimal way to prioritize problems and iden- tify target areas for improvement. Just as in the hospital setting, make the patient (in this case the community) the center of your focus. Box 18-5 can assist you in steps to prioritize the com- munity problem list. Identifying the top three community
418 PART 4 Issues and Approaches in Population-Centered Nursing
problems or needs should then lead to creating the priority nursing diagnoses (see Use of Secondary Data Sources).
The ethical concepts of utilitarianism and justice can help you navigate the negotiations and advocacy inherent in priori- tizing one health problem over another. Utilitarianism means doing the most good for the most people, so a priority problem would ideally be one that affects a large proportion of the com- munity. However, justice focuses on the fair distribution of resources among all people. Social justice means advocating for the most vulnerable populations in a community, to ensure that their problems receive higher priority than the problems found throughout the general population. For example, secondary data might find that infant mortality occurs rarely in the com- munity; but if there is a wide disparity among racial groups in infant mortality rates, social justice would call for this problem to be given higher priority in order to address underlying deter- minants of health that may cause the disparity.
Nursing Diagnosis The community health nursing diagnosis in this phase of the process helps clarify the prioritized problems and is an impor- tant first step to planning. Community diagnoses clarify the target population for care and identify the factors contributing to the identified problem. As the analysis of the data proceeds, the nursing care plan can be formed. In the planning phase, community-focused interventions are identified, along with ways to measure outcomes.
There are several standardized classification systems to accommodate this diagnosis formation. North American Nursing Diagnosis Association (NANDA) and the Omaha system are two prominent systems of classification. NANDA may require some adaptation to the community for certain diagnoses; Carpenito’s Nursing Diagnosis: Application to Clinical Practice (based on NANDA) does recognize several community diagnoses and health seeking behaviors that can apply to com- munities (Carpenito, 2013, pp. 797-816). The Omaha system includes domains and problem classifications that are specific to community health.
The NANDA system outlines the systematic nursing diagno- sis process by identifying the (1) problem or potential problem; (2) its relation to factors, stressors, or health issues; and (3) then supporting data that document the problem. The identification of the problem in the NANDA classification has strict param- eters dividing problems into categories and systems. This can be confining when working within the community as client, since even though the NANDA classification system does offer several community-based diagnoses, it is more focused on individuals or families. For more information on NANDA nursing diagnosis, please consult Carpenito (2013), http://www .nanda.org or the nursing diagnosis text recommended by your faculty.
The Omaha system was developed by visiting nurses and expands beyond the physiological domain and includes envi- ronmental, psychosocial, and health-related behaviors domains. In addition to the problem, the Omaha system addresses the intervention scheme and the problem rating scale for outcomes. Omaha-based computer software applications are available to
LINKING CONTENT TO PRACTICE
In this chapter, the focus is placed on the partnership between the public health nurse and the community throughout the process of community assess- ment, problem identification, planning, intervention, and evaluation. One of the Institute of Medicine’s (IOM) three core functions of public health is assessment. The process of community assessment outlined and described in this chapter closely follows The Council on Linkages’ Core Competencies for Public Health (adopted June 11, 2011). This includes the need for public health nurses to “maintain partnerships with key stakeholders.” Among other identi- fied competencies for public health providers, including public health nurses, is the ability to “assess the health status of populations and their related determinants of health and illness.” This chapter presents the means by which public health nurses can construct a composite database containing assess- ment data from a wide variety of sources. This initial community assessment phase also directly links with The Quad Council Domains of Public Health Practice: Domain #1: Analytic Assessment Skills; Domain #5: Community Dimensions of Practice Skills; and Domain #6: Basic Public Health Sciences Skills. The Council on Linkages: Core Competencies for Public Health also emphasizes the public health nurse’s ability to describe “the characteristics of a population-based health problem.” Development of goals and objectives along with their problem correlates as part of the community health assess- ment directly relates to this competency; whereas another Council on Linkages competency—“Develops a plan to implement policy and programs”—directly relates to the development of intervention actions described in this chapter.
streamline electronic records (Omaha System, 2014). The Omaha system website, http://www.omahasystem.org, contains case studies and full explanation of the use of its standardized taxonomy and problem oriented approach.
Community nursing diagnosis language must describe at the aggregate level—in other words, the community level— responses to actual and potential illnesses and life processes. This also means that the defining characteristics for community diagnoses must be observable and measurable at the aggregate level. To do this, community-level data must be used. Epidemio- logic supporting data or community survey data are two exam- ples of community-level data. The comparison of local data with state, regional, or national data, as rates and across mul- tiple years, is one key means of identifying community-level problems, as well as patterns and trends.
The community nursing diagnosis, no matter which classi- fication system the PHN uses, then leads to expected outcomes and evidence-based health promotion strategies to address and improve the problem identified in the diagnosis. This becomes the nursing care plan. The expected outcomes and evaluations derived from the nursing diagnosis systems suggest subsequent evaluation measures for identified needs or problems. Just as problems are recognized and prioritized, so can strengths be identified that may offer avenues through which the PHN can address existing challenges facing the community.
Program Planning, Implementation, and Evaluation Once interventions and evaluation measures are identified through the nursing diagnosis framework, the PHN arrives at a new step in the nursing process—the program planning phase. This includes analyzing and establishing priorities among
419CHAPTER 18 Community As Client: Assessment and Analysis
P R A C T I C E A P P L I C A T I O N Lily, a nurse in a small city, became aware of the increased inci- dence of respiratory diseases through contact with families in the community and the local chapter of the American Lung Association. During family visits, Lily noticed that many of the parents were smokers. Because most of the families Lily visited had small children, she became concerned about the effects of secondhand smoke on the health of the infants and children in her family caseload.
Further assessment of this community indicated that the community recognized several problems, including school safety and the risk of water pollution, in addition to the smoking problem that Lily had identified during her family visits. Talks
with different community members revealed that they wanted each of these identified problems “fixed,” although these same community members were uncertain about how to start. In deciding which of the three identified problems to address first, which criterion would be most important for Lily to consider? A. The amount of money available B. The level of community motivation to “fix” one of the three
identified problems C. The number of people in the community who expressed a
concern about each of the three identified problems D. How much control she would have in the process
Answers can be found on the Evolve site.
K E Y P O I N T S • Most definitions of community include three dimensions:
(1) networks of interpersonal relationships that provide friendship and support to members, (2) residence in a common locality, and (3) shared values, interests, or concerns.
• A community is defined as a locality-based entity, composed of systems of formal organizations reflecting societal institu- tions, informal groups, and aggregates that are interdepen- dent and whose function or expressed intent is to meet a wide variety of collective needs.
• A community practice setting is insufficient reason for stating that practice is oriented toward the community client. When the location of the practice is in the community but the focus of the practice is the individual or family, the nursing client remains the individual or family, not the whole community.
• Population-centered practice is targeted to the community— the population group in which healthful change is sought.
• Community health as used in this chapter is defined as the meeting of collective needs through identification of prob- lems and management of behaviors within the community itself and between the community and the larger society.
• Most changes aimed at improving community health involve, out of necessity, partnerships among community residents and health workers from a variety of disciplines.
• Assessing community health requires gathering existing data and interpreting the database.
• Five methods of collecting data useful to the nurse are analy- sis of existing secondary data, and primary data collection through informant interviews, participant observation, surveys, and windshield surveys.
• Nurses should identify and partner with gatekeepers, formal or informal community leaders, to gain entry or acceptance into the community.
• The planning phase includes analyzing and establishing pri- orities among community health problems already identi- fied, establishing goals and objectives, and identifying intervention activities that will accomplish the objectives.
• Once high-priority problems are identified, broad relevant goals and objectives are developed; the goal is generally a broad statement of the desired outcome while the objectives are precise statements of the desired outcome.
• Intervention activities, the means by which objectives are met, are the strategies that clarify what must be done to achieve the objectives, the ways change will be effected, and the way the problem will be interpreted.
• Implementation, the next phase of the nursing process, means transforming a plan for improved community health into achieving goals and objectives. This essentially is the implementation of the program.
• Simply defined, evaluation is the appraisal of the effects of some organized activity or program.
community health problems already identified through nursing diagnosis, establishing goals and objectives, and identifying intervention activities that will accomplish the objectives. These interventions must be clearly supported by the community stakeholders in order for the community to buy in to the identi- fied program plans. Intervention activities, the means by which objectives are met, are the strategies that clarify what must be done to achieve the objectives or the ways change will be effected. The next phase of the nursing process is program implementation. This involves enacting the plan for improved community health using the identified goals and objectives.
Finally, upon implementation of the program and by using the established evaluation measures, the PHN can measure the
success of the program and determine community satisfaction with the outcome. These evaluation criteria will already be identified through the nursing diagnosis format chosen.
Program planning and implementation should be based on the community’s problems AND its strengths, as well as the priorities of the community members. If the identified problem is not resolved to the satisfaction of the community at large following program implementation, the PHN will return to the data-gathering phase and begin the process again using the updated data. As shown in Figure 18-2, this can be an ongoing, circular process, just like the nursing process. Program manage- ment, encompassing program planning, implementation, and evaluation is discussed in detail in Chapter 25.
420 PART 4 Issues and Approaches in Population-Centered Nursing
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C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Observe an occupational health nurse or public health nurse,
school nurse, family nurse practitioner, or emergency depart- ment nurse for several hours. Determine which of the nurse’s activities are population centered. Give specific examples and present your reasons for considering them population centered.
2. Using your own community as a frame of reference, develop examples illustrating the concepts of community, commu- nity client, community health, and partnership for health. What are some of the complexities of this question?
3. Read your local newspaper and identify articles illustrating the concepts of community, community client, community health, and partnership for health. How does your article specifically relate to the concept?
4. Using any two of the conditions of community competence given in the chapter, briefly analyze your own community. Give examples of each condition.
5. Search the Boone County, Iowa, website (http://www .co.boone.ia.us/) for information on county festivals. Ask yourself the following question: To what extent do the county festivals depicted on the website reveal community cohesion?
6. Search the Washtenaw County, Michigan, website (http:// www.ewashtenaw.org/) for information about “county con- versations.” Identify which issues are being addressed, and read the local newspaper for additional information. Did you find other countywide issues when you read the newspaper? Are there positions on the issues that are not presented?
421CHAPTER 18 Community As Client: Assessment and Analysis
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19 Population-Centered Nursing in Rural and Urban Environments
Angeline Bushy, PhD, RN, FAAN, PHCNS-BC Dr. Angeline Bushy, Professor and Bert Fish Endowed Chair at the University of Central Florida, College of Nursing holds a BSN degree from the University of Mary in Bismarck, North Dakota; an MN degree in rural community health nursing from Montana State University in Bozeman; an MEd in adult education from Northern Montana College in Havre; and a PhD in nursing from the University of Texas at Austin. She is a Fellow in the American Academy of Nursing and a Clinical Specialist in Public Health Nursing. Dr. Bushy has worked in rural health care facilities located in the north-central and intermountain states; presented nationally and internationally on various rural nursing and rural health issues; published six textbooks and numerous articles on that topic; and, is a Lieutenant Colonel (Ret.) in the U.S. Army Reserve.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Compare and contrast definitions of rural and urban. 2. Describe residency as a continuum, ranging from farm
residency to core inner city. 3. Compare and contrast the health status of rural and urban
populations on select health measures. 4. Analyze barriers to care in health professional shortage
areas and for underserved populations.
5. Evaluate issues related to the delivery of public health services for rural underserved populations.
6. Describe characteristics of rural and small-town residency. 7. Examine the role and scope of public health nursing
practice in rural and underserved areas. 8. Evaluate two professional-client-community partnership
models that can effectively provide a continuum of health care to residents living in an environment with sparse resources.
K E Y T E R M S farm residency, p. 424 frontier, p. 428 health professional shortage area (HPSA), p. 428 medically underserved, p. 436 metropolitan area, p. 424 micropolitan area, p. 424 non-core areas, p. 424
non-farm residency, p. 424 rural, p. 423 rural-urban continuum, p. 424 suburbs, p. 425 urban, p. 424 —See Glossary for definitions
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz
• Case Studies • Glossary • Answers to Practice Application
C H A P T E R O U T L I N E Historic Overview Definition of Terms
Rurality: A Subjective Concept Rural-Urban Continuum Current Perspectives
Population Characteristics Health Status of Rural Residents
Rural Health Care Delivery Issues and Barriers to Care Nursing Care in Rural Environments
Theory, Research, and Practice Research Needs Preparing Nurses for Rural Practice Settings
423CHAPTER 19 Population-Centered Nursing in Rural and Urban Environments
Farm residency: Residency outside area zoned as “city limits”; usually infers involvement in agriculture
Frontier: Regions having fewer than six persons per square mile Large central: Counties in large (1 million or more population) metro areas
that contain all or part of the largest central city Large fringe: Remaining counties in large (1 million or more population)
metro areas Metropolitan county: Regions with a central city of at least 50,000
residents Non-farm residency: Residence within area zoned as “city limits” Micropolitan county: Counties that do not meet SMSA (see below)
criteria Rural: Communities having fewer than 20,000 residents or fewer than 99
persons per square mile Small: Counties in metro areas with fewer than 1 million people Standard metropolitan statistical area (SMSA): Regions with a central
city of at least 50,000 residents Suburban: Area adjacent to a highly populated city Urban: Geographic areas described as non-rural and having a higher popula-
tion density; more than 99 persons per square mile; cities with a population of at least 20,000 but less than 50,000
BOX 19-1 Terms and Definitions
C H A P T E R O U T L I N E — cont’d Future Perspectives
Scarce Resources and a Comprehensive Health Care Continuum
Healthy People 2020 National Health Objectives Related to Rural Health
Building Professional-Community-Client Partnerships in Rural Settings
Case Management Community-Oriented Primary Health Care
Access to health care is a national priority, especially in regions with an insufficient number of health care providers. Recruit- ing and retaining qualified health professionals can be a chal- lenge in underserved communities, particularly inner cities and rural areas of the United States. Until recently, however, only limited research has been undertaken on the special challenges, problems, and opportunities of nursing practice— especially public health nursing in rural settings. This chapter presents major issues surrounding health care delivery in rural environments, which sometimes differs from that in urban or more populated settings. Common definitions for the term rural are discussed, as are its associated lifestyle, the health status of rural populations, barriers to obtaining a continuum of health care services, and public health nursing practice issues. Strategies are discussed to help nurses deliver more effective population-focused nursing services to clients who live in more isolated environments with sparser resources. This chapter describes rural public health nursing practice and can be used by students, nurses who practice in rural public health departments, and those who work in agencies located in urban areas that offer outreach services to rural populations in their catchment area.
HISTORIC OVERVIEW Formal rural nursing originated with the Red Cross Rural Nursing Service, which was organized in November 1912. The Committee on Rural Nursing was directed by Mabel Boardman (Chair), Jane Delano (Vice-Chair), and Annie Goodrich along with other Red Cross leaders and philanthropists (Bigbee and Crowder, 1985). Before the formation of the Red Cross Rural Nursing Service, care of the sick in a small community was provided by informal social support systems. When self-care and family care were not effective in bringing about healing, this task was assigned to healers, who often were women who lived in the local community. Historically, the health needs of rural Americans have been numerous, and although not necessarily unique, they are different from those of urban populations. Consistent problems of maldistribution of health professionals, poverty, limited access to services, ignorance, and social isolation have plagued many rural communities for generations.
The history of the Red Cross Rural Nursing Service shows a consistent movement away from its initial rural focus, as dem- onstrated by its frequent name changes. Unfortunately, concern for rural health is similarly often temporary and replaced by other areas of greater need. It can be hoped that health care
reform initiatives will ensure equitable access to care for rural and urban residents alike (NACRHHS, 2012).
DEFINITION OF TERMS Rurality: A Subjective Concept Everyone has an idea as to what constitutes rural as opposed to urban residence. However, the two cannot be viewed as oppos- ing entities. With the increased degree of urban influence on rural communities, the differences may not be as distinct as they may have been even a decade ago (Bureau of the Census, 2011, 2012, 2013; Meckler & Chinni, 2014). In general, rural is defined in terms of the geographic location and population density, or it may be described in terms of the distance from (e.g., 20 miles) or the time (e.g., 30 minutes) needed to commute to an urban center. See Box 19-1 for selected terms and definitions.
Both urban and rural communities are highly diverse and vary in their demographic, environmental, economic, and social characteristics. In turn, these characteristics influence the mag- nitude and types of health problems that communities face. Urban counties, however, tend to have more health care provid- ers in relation to population, and residents of more rural coun- ties often live farther from health care resources (Bushy, 2013).
424 PART 4 Issues and Approaches in Population-Centered Nursing
RURAL-URBAN CONTINUUM Frequently used definitions to describe rural and urban and to differentiate between them are provided by several federal agen- cies (Bureau of the Census, 2011; USDA, 2013a; 2013b) (see Box 19-1). These definitions, which in many cases are dichotomous in nature, fail to take into account the relative nature of rural- ness. Rural and urban residencies are not opposing lifestyles. Rather, they must be seen as a rural-urban continuum ranging from living on a remote farm, to a village or small town, to a larger town or city, to a large metropolitan area with a core inner city. See Figure 19-1, which describes the continuum of rural- urban residency.
Several federal agencies classify U.S. counties and county equivalents (N = 3007) according to population density, specifi- cally, metropolitan counties (84% of the total population) and non-metropolitan counties (16% of the total population) (USDA, 2013b). The terms metropolitan area and micropoli- tan area (metro and micro areas) refer to geographic entities primarily used for collecting, tabulating, and publishing federal statistics. Core-based statistical area (CBSA) is a collective term for both metro and micro areas. A metro area contains a core urban area of 50,000 or more population. A micro area contains an urban core of at least 10,000 (but less than 50,000) popula- tion. Each metro or micro area consists of one or more counties containing the core urban area. Likewise, adjacent counties have a high degree of social and economic integration (as measured by commuting to work) with their urban core (USDA, 2013b).
Demographically, micro areas contain about 60% of the total non-metro population, with an average of 43,000 people per county. In contrast, non-core areas, with no urban cluster of 10,000 or more residents, have on average about 14,000 resi- dents. In general, lack of an urban core and low overall popula- tion density may place these counties at a disadvantage in efforts to expand and diversify their economic base. The designation
Some equate the idea of rural with farm residency and urban with non-farm residency, whereas others consider rural to be a “state of mind.” For the more affluent, rural may bring to mind a recreational, retirement, or resort community located in the mountains or in lake country where one can relax and participate in outdoor activities, such as skiing, fishing, hiking, or hunting. For the less affluent, the term can impose grim scenes. For example, some people may think of an impoverished Indian reservation as comparable to an underdeveloped country, and other people may think about a migrant labor camp with several families living in a one-room shanty with no access to safe drinking water or adequate sanitation.
Just as each city has its own unique features, also it is difficult to describe a “typical rural town” because of the wide popula- tion and geographic diversity. For example, rural towns in Florida, Oregon, Alaska, Hawaii, and Idaho are different from one another, and quite different from those in Vermont, Texas, Alabama, or California. Also, there can be vast differences between rural areas within one state. Still, descriptions and definitions for rural tend to be more subjective and relative in nature than those for urban.
For example, “small” communities with populations of more than 20,000 have some features that one may expect to find in a city. Then again, residents who live in a community with a population of less than 2000 may consider a community with a population of 5000 or 10,000 to be a city. Although some communities may seem geographically remote on a map, the residents who live there may not feel isolated. Those residents believe they are within easy reach of services through telecom- munication and dependable transportation, although extensive shopping facilities may be 50 to 100 miles from the family home, obstetric care may be 150 miles away, or nursing services in the district health department in an adjacent county may be 75 or more miles away (Bolin & Bellamy, 2014; Gamm et al, 2003).
FIG 19-1 The continuum of rural-urban residency.
Frontier
Micropolitan (micro) 10,000 - �50,000
Core Base Statistical Area (CBSA)
Metropolitan (metro) �50,000
Core metro (inner city) (�1,000,000)
Term:
Term:
Term:
�6 persons per square mile
�99 persons per square mile
7-98 persons per square mile
Rural Urban
Suburban
Population:
Farm residency Nonfarm residency
425CHAPTER 19 Population-Centered Nursing in Rural and Urban Environments
encounter more residents under the age of 18 and over 65 years of age in rural areas compared with an urban setting. Rural residents 18 years of age and older are more likely to be, or to have been, married than are their urban counterparts. As a group, rural adults are more likely to be widowed and have fewer years of formal education than urban adults (Meckler & Chinni, 2014; USDA, 2013a).
Although there are regional variations, rural families in general tend to be poorer than their urban counterparts. Com- paring annual incomes with the standardized index established, more than one fourth of rural Americans live in or near poverty, and nearly 40% of all rural children are impoverished. Com- pared with those in metropolitan settings, a substantially smaller proportion of rural families are at the high end of the income scale. Accompanying the recent population shifts from urban to formerly rural areas, one can speculate that average income level might also change; however, no data are available at this time to substantiate this estimate. Regardless, level of income is a critical factor in whether a family has health insurance or qualifies for public insurance. Consequently rural families are less likely to have private insurance and more likely to receive public assistance or to be uninsured.
The working poor in rural areas are particularly at risk for being underinsured or uninsured. In working poor families, one or more of the adults are employed but still cannot afford private health insurance. Furthermore, their annual income is such that it disqualifies the family from obtaining public insurance. Several factors help explain why this phenomenon occurs more often in rural settings (Bushy, 2013). For example, a high pro- portion of rural residents are self-employed in a family business, such as ranching or farming, or they work in small enterprises, such as a service station, restaurant, or grocery store. Also, an individual may be employed in part-time or in seasonal occupa- tions, such as farm laborer and construction, in which health insurance often is not an employee benefit. In other situations, a family member may have a preexisting health condition that makes the cost of insurance prohibitive, if it is even available to them. At present it remains to be seen if this situation will change with the recent health care reform. A few rural families fall through the cracks and are unable to access any type of public assistance because of other deterrents, such as language barriers, compromised physical status, the geographic location of an agency, lack of transportation, or undocumented worker status. Insurance, or the lack of it, has serious implications for the overall health status of rural residents and the nurses who provide services to them (AHCPR, 2013a, 2013b; NCHS, 2014).
Health Status of Rural Residents Even though rural communities constitute about one fourth of the total population, the health problems and the health behaviors of the residents in them are not fully understood. This section summarizes what is known about the overall health status of rural adults and children. The health status measures that are addressed are perceived health status, diag- nosed chronic conditions, physical limitations, frequency of seeking medical treatment, usual source of care, maternal– infant health, children’s health, mental health, minorities’
of micro areas is an important step in recognizing non-metro diversity. The term also provides a framework to understand population growth and economic restructuring in small towns and cities that have received less attention than metro areas. Nationally and regionally, many measures of health, health care use, and health care resources among rural populations vary by the level of urban influence in a particular region.
Micro areas embody a widely shared residential preference for a small-town lifestyle—an ideal compromise between large highly populated urban cities and sparsely populated rural set- tings. As information about these places makes its way into government data and publications alongside metro areas in the coming years, hopefully the notion of “micropolitan” will draw increased attention from policy makers and the business community.
In the past two decades there has been a steady population shift from urban to less-populated regions of the United States. Demographers metaphorically refer to this demographic phe- nomenon as the “doughnut effect.” That is to say, people are moving away from highly populated areas to outlying suburbs of urban centers. Most of the population growth has been in rural counties with a booming economy coupled with the geo- graphic area to expand, such as in many western and southern states (USDA, 2013a, 2013b).
Clearly, a notable population shift will also affect the health status and lifestyle preferences of communities in which the shift occurs. As beliefs and values change over time, urban-rural differences narrow in some aspects and others became more pronounced. Depending on the definition that is used, the actual rural population might vary slightly. According to Bureau of the Census estimates (2011, 2012, 2013), almost 20% of all U.S. residents live in rural settings. In this chapter, rural refers to areas having fewer than 99 persons per square mile and com- munities having 20,000 or fewer inhabitants.
CURRENT PERSPECTIVES Population Characteristics Adding to the confusion about what constitutes rural versus urban residency are the special needs of the numerous under- represented groups (minorities, subgroups) who reside in the United States. In general, there are a higher proportion of whites in rural areas than in urban areas. There are, however, regional variations, and some rural counties have a significant number of minorities. Little is documented on the needs and health status of special rural populations (AHCPR, 2013a, 2013b; Bolin & Bellamy, 2014; USDHHS, 2013). Anthropologists are quick to report that, within a group, there often exists a wide range of lifestyles. Consequently, even in the smallest or most remote town or village, a subgroup may behave differently and have different values about health, illness, and patterns of accessing health care. Also, a group’s lifestyle may be associated with health problems that are different from those of the predominant cul- tural group in a given community. Background information on selected populations can be found in Chapters 7 and 32.
Demographically, rural communities include a higher pro- portion of younger and older residents. Nurses can expect to
426 PART 4 Issues and Approaches in Population-Centered Nursing
health, and environmental and occupational health risks (Bolin & Bellamy, 2014; OSHA, 2013). Residents of rural areas suffer some of the same health problems as migrant farmworkers, as described in Chapter 34, including exposure to environ- mental factors and accidents.
Perceived Health Status In general, people in rural areas have a poorer perception of their overall health and functional status than their urban coun- terparts. Rural residents over 18 years of age assess their health status less favorably than do urban residents. Studies show that rural adults are less likely to engage in preventive behavior, which ultimately increases exposure to risk. Specifically, they are more likely to use tobacco products and self-report higher rates of alcohol consumption and obesity; furthermore, they are less likely to engage in routine physical activity during leisure time, wear seat belts, have regular blood pressure checks, have Pap smears, complete breast self-examinations, and have colorectal screenings. Ultimately, failure to participate in health-promoting lifestyle behaviors impacts the overall health status of rural residents, their level of function, physical limitations, degree of mobility, and level of self-care activities (American Legacy Foundation, 2013; Crosby et al, 2012; NCHS, 2014).
Chronic Illness Rural adults are more likely than urban adults to have one or more of the following chronic conditions: heart disease, chronic obstructive pulmonary disease, hypertension, arthritis and rheumatism, diabetes, cardiovascular disease, and cancer. Nearly half of all rural adults have been diagnosed with at least one of these chronic conditions, compared with about one fourth of non-rural adults. Also, the prevalence of diagnosed diabetes in rural adults is about 7 out of 100 as opposed to 5 out of 100 in non-rural environments. Rural adults are more likely to have cancer (almost 7%) compared with urban adults (about 5%). Although most cases of acquired immunodeficiency syndrome (AIDS) are still found in urban areas, the rate is increasing in some rural populations (Smalley, Warren, Rainer, 2012; South Carolina Research Center, 2013).
Rural-urban health disparities have been documented in health status (Box 19-2) and for health behaviors (Box 19-3). For example, there are disparities in the proportion of rural adults who receive medical treatment for both life-threatening illness and degenerative or chronic conditions compared with urban adults. The proportion of rural residents who receive these treatments is high in rural versus urban areas. Life- threatening conditions include malignant neoplasms, heart disease, cardiovascular problems, and liver disorders. Degenera- tive or chronic diseases include diabetes, kidney disease, arthri- tis, and chronic diseases of the circulatory, nervous, respiratory, and digestive systems. In essence, chronic health conditions, coupled with their poor health status, limit the physical activities of a larger proportion of rural residents than of their urban counterparts (Bolin & Bellamy, 2014; NCHS, 2014).
Physical Limitations Limitations in mobility and self-care are strong indicators of an individual’s overall health status. Specific assessed measures on
a national health survey included walking one block, walking uphill or climbing stairs, bending, lifting, stooping, feeding, dressing, bathing, and toileting. In fact, almost 10% of rural adults report at least three or more of these physical limitations, compared with about 6% of metropolitan adults. The increased prevalence of poor health status and impaired function is not necessarily attributable to the increased number of older adults found in rural areas. Similar patterns are evident in adults 18 to 64 years of age. Rural adults under 65 years of age are more likely than urban adults to assess their health status as fair to poor, and a greater percentage have been diagnosed with a chronic health condition (NCHS, 2014; USDHHS, 2013).
Based on data from national health surveys, the overall health status of rural adults leaves much to be desired. This is attributed to a number of factors, including impaired access to health care providers and services, coupled with other rural factors. Thus nurses who practice in rural areas are essential in providing a continuum of care to to their clients. Specifically, nurses can help clients have healthier lives by teaching them how to prevent accidents, engage in more healthful lifestyle behaviors, and reduce the risk of chronic health problems. Once clients in rural environments have been diagnosed with a long- term problem, nurses can help them manage chronic conditions to achieve better health outcomes and functioning (Gamm et al, 2003; Bolin & Bellamy, 2014).
Residents of fringe counties near large metro areas have the following: • Lowest levels of premature mortality, partly reflecting lower death rates
for unintentional injuries, homicide, and suicide • Lowest levels of smoking, alcohol consumption, and childbearing among
adolescents • Lowest prevalence of physical inactivity during leisure time among women • Lowest levels of obesity among adults • Greatest number of physician specialists and dentists per capita • Lowest percentage of the population without health insurance • Lowest percentage of the population who had no dental visits
Residents in the most rural counties have the following: • Highest death rates for children and young adults • Highest death rates for unintentional and motor vehicle traffic–related
injuries • Highest death rates among adults for ischemic heart disease and suicide • Highest levels of smoking among adolescents • Highest levels of physical activity during leisure time among men • Highest levels of obesity among adults • Highest percentage of adults with activity limitations caused by chronic
health conditions • Fewest physician specialists and dentists per capita • Least likely to have seen a dentist • Highest percentage of the population without health insurance
BOX 19-2 Disparities Among U.S. Urban (Metropolitan) and Rural (Micropolitan) Residents’ Health Status
From Centers for Disease Control and Prevention: United States, 2001—Urban and Rural Chartbook, Washington, DC. Available at http://www.cdc.gov/nchs/data/hus/hus01.pdf. Accessed December 22, 2010; Gamm L, Hutchison L, Dabney B, Dorsey A: Rural Healthy People 2010: A Companion Document to Healthy People 2010 (Vol. I, II, III), 2003. Available at http://www.srph.tamhsc.edu/centers/ rhp2010/publications.htm. Accessed June 28, 2005.
427CHAPTER 19 Population-Centered Nursing in Rural and Urban Environments
Patterns of Health Service Use When the use of health care services is measured, it is found that more than three fourths of adults in rural areas received medical care on at least one occasion during a year. Despite their overall poorer health status and higher incidence of chronic health conditions, rural adults seek medical care less often than urban adults. In part, this discrepancy can be attributed to scarce resources and lack of providers in rural areas. Other reasons for this phenomenon are discussed later under Rural Health Care Delivery Issues and Barriers to Care (AHCPR, 2013a, 2013b; NACRHHS, 2012). Nurses must be especially thorough in their health assessment of rural clients who may not receive regular care for chronic health conditions.
Availability and Access of Health Care The ability of a person to identify a usual source of care is con- sidered a favorable indicator of access to health care and a person’s overall health status. Essentially, a person who has a usual source of care is more likely to seek care when ill and adhere to prescribed regimens. Having the same provider of care can enhance continuity of care, as well as a client’s percep- tion of the quality of that care. Rural adults are more likely than urban adults to identify a particular medical provider as their usual source of care. Rural adults are more likely to receive care from general practitioners and advanced practice registered nurses (APRNs) compared to urban adults who are more likely to seek care from a medical specialist. However, this trend may
be changing with health care reform, which emphasizes the importance of primary care (BHPR, 2013a, 2013b; Bushy, 2012; IOM, 2010; Krey, 2014).
Another measure of access to care is traveling time and/or distance to ambulatory care services. Rural persons who seek ambulatory care are more likely to travel more than 30 minutes to reach their usual source of care. Extended commuting time may also be a factor for residents in highly populated urban areas and those who must rely on public transportation. Once the person arrives at the clinic or physician’s office, no differ- ences between rural and urban residents are found in the waiting time to see the provider.
In general there is a maldistribution of health professionals among rural and urban counties. For instance, 1 out of 17 rural counties is reported to have no physician. Among rural respon- dents on national surveys, the ability to identify a usual site of care or a particular provider often stems from a community or county having only one, perhaps two, health care providers. The limited number of health care facilities is reinforced by the finding that nearly all rural residents who seek health care use ambulatory services that are provided in a physician’s office as opposed to a clinic, community health center, hospital outpa- tient department, or emergency department (NACRHHS, 2012). One can speculate about the indicator of usual place and usual provider; that is to say, it suggests that rural residents are at least as well off as urban residents in regard to access to care. However, this finding may be related to the fact that rural
• Residents in any rural areas are more likely to report fair to poor health status (19.5%) than were residents of urban counties (15.6%).
• Rural residents are more likely to report having diabetes (9.6%) versus urban adults (8.4%).
• Rates of diabetes are markedly higher among rural American Indians (15.2%) and African American adults (15.1%).
• Rural residents are more likely to be obese (27.4%) versus urban residents (23.9%).
• Rural black adults are particularly at risk for obesity; ranging from 38.9% in rural micropolitan counties to 40.7% in remote rural counties.
• Rural residents are less likely to meet CDC recommendations for moderate or vigorous physical activity (44%) versus urban residents (45.4%).
• Rural African American adults are less likely to meet recommendations for physical activity than other rural residents; this difference persists across all levels of rurality.
Access to Health Care Services • Rural residents are more likely to be uninsured (17.8%) versus urban residents
(15.3%). • Hispanic adults are more likely to lack insurance, with uninsured rates
ranging from 40.8% in rural micropolitan counties to 56.1% in small remote counties.
• Most rural residents (81%) and urban residents (79.4%) report having a personal health care provider. However, residents in remote rural counties were least likely to have a personal physician (78.7%).
• Rural white adults are more likely to have a personal health care provider than were other adults. Among Hispanic adults, the proportion with a
personal provider ranged from 60.4% in rural micropolitan counties to 47.7% in remote rural counties.
• Rural adults are more likely than urban adults to defer seeking health care because of cost (15.1% vs 13.1%)
• Rural adult African Americans, Hispanics, and American Indians are more likely to report having deferred care due to cost compared with white rural residents.
Receipt of Preventive Services • Rural women are less likely (70.7%) than urban women (77.9%) to be in
compliance with mammogram screening guidelines. • Rural women are less likely (86%) than urban women (91.4%) to have had a
Pap smear within the past 3 years. • Rural residents over age 50 years are less likely (57.7%) to have had a
colorectal screening versus urban counterparts (61.4%).
Quality of Diabetes Care • The proportion of adults with diabetes who reported receiving at least two
hemoglobin A1c tests within the past year was low among both rural (33.1%) and urban residents (35%).
• White rural residents with diabetes were more likely than African American or Hispanic residents to receive at least two hemoglobin A1c tests in the past year.
• Only 64.2% of rural and 69.1% or urban residents with diabetes reported receiving an annual dilated eye examination.
BOX 19-3 Rural-Urban Disparities: Lifestyle and Health Behaviors
From Bennett K, Olatosi B, Probst J: Health disparities: a rural-urban chartbook, 2008. Available at http://rhr.sph.sc.edu/report/(73)%20Health%20 Disparities%20A%20Rural%20Urban%20Chartbook%20-%20Distribution%20Copy.pdf. Accessed December 8, 2011.
428 PART 4 Issues and Approaches in Population-Centered Nursing
nurses in rural communities also varies from region to region. More specifically, in frontier and rural areas of the United States, school nurses usually are scarce. In part, this deficit can be attributed to limited resources associated with very low local tax revenues and shortages of health personnel in those coun- ties. In other words, there are fewer taxpayers living in those large geographic areas. Some frontier areas have fewer than four persons per square mile and a few areas have fewer than two persons per square mile. Consequently, rural county commis- sioners, like their urban counterparts, are forced to prioritize the allocation of scarce resources, in particular for essential public services such as maintaining the infrastructures of utili- ties, roads, bridges, and education; supporting a financially suffering county hospital; hiring a county health nurse; and offering school health services. In rural communities there are fewer resources overall, yet certain public services must be pro- vided to local residents—albeit in many situations with aging and outdated infrastructures.
Clearly, creativity is required by both community residents and local public health care providers to resolve health care and school nursing needs. Partnership arrangements, for example, have been negotiated by two or more counties that agree to share the cost of a “district” public health nurse. Other county commissioners have forged partnerships with an agency in an urban setting and contracted for specific health care services. In both of these situations, it is not unusual for the nurse to provide services to all children attending all schools in the health district’s participating counties. In some frontier states, schools may be situated more than 100 miles apart and as many miles or more from the district health office. Because of the number of schools and distances between them, the county nurse may be able to visit each school only once or twice in a school term. Usually the nurse’s visit is to update immuniza- tions and perhaps teach maturation classes to students in the upper grades.
The health status of rural women, infants, and children is less than optimal. In part this can be attributed to inadequate preventive, primary, and emergency services to meet their par- ticular health care needs. On one hand, scarce resources can pose a challenge to a nurse who provides care to rural residents, especially those in underserved areas. On the other hand, resource deficits encourage creativity and innovation; both of these behaviors are characteristic of nursing in general and of rural nurses in particular.
Mental Health Like many other measures of health, the facts about the mental health status of rural people are also ambiguous and conflicting (AHCPR, 2013a, 2013b; Crosby et al, 2012; NCHS, 2014). Stress, stress-related conditions, and mental illness are prevalent among populations who are economically deprived. Increasing federal regulations imposed on agriculture, timber, and marine- and mining-related industries in the past two decades led to many job losses in rural communities. The term farm stress is associated with the economic downturn in the agriculture industry as it affects an individual, family, and the community. This same term or diagnosis could be applied to other
physicians tend to live and practice in a particular community for decades, thus providing care to multigenerational families who seek care from this particular provider.
Moreover, in a health professional shortage area (HPSA), a physician or a nurse practitioner may provide services to residents who live in surrounding counties. One or two nurses in a public health department usually offer a full range of ser- vices for all residents in a rural catchment area, which may span more than 100 miles from one end to the other end of a county or health district. Consequently, rural physicians and nurses frequently report, “I provide care to individuals and families with all kinds of conditions, in all stages of life, and across several generations.” It should not come as a surprise that rural respondents who participate in national surveys are able to identify a usual source and a usual provider of health care (Woolston, 2010).
Maternal–Infant Health Reports in the literature conflict regarding pregnancy outcomes in rural areas. Overall, rural populations have higher infant and maternal morbidity rates, especially counties designated as HPSAs, which often have a high proportion of racial minorities. Here one also finds fewer specialists, such as pediatricians, obste- tricians, and gynecologists, to provide care to at-risk populations. There are extreme variations in pregnancy outcomes from one part of the country to another, and even within states. For example, in several counties located in the north-central and intermountain states, the pregnancy outcome is among the finest in the United States. However, in several other counties within those same states, the pregnancy outcome is among the worst. Particularly at risk are women who live on or near Indian reserva- tions, are migrant workers, and are of African American descent residing in rural areas in southeastern states (Bolin & Bellamy, 2014; Leipert, Leach & Thurston, 2012; USDHHS, 2013).
Public health nurses appreciate the interactive effects of socioeconomic factors, such as income level (poverty), educa- tion level, age, employment-unemployment patterns, and use of prenatal services, on pregnancy outcomes. There are other, less well-known health determinants, such as environmental hazards, occupational risks, and the cultural meaning placed on child-bearing and child-rearing practices by a community. The interaction effects of these multifaceted factors vary and often are difficult to measure (Nelson, 2009; Warren & Smalley, 2014).
Health of Children Reports on the health status of rural children show regional variations and conflicting data. Comparing rural children with urban children under 6 years of age on the measures of access to providers and use of services reveals the following (AHCPR 2013a, 2013b; Bolin & Bellamy, 2014; USDHHS, 2013): • Urban children are less likely to have a usual provider but
are more likely to see a pediatrician when they are ill. • Like rural adults, rural children are more likely to be cared
for by a general practitioner who is identified as their usual caregiver. School nurses play an important role in the overall health
status of children in the United States. The availability of school
429CHAPTER 19 Population-Centered Nursing in Rural and Urban Environments
should be aware, however, that at-risk and underrepresented groups may experience some unique challenges associated with rural social structures, lifestyle, and sparse resources.
Environmental and Occupational Health Risks A community’s primary industry or industries are a determi- nant in the local lifestyle, the health status of its residents, and the number and types of health care services it may need. For example, four high-risk industries identified by the Occupa- tional Safety and Health Administration (OSHA) and found in predominantly rural environments are forestry, mining, marine- related fields, and agriculture. See Table 19-1 for a description of rural groups, their typical health care needs, and their health risks or conditions. Associated health risks of these industries are machinery and vehicular accidents, trauma, selected types of cancer related to environmental factors, and allergies and respiratory conditions associated with repeated exposure to toxins, pesticides, and herbicides (NCFH, 2014; NCHS, 2014; OSHA, 2013; USDA, 2013b).
For example, agriculture production industries such as farming and ranching are often owned and operated by a family. Small enterprises with a low number of employees do not fall under OSHA guidelines. For that reason safety standards are not enforceable on most farms and ranches, since these often are family enterprises. Moreover, small businesses, such as farms, are not covered under workers’ compensation insurance. Additional concerns arise because family members participate in the farm or ranch work. This means that some adults and children may work with animals and operate dangerous machinery with minimal operating instructions on the hazards and on safety precautions. Also, many agriculture workers do not speak or read English. Consequently, agriculture-related accidents result in a significant number of deaths and long-term injuries, particularly among children and women. The morbid- ity and mortality rates associated with agriculture vary from state to state. The rising incidence of these injuries and deaths, however, has become a national concern. Nurses in rural set- tings can help address this problem by including farm safety content in school and community education programs (NCFH, 2014; OSHA, 2013).
In summary, it is risky to generalize about the health status of rural Americans because of their diversity coupled with conflicting definitions of what differentiates rural from urban residences. Many vulnerable individuals and families live in rural communities across the United States, but little is known about most of them. This information deficit therefore is a potential area of research for nurses who practice in rural environments.
RURAL HEALTH CARE DELIVERY ISSUES AND BARRIERS TO CARE Although each rural community is unique, the experience of living in a rural area has several common characteristics (Bushy & Winters, 2013; Hurme, 2009; Molinari & Bushy, 2012). Barriers to health care may be associated with these character- istics (e.g., whether services and professionals are available,
communities experiencing economic recessions in their pre- dominate enterprises, such as marine-, automobile-, and timber-related industries. Economic factors also contribute to a family’s being underinsured or uninsured. Interestingly, even if mental health services are available and accessible, rural residents delay seeking care when they have an emotional problem until there is an emergency or a crisis. This behavior is reflected in the lower number of annual visits for mental health services and chronic health conditions by rural residents.
Mental health professionals who serve rural populations report a persistent, endemic level of depression among residents in economically stressed rural areas. They speculate this condi- tion is exacerbated by high levels of poverty, geographic isola- tion, and an insufficient number of mental health services. Depression may also contribute to the escalating incidence of accidents and suicides, especially among rural male adolescents and young men. These incidents have increased dramatically over the last decade and continue to rise within this group, to the point of being epidemic in some small communities. Like- wise, the stigma associated with mental illness remains, espe- cially in communities having fewer health care providers to educate the public about mental and behavioral health condi- tions (Smalley et al, 2012).
There are conflicting reports on the prevalence of interper- sonal violence and alcohol and substance use among rural populations. These behaviors are less likely to be reported in areas where residents are related or personally acquainted. Over time, destructive coping behaviors in small, tight-knit commu- nities may be accepted by local residents as “business as usual” for a particular family. Family problems may also be ignored if formal social services and public health services are sparse or nonexistent, or if residents do not trust the professionals who provide services at a local agency. In underserved rural areas, there are gaps in the continuum of mental health services, which, ideally, should include preventive education, anticipa- tory guidance, screenings, early intervention programs, crisis and acute care services, and follow-up care. As with other aspects of health care, nurses in rural areas play an important role in community education, case finding, advocacy, and case management of client systems experiencing acute and chronic emotional and behavioral health problems (Bushy, 2012, 2014; Smalley et al, 2012).
Health of Minorities As mentioned previously, a significant number of at-risk minor- ity groups in rural America have some rather distinctive con- cerns (particularly children, older adults, Native Americans, Native Alaskans, Native Hawaiians, migrant workers, African Americans, and the homeless) (CDC, 2013b; NCFH, 2014; USDHHS, 2013). The rural homeless, for example, may be migrant farmworkers or local families whose homes were fore- closed. Sometimes the family may be allowed by law to continue living in the house that once was theirs. The family no longer has a means of livelihood and often remains hidden in the com- munity with insufficient income to purchase food or other nec- essary services. The particular health problems of these at-risk groups are discussed in Chapters 7 and 27 through 38. Nurses
430 PART 4 Issues and Approaches in Population-Centered Nursing
Adapted from: CDC (2013b). Health disparities and inequalities report: United States 2013. Available at http://www.cdc.gov/mmwr/pdf/other/ su6203.pdf. Accessed March 28, 2014; Bolin & Bellamy, 2014; Rural Healthy People 2020: a companion document to Healthy People 2020, Vol I, II, III, College Station, TX, 2003, The Texas A&M University System Health Science Center, School of Rural Health, Southwest Rural Health Research Center. Available at http://www.srph.tamhsc.edu/centers/srhrc/rural-healthy-people-2020.html. Accessed March 28, 2014.
Rural Aggregates Health Care Needs Health Risks/Conditions
Farmers/ranchers Advanced life support/emergency services Oral/dental care Obstetric/perinatal/pediatric services Mental/behavioral health services Agricultural health nurses Geriatric specialists
Agricultural chemicals and environmental hazards Dermatitis Stress/depression/anxiety disorders Respiratory conditions (i.e., farmer’s lung) Accidents (vehicular/machinery) Trauma-related chronic conditions Dental caries/loss Interpersonal/domestic violence
Native Americans Advanced life support/emergency services Oral/dental care Obstetric/perinatal/pediatric services Mental/behavioral health services Culturally appropriate substance abuse treatment programs Epidemiologists Diabetes screening and educators Community health workers/education
Infectious diseases (e.g., hepatitis, TB) Sudden infant death syndrome (SIDS) Interpersonal/domestic violence Diabetes Alcohol/substance abuse Cirrhosis of the liver Vehicular accidents Hypothermic/environmental injuries Trauma-related injuries/chronic conditions Dental caries/loss
African Americans Community nursing health promotion and screening services Diabetes screening and educators Hypertension screening/education Prenatal and perinatal health care services Oncology services (education/screening/follow-up interventions) HIV/AIDS prevention education/screening/follow-up care Mental/behavioral health services
Diabetes Hypertension Sickle cell anemia Infectious diseases (e.g., hepatitis, HIV/AIDS) Cancer (e.g., prostate, breast) Dental caries/loss Depression Interpersonal/domestic violence
Migrant farmworkers Environmental protection policies (safe drinking water/sanitation) Community nursing/migrant health services (primary, secondary,
tertiary prevention) Diabetes screening and educators Hypertension screening/education Maternal/child services Oncology services (education/screening/follow-up interventions) Mental/behavioral health services
Infectious diseases (e.g., hepatitis, typhoid, TB, HIV/AIDS, STDs)
Exposure effects of pesticides/herbicides Otitis media (children) Substance abuse (alcohol, recreational drugs, imported
medicinal/herbs) Dental caries/loss Interpersonal/domestic violence
Native Alaskans Advanced life support/emergency care services Medical transport services Oral/dental care Obstetric/perinatal/pediatric services Mental/behavioral health services Culturally appropriate substance abuse treatment programs Epidemiologists Diabetes screening and educators
Infectious diseases (e.g., hepatitis, TB) Dental caries/loss Depression Interpersonal/domestic violence Environmental health risks (e.g., exposure to toxic
substances/contaminants, hypothermia) Diabetes Alcohol/substance abuse Cirrhosis of the liver Vehicular accidents/trauma/long-term chronic residual effects
Coal miners Occupational Safety and Health Administration policy/standards Mental/behavioral health services Emergency/advanced life support services Occupational health nurses Grief counselors
Depression/substance abuse Occupational-related accidents/trauma Respiratory conditions (e.g., black lung, chronic obstructive
pulmonary disease) Interpersonal/domestic violence
TABLE 19-1 Select Health Care Needs, Risks/Conditions of Select Rural Aggregates
affordable, accessible, or acceptable to rural consumers). Box 19-4 lists common barriers to health care in rural areas.
Availability implies the existence of health services as well as the necessary personnel to provide essential services. Sparseness of population limits the number and array of health care
services in a given geographic region. Lacking a critical mass, the cost of providing special services to a few people often is prohibitive, particularly in frontier states where there are an insufficient number of physicians, nurses, and other types of health care providers. Consequently, where services and
431CHAPTER 19 Population-Centered Nursing in Rural and Urban Environments
feelings of professional isolation and community nonaccep- tance. To address disparate views, nursing faculty members should expose students to the rural environment and the people who live there. Clinical experiences must include opportunities to provide care to clients in their natural (e.g., rural) setting to gain accurate insight about a particular community.
To design population-focused programs that are available, accessible, affordable, and appropriate, nurses must implement interventions that mesh with clients’ beliefs. This implies that a family and a community are actively involved in planning and delivering care for those who receive it. Nurses must have an accurate perspective on rural clients. Although the importance of forming partnerships and ensuring mutual exchange seems obvious, to date, most research about rural communities has been for policy or reimbursement purposes. Empirical data about rural family systems are sparse in terms of their health beliefs, values, perceptions of illness, and health care–seeking behaviors as well as what is deemed to be appropriate nursing care. Therefore, nurse scholars must assume a more active role in implementing research on the needs of rural populations for nursing services to expand the profession’s theoretical base and subsequently implement community-oriented, empirically based clinical interventions (deValpine, 2014; Williams, 2012; Williams et al, 2012).
NURSING CARE IN RURAL ENVIRONMENTS Theory, Research, and Practice Information on nursing practice in small towns and rural envi- ronments is growing, and several themes have emerged as shown in Box 19-6. A nurse who practices in this setting can view each of these dimensions either as an opportunity or as a challenge.
Researchers from the University of Montana contend that existing theories do not fully explain rural nursing practice (Long & Weinert, 1989; Winters, 2013; Winters & Lee, 2009). Their focus has been on the key concepts pertinent to nursing theory (health, person, environment, and nursing/caring) and proposed relational statements that are relevant to clients and nurses in rural environments (see the Evidence-Based Practice box). Because the focus of their research was primarily with non-Hispanic whites living in the Rocky Mountain area, care must be taken about generalizing those findings to other geo- graphic regions and minorities. These researchers propose that rural residents often judge their health by their ability to work. They consider themselves healthy, even though they may suffer from several chronic illnesses, as long as they are able to continue working. For the rural person, being healthy is the ability to be productive. Chronically ill people emphasize emotional and spiritual well-being rather than physical wellness.
Distance, isolation, and sparse resources characterize rural life and are seen in residents’ independent and innovative coping strategies. Self-reliance and independence are demon- strated through their self-care practices and preference for family and community support. Community networks provide support but still allow for each person’s and family’s
personnel are scarce, these must be allocated wisely. Accessibil- ity implies that a person has logistical access to, as well as the ability to purchase, needed services. Affordability is associated with both availability and accessibility of care. It infers that services are of reasonable cost and that a family has sufficient resources to purchase these when needed. Acceptability of care means that a particular service is appropriate and offered in a manner that is congruent with the values of a target population. This can be hampered by a client’s cultural preference and the urban orientation of health professionals (Bushy, 2013; NACRHHS, 2012). Box 19-5 lists barriers to health care in rural areas.
Providers’ attitudes, insights, and knowledge about rural populations are also important. A patronizing or demeaning attitude, lack of accurate knowledge about rural populations, or insensitivity about the rural lifestyle on the part of a nurse can perpetuate difficulties in relating to those clients. Moreover, insensitivity fosters mistrust, resulting in rural clients’ perceiving professionals as outsiders to the community. Some nurses in rural public health practice settings express
• Lack of health care providers and services • Great distances to obtain services • Lack of personal transportation • Unavailable public transportation • Lack of telephone services • Unavailable outreach services • Inequitable reimbursement policies for providers • Unpredictable weather and/or travel conditions • Inability to pay for care/lack of health insurance • Lack of “know how” to procure publicly funded entitlements and services • Inadequate provider attitudes and understanding about rural populations • Language barriers (caregivers not linguistically competent) • Care and services not culturally and linguistically appropriate
BOX 19-5 Barriers to Health Care in Rural Areas
• More space; greater distances between residents and services • Cyclical/seasonal work and leisure activities • Informal social and professional interactions • Access to extended kinship systems • Residents who are related or acquainted • Lack of anonymity • Challenges in maintaining confidentiality stemming from familiarity among
residents • Small (often family) enterprises; fewer large industries • Economic orientation to land and nature with industries that are extractive
in nature (e.g., agriculture, mining, lumbering, marine-related; outdoor rec- reational activities)
• More high-risk occupations • Town as center of trade • Churches and schools as socialization centers • Preference for interacting with locals (insiders) • Mistrust of newcomers to the community (outsiders)
BOX 19-4 Characteristics of Rural Life
432 PART 4 Issues and Approaches in Population-Centered Nursing
• Variety/diversity in clinical experiences • Broader/expanding scope of practice • Generalist skills • Flexibility/creativity in delivering care • Sparse resources (e.g., materials, professionals, equipment, fiscal) • Professional/personal isolation • Greater independence/autonomy • Role overlap with other disciplines • Slower pace • Lack of anonymity • Increased opportunity for informal interactions with clients/coworkers • Opportunity for client follow-up upon discharge in informal community
settings • Discharge planning allowing for integration of formal and informal resources • Care for clients across the life span • Exposure to clients with a full range of conditions/diagnoses • Status in the community (viewed as prestigious) • Viewed as a professional role model • Opportunity for community involvement and informal health education
BOX 19-6 Characteristics of Nursing Practice in Rural Environments
From Bushy A: Conducting culturally competent rural nursing research. In Merwin B, editor: Annual Review of Nursing Research: Focus on Rural Health, 26:221–236, 2008; Hurme E: Competencies for nursing practice in a rural critical access hospital, Online J Rural Nurs Health Care 9(2):67–81, 2009. Available at http://www.rno.org/ journal/index.php/online-journal/article/viewFile/198/256. Accessed January 8, 2011; Nelson W, editor: Handbook for Rural Health Care Ethics, Lebanon, NH, 2009, Dartmouth. Available at http://dms. dartmouth.edu/cfm/resources/ethics/. Accessed January 8, 2011; Winters C, Lee H: Rural Nursing: Concepts, Theory and Practice, ed 3, New York, 2009, Springer Publishing.
Nurse researchers at Montana State University proposed the following theo- retical concepts and dimensions of rural nursing practice: (Long & Weinert, 1989; Winters, 2013; Winters & Lee, 2009). • Health: Defined by rural residents as the ability to work. Work and health
beliefs are closely related for rural Montana sample. • Environment: Distance and isolation are particularly important for rural
dwellers. Those who live long distances neither perceive themselves as isolated nor perceive health care services as inaccessible.
• Nursing: Lack of anonymity, outsider versus insider, old-timer versus new- comer. Lack of anonymity is a common theme among rural nurses who report knowing most people for whom they care, not only in the nurse– client relationship, but also in a variety of social roles, such as family member, friend, or neighbor. Acceptance as a health care provider in the community is closely linked to the outsider/insider and newcomer/old- timer phenomena. Gaining trust and acceptance of local people is identified as a unique challenge that must be successfully negotiated by nurses before they can begin to function as effective health care providers.
• Person: Self-reliance and independence in relationship to health care are strong characteristics of rural individuals. They prefer to have people they know care for them (informal services) as opposed to an outsider in a formal agency.
Nurse Use In working with rural residents, it is important to know how they define their health and their environment, because their definitions may differ from yours. Understand that you may not find acceptance and trust immediately; rural resi- dents often trust informal caregivers more than those in a formal organization.
EVIDENCE-BASED PRACTICE
Long K, Weinert C: Rural nursing: developing a theory base, Sch Inq Nurs Pract 13(3):275–279, 1999; Winters C, Lee H: Rural Nursing: Concepts, Theory and Practice, ed 3. New York, 2009, Springer Publishing.
independence. Ruralites prefer and usually seek help through their informal networks, such as neighbors, extended family, church, and civic clubs, rather than seeking a professional’s care in the formal system of health care, including services such as those provided by a mental health clinic, social service agency, or health department.
Although nursing is generally similar across settings and populations, there are some unique features associated with practice in a geographically remote area or in small towns where most people know one another. The following paragraphs high- light a few of the variations that nurses in rural practice report (Roberge, 2009; Winters, 2013; Woolston, 2010).
A nurse’s professional and personal boundaries often overlap and are diffuse. It is not unusual for a nurse to have more than one work-related role in the community. For example, a nurse may work at the local hospital or in a physician’s office and may also be actively involved in managing the family farm, a local grocery store, or pharmacy. For nurses, this means that many, if not all, clients they encounter are known also as neighbors, as friends of an immediate family member, or as part of one’s extended family. Associated with social informality is a corre- sponding lack of anonymity in a small town. Some rural nurses say, “I never really feel like I am off duty because everybody in the county knows me through my work.” In part, this can be attributed to nurses being highly respected and viewed by local
people as experts on health and illness. Often rural residents informally ask a nurse’s advice before seeing a physician for a health problem. Rural residents may ask health-related ques- tions when they see a local nurse (who may be a neighbor, friend, or relative) in a grocery store, at a service station, during a basketball game, or at church functions (Bushy, 2012).
Nurses in rural public health practice must make decisions about the care of individuals of all ages with a variety of health conditions. They assume many roles because of the range of services they provide in a rural health care facility and because of the scarcity of nurses and other health professionals. Nurses who work in rural areas need to have skills that include techni- cal and clinical competency, adaptability, flexibility, strong assessment skills, organizational abilities, independence, inter- est in continuing education, sound decision-making skills, lead- ership ability, self-confidence, and skills in handling emergencies, teaching, and public relations. The nurse administrator is also expected to be a jack-of-all-trades (i.e., a generalist) and to demonstrate competence in several clinical specialties in addi- tion to managing and organizing staff within the facility for which he or she is responsible (Hurme, 2009; Roberge, 2009; Woolston, 2010).
Rural nursing practice provides challenges, opportunities, and rewards. The way in which each factor is perceived depends on individual preferences and the situation in a given
433CHAPTER 19 Population-Centered Nursing in Rural and Urban Environments
departments as including: political/bureaucratic problems and intraprofessional and interpersonal conflicts associated with inadequate communication; unsatisfactory work environment and understaffing; difficult or unpleasant nurse–client encoun- ters, such as with relatives who refuse to deliver needed care to clients, and with clients who are hostile, apathetic, dependent, or of low intelligence; fear for personal safety; difficulty locating clients, and clients falling through the cracks of the health care system. These same stressors continue to be cited by nurses who work in rural as well as urban public health agencies. Anecdotal reports describe specific stressors associated with geographic distance, isolation, sparse resources, and other environmental factors that characterize rurality.
Nursing in rural areas is characterized by physical isolation that may lend itself to any one of the following: professional isolation; scarce financial, human, and health care resources; and a broad scope of practice. Associated with personal familiarity with local residents, nurses often possess in-depth knowledge about clients and their families. Along with the acknowledged benefits, informal (face-to-face) interactions can significantly reduce a nurse’s anonymity in the community and at times be a barrier to completing an objective assessment on a client. Like urban practice, rural community nursing as shown in Figure 19-2 takes place in a variety of locations, including homes, clinics, schools, occupational settings, and correctional facilities, and at community events such as county fairs, rodeos, civic and church-sponsored functions, and school athletic events.
Research Needs Recent empirical studies on rural nursing practice reinforce anecdotal reports by nurses (Bushy & Winters, 2013; Graves, 2009; Hurme, 2009; Merwin, 2006). Specific research topics of importance to nursing practice in rural environments include the following: 1. Most nurses indicate that they enjoy practicing in rural areas
and are proud of what they do. They believe that their work deserves more recognition by professional nursing organiza- tions. Also, the retention rate of nurses in some practice
community. Challenges of rural practice sometimes include professional isolation, limited opportunities for continuing education, lack of other kinds of health personnel or profes- sionals with whom one can interact, heavy workloads, an ability to function well in several clinical areas, lack of anonymity, and, for some, a restricted social life (Molinari & Bushy, 2012; Smalley et al, 2012; Warren & Smalley, 2014).
The most often cited opportunities and rewards in rural nursing practice are close relationships with clients and cowork- ers, diverse clinical experiences that evolve from caring for clients of all ages who have a variety of health problems, caring for clients for long periods of time (in some cases, across several generations), opportunities for professional development, and greater autonomy. Many nurses value the solitude and quality of life found in a rural community personally and for their own family. Others thrive on the outdoor recreational activities. Still others thoroughly enjoy the informal, face-to-face interactions coupled with the public recognition and status associated with living and working as a nurse in a small community. Disease prevention is also an important consideration in rural com- munities. The Levels of Prevention box shows the levels of prevention that nurse in a rural locale might use.
FIG 19-2 A hospital-sponsored health fair is one example of a community event to provide health services to individuals in a rural area.
LEVELS OF PREVENTION
Primary Prevention • The public health nurse partners with a women’s organization in a faith
community located in a small Midwestern town to instruct members on meal planning as a strategy to offset the tendency to develop diabetes in family members.
• The public health nurse advocates for policy changes regarding sexual education content (to include information on contraception that goes beyond abstinence) in the schools with the district commissioners of education.
Secondary Prevention • The public health nurse screens congregation members of the faith com-
munity in the Midwestern town for the presence of diabetes. • The public health nurse partners with the local critical access hospital to
offer free cholesterol, blood pressure, and blood sugar screening as well as the influenza vaccine to adults attending the annual county health fair.
Tertiary Prevention • The public health nurse collaborates with the senior center in the small
community town, which provides meals on a routine basis to the elderly, to reach individuals with a diagnosis of diabetes.
• The public health nurse provides consultation on diabetic nutrition, exercise habits, foot care, and, if needed, assists clients in obtaining medications through a mail-order pharmaceutical vendor.
Rural Health
Although most of the publications about rural health care and nursing focus on hospital practice, much of that informa- tion is applicable to both community agencies and community- focused nursing (Davis and Droes, 1993; Molinari and Bushy, 2012). There are some work-related stressors of nursing in rural communities. Case (1991) in the 1990s identified stressful expe- riences of nurses working in rural Oklahoma public health
434 PART 4 Issues and Approaches in Population-Centered Nursing
nurses use their knowledge of resources and their ability to coordinate formal and informal services to coordinate a con- tinuum of services for clients even when resources are sparse and fragmentation exists in the health care delivery system.
Technology has great potential for connecting rural public health providers and consumers with resources outside of their community. The concept of telehealth is an expansion of the term telemedicine. Essentially, telemedicine more narrowly focuses on the curative aspect of health care, whereas telehealth encompasses preventive, promotive, and curative aspects of health care and can include delivery of education/information to a more distant site. Telehealth uses a variety of technology solutions such as a health care provider communicating by e-mail with clients, ordering medications from a pharmacy, consulting with other health care providers, or accessing advanced or continuing education offered by a university located some distance from the receiving site. More specifically, telecommunication technology could be as simple as nurses in two or more different public health settings consulting over the telephone or via computer video conferencing coordinating local health fairs, or as complex as nurse scholars collaborating with international peers on a community health–focused research project or a medical specialist located at a health science center using complex robotic surgical technology on a client who is located in another country. Regardless of the practice setting, the nurse must be computer literate and be proficient in using the communication technology that is available in that community. Increasingly, the Internet is linking nurses in rural public health practice with nursing colleagues, educators, and researchers in urban-based academic settings, thereby address- ing often-cited concerns associated with professional isolation (ANCC, 2013; Molinari & Bushy, 2012; Bushy & Winters, 2013).
FUTURE PERSPECTIVES It is important for all people involved in providing health care in rural areas to understand the possible problems they might encounter when trying to provide the continuum of needed services in an area with a disproportionally high number of underserved persons. Those who should be involved include residents, their elected representatives, the administrators of public and private health care agencies, and members of the media. The media need to focus on public health as well as hospital care and the lack of primary care providers in rural areas (deValpine, 2014). As discussed later, both case manage- ment and community-oriented primary health care (COPHC) are effective models for dealing with some of the care deficits and resolving rural health disparities.
Scarce Resources and a Comprehensive Health Care Continuum The current fragmented health care system makes it difficult to provide a comprehensive continuum of care to populations living in areas having scarce resources, such as money, person- nel, equipment, and ancillary services. In rural communities, the most critically needed services are usually preventive ser- vices, such as health screening clinics, nutrition counseling, and
settings is poor. The perspective of nurses who are dissatis- fied with rural nursing provides a more complete picture of the rural experience. This information can be useful to a variety of people: other nurses who are considering rural practice, nurse managers in need of better screening tools to assess the fit between the nurse and the environment when interviewing applicants, planners of continuing nursing education programs, and faculty members who teach public health to undergraduate and graduate students.
2. More information is needed about the stressors and rewards of rural practice, in particular public health nursing. These data could lead to the development of stress management techniques to be used by nurses and their supervisors to retain nurses and to improve the quality of their workplace environment.
3. With the increasing number of rural residents in all regions of the United States, empirical data are needed on the par- ticular nursing needs of rural client systems, especially under-represented groups, minorities, and other at-risk pop- ulations that vary by region and state.
4. A need also exists for the international perspective on the health of rural populations, and on nursing practice within the rural community. Australian, New Zealand, and Cana- dian nurse scholars have provided some insights into rural practice in these nations. Information is needed from less- industrialized nations as well as from those that are highly industrialized.
5. Technology increasingly is used in health care and seems to hold great potential in improving access to health care in rural and underserved areas. However, research is needed to determine the most efficient and effective way to meet the needs and preferences of rural clients, and to ensure quality.
6. Communication technology increasingly is used by institu- tions of higher learning to deliver educational programs to nurses who live and work some distance from campus. Empirical studies are needed to measure the most effective modalities to achieve desired learning outcomes and the impact on recruitment and retention of nurses in rural settings.
7. Rural–urban disparities in health status and health behaviors need closer examination from the nursing perspective. Evidence-based practice nursing guidelines are needed that take into consideration the rural context and preferences of residents who obtain health care in these settings.
Preparing Nurses for Rural Practice Settings Nurses in rural practice need broad knowledge about nursing including health promotion, primary prevention, rehabilitation, obstetrics, medical-surgical specialties, pediatrics, planning and implementing community assessments, and understanding the public health risks and needs for emergency preparedness in a particular state. A community’s demographic profile and its principal industry(ies) can provide a snapshot of local social determinants that can affect health. Using demographic infor- mation, a nurse can anticipate the particular nursing skills that will be needed to care for clients in a catchment area (U.S.A. Center for Rural Health Preparedness, n.d.). In rural areas
435CHAPTER 19 Population-Centered Nursing in Rural and Urban Environments
professionals, as well as on economic development efforts in a small community (USDA, 2013a, 2013b; USDHHS, 2013).
The short supply and increasing demand for primary care providers in general, and nurses in particular, will continue for some time. To help solve this problem, elected officials and policy developers need nurses, especially those in advanced practice roles, to provide vital services in underserved areas. In an effort to effectively respond to this opportunity, nurses must be creative to ensure delivery of appropriate and acceptable services to at-risk and vulnerable populations who live in rural and underserved regions. Nurses must be sensitive to the health beliefs of clients, and then plan and provide nursing interven- tions that mesh with the community’s cultural values and preferences.
Healthy People 2020 National Health Objectives Related to Rural Health Because the demographic profile varies from community to community, each state has variations in the health status of its population. Healthy People 2020 has important implications for nurses in that a significant number of at-risk populations cited in that policy-guiding document live in rural areas across the United States (Bolin and Bellamy, 2014; AHCPR, 2013a, 2013b). Consequently, priority objectives vary, depending on popula- tion mix, health risks, and health status of residents in the state.
wellness education (Bolin and Bellamy, 2014; Gamm et al, 2003). Box 19-7 lists several health related priorities for rural communities.
Although the nursing needs vary by community, there is generally a need in most rural areas for the following: • School and parish nurses • Family planning services • Prenatal and postpartum services • Resources for individuals diagnosed with HIV/AIDS and
their families • Emergency medical services • Resources for families of children with special needs, includ-
ing those who are physically and mentally challenged • Mental health services • Resources for older adults (especially the frail elderly and
those with declining mental capacity) to include a contin- uum of residential and respite services, including adult day care, hospice, homemaker assistance, and provision of nutri- tional meals along with public transportation for those who remain at home Providing a continuum of care has been further hindered by
the closure of many small hospitals in the past two decades. Of those that remain, many report financial problems that could lead to closure (NACRHHS, 2012). A shortage or the absence of even one provider, most often a physician or nurse, could mean that a small hospital must close its doors. Closure of the hospital has a ripple effect on the health of local residents, other health care services, recruitment and retention of health
• Access to care • Cancer (screening, early intervention, oncology services) • Diabetes (prevention, screening, tertiary care) • Maternal–infant and children services • Mental illness and behavioral health services • Nutrition/obesity • Drugs, alcohol, and substance abuse • Use of tobacco products • Education and an array of community-based programs • Public health infrastructures • Immunizations and infectious diseases • Injury and violence prevention • Family planning • Environmental and occupational health • Emergency medical services infrastructures • Long-term care/assistive living facilities
BOX 19-7 Health-Related Priorities for Many Rural Communities
From Bennett K, Olatosi B, Probst J: Health Disparities: A Rural- Urban Chartbook, 2008. Available at http://rhr.sph.sc.edu/ report/(7-3)%20Health%20Disparities%20A%20Rural%20Urban%20 Chartbook%20-%20Distribution%20Copy.pdf. Accessed January 8, 2011; Gamm L, Hutchison L, Dabney B, et al: Rural Healthy People 2010: A Companion Document to Healthy People 2010, Vol I, II, III, College Station, TX, 2003, The Texas A&M University System Health Science Center, School of Rural Health, Southwest Rural Health Research Center. Available at http://www.srph.tamhsc.edu/centers/ rhp2010/publications.htm. Accessed January 8, 2011.
HEALTHY PEOPLE 2020
These selected objectives pertain to residents of both rural and urban areas: • AHS-3: Increase the proportion of persons with a usual primary care
provider. • IVP-13: Reduce motor vehicle crash–related deaths. • MHMD-9: Increase the proportion of adults with mental disorders who
receive treatment. • HDS-2: Reduce coronary heart disease deaths. • IVP-1: Reduce fatal and nonfatal injuries.
From U.S. Department of Health and Human Services: Healthy People 2020, 2010. Available at http://www.healthypeople.gov/2020/ default.aspx. Accessed January 9, 2011.
At the local level, communities have been using Healthy People as a guide for action and to identify objectives and estab- lish meaningful goals. The three-volume Rural Healthy People 2010: A Companion Document to Healthy People 2010 focused on the particular concerns relative to vulnerable populations in rural environments (Gamm et al, 2003). A parallel rural com- pendium is being developed for Healthy People 2020 (Bolin and Bellamy, 2014).
The Center for Disease Control’s (CDC, 2013a) Healthy Communities Initiative mobilized rural as well as urban com- munities to focus on chronic disease prevention. Individuals and groups at the local level collaborated with state health departments, the CDC, and other organizations to implement programs that promote and support good health in their com- munity. This CDC initiative is a useful tool for state and local officials and health care planners to use to tailor Healthy People
436 PART 4 Issues and Approaches in Population-Centered Nursing
Content to Practice box, nursing practice in rural areas is com- prehensive and incorporates skills from nursing and public health. Two models have been found to be particularly useful for nurses in rural environments: case management and Com- munity-Oriented Primary Health Care (COPHC).
objectives to fit a community’s specific needs, both rural and urban. Translating national objectives highlighted in Healthy People 2020 (USDHHS, 2013) into achievable community health goals requires integration of the following components to ensure that services will be acceptable and appropriate for rural clients: • Health statistics must be meaningful and understandable,
and they must include appropriate process and outcome objectives that can be readily measured.
• Strategies must be designed that involve the public, private, and voluntary sectors of the community to achieve agreed-on local objectives.
• Coordinated efforts are needed to ensure that the commu- nity works together to achieve the goals. Consider, for example, general objectives in developing a
health plan for a rural county having a large population of young people. Healthy People 2020 objectives for the county should target women of child-bearing age, children, and ado- lescents. Priority objectives should include offering accessible prenatal care programs, improving immunization levels, pro- viding preventive dental care instructions, implementing vehic- ular accident prevention and firearm safety programs, and educating teachers and health professionals for early identifica- tion of cases of interpersonal violence. On the other hand, consider a rural county that has a higher number of residents over the age of 65 years, compared with the national average. Priority objectives in the health plan should target health risks and problems of older adults in that community. Specific objec- tives might include developing health-promoting programs to prevent chronic health problems, or establishing community programs to meet the needs of those having chronic illness, specifically cardiovascular disease, diabetes, hypertension, and accident-related disabilities; or, organizing a partnership to build progressive/assistive care residential facilities in the com- munity. In general, the objectives in Healthy People 2020 are pertinent to people living in all areas and not unique to rural residents. The Healthy People 2020 box illustrates selected objec- tives that fit people in rural as well as more urban areas.
When implementing community-focused health plans that emerge from Healthy People 2020, consideration must always be given to the rural context, such as sparse population, geographic remoteness, scarce resources, personnel shortages, and physical, emotional, and social isolation. In addition to being actively involved in empowering the community and planning and delivering care, nurses play an important role in representing their community’s perspective to local, state, regional, and national health planners and to their elected officials.
BUILDING PROFESSIONAL-COMMUNITY- CLIENT PARTNERSHIPS IN RURAL SETTINGS Health care reform initiatives are focusing on cutting costs while improving access to care with equitable quality for all citizens, especially vulnerable and underserved populations. State and local grassroots organizations must be actively involved for health care reform to succeed in rural areas. Specifi- cally, professional-client-community partnerships are essential to accomplish reform at the local level. As seen in the Linking
LINKING CONTENT TO PRACTICE
As discussed, practice in rural areas relies on excellent nursing and public health skills in assessment, communication, cultural competency, problem solving, coalition building, coordination, and policy development, among others. Documents that guide the practice include the American Nurses Asso- ciation Standards of Nursing Practice, the core competencies as identified by the Council on Linkages, and the Quad Council Public Health Nursing Compe- tencies. As one example of the congruence, consider assessment. The Council on Linkages’ Core Competency of “Assess the health status of populations and their related determinants of health and illness” under their analytic assessment skills is then elaborated on by the Quad Council as a public health nursing skill of “Conducts thorough health assessments of individuals, fami- lies, communities and populations” and the public health nursing practice standard under assessment of “the public health nurse collects comprehen- sive data pertinent to the health status of populations” (p. 15). The relation- ship among these three sets of standards continues through all phases of the public health care provision process.
From American Nurses Association: Public Health Nursing: Scope and Standards of Practice, Silver Spring, MD, 2007, Available at http:// www.nursebooks.org; Public Health Foundation: Council on Linkages: Core Competencies for Public Health Professionals, 2008, Washington, DC, Author. Available at http://www.phf.org/link/index .htm. Accessed June 24, 2010; Quad Council: Public Health Nursing Competencies, 2009. Available at http://www.astdn.org/publication squadcouncilphncompetencies.htm. Accessed January 17, 2011.
Case Management Case management is a client-professional partnership that can be used to arrange a continuum of care for rural clients, with the case manager tailoring and blending formal and informal resources. Collaborative efforts between a client and the case manager allow clients to participate in their plan of care in an acceptable and appropriate way, especially when local resources are few and far between. The Practice Application at the end of this chapter demonstrates how nursing case management can allow an older adult resident to stay at home in a rural environ- ment if adequate supports can be provided. Outcomes are often remarkably different when case management is used. Addi- tional information on case management is found in Chapter 22.
Community-Oriented Primary Health Care COPHC is an effective model for delivering available, accessible, and acceptable services to vulnerable populations living in medically underserved areas. This model emphasizes flexibil- ity, grassroots involvement, and professional-community part- nerships. It blends primary care, public health, and prevention services, which are offered in a familiar and accessible setting. As shown in Box 19-8 the COPHC model is interprofessional, uses a problem-oriented approach, and mandates community involvement in all phases of the process (Graves, 2009; Molinari & Bushy, 2012).
437CHAPTER 19 Population-Centered Nursing in Rural and Urban Environments
Building professional-community partnerships is an ongoing process. At various times, nurses, other health professionals, and community leaders must assume the role of advocate, change agent, educator, expert, or group facilitator to gain both active and passive support from the community. Partnerships involve give-and-take negotiations by all participants to reach consensus. Essentially, the process begins with professionals gaining entrance into a community, establishing rapport and trust with local people, and then working together to empower the community to resolve mutually defined problems and goals. As mentioned previously and discussed also in Chapter 20, the Healthy Communities Initiative is an excellent resource for developing, defining, and responding to the stated goals. Because of the importance of churches and schools in a rural community, leaders from those institutions often are key players in building provider-community partnerships. The organiza- tional phase is a priority because it forms the foundation for all other activities related to planning, implementing, and evaluat- ing community initiatives.
As was described for case management, professional-com- munity partnerships allow more effective identification of exist- ing informal support systems that are accepted by rural residents. The goal is to integrate community preferences with new or existing formal services. Public input should be encouraged early in the planning process and must continue throughout the process to allow the community to feel that it has ownership in the project. This strategy can go a long way to address local residents viewing the process as outsiders bringing another bureaucratic program into town. Strategies that nurses can use to enhance the building of partnerships in rural environments are listed in the How To Build Professional-Community-Client Partnerships box.
HOW TO Build Professional-Community-Client Partnerships 1. Gain the local perspective. 2. Assess the degree of public awareness and support for the
cause. 3. Identify special interest groups. 4. List existing services to avoid duplication of programs. 5. Note real and potential barriers to existing resources and
services. 6. Generate a list of potential community volunteers and profes-
sionals who are willing to assist with the project. 7. Create awareness among target groups of a particular program
(e.g., individuals, families, seniors, church and recreation groups, health care professionals, law enforcement personnel, and members of other religious, service, and civic clubs).
Prepared by Gail Armstrong, DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Quality Improvement Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
Important aspects of quality improvement include: • Knowledge: Explain the importance of variation and measurement in
assessing quality of care. • Skills: Use quality measures to understand performance. • Attitudes: Value measurement and its role in good client care.
Quality Improvement Question: Examine health statistics and demographic data in your geographic area to deter- mine which vulnerable groups are predominant. Look on the web for examples of agencies you think provide services to these vulnerable groups. If the agency has a web page, read about the target population they serve, the types of services they provide, and how they are reimbursed for services. Learn about different agencies and share results during class. Based on your findings, identify gaps or overlaps in services provided to vulnerable groups in your community. Which data do these agencies collect to demonstrate the efficacy of their services? How could you deal with these gaps and overlaps to help clients receive needed services?
8. Identify potential funding sources needed to implement the program.
9. Establish the community’s health care priority list, and involve many community members in considering and selecting their health care options.
10. Incorporate business principles in marketing the program. 11. Measure the health system’s local economic impact. 12. Educate residents about the important role the local health care
system plays in the economic infrastructure of the community and the consequences of a system failure.
13. Develop local leadership and support for the community’s health system through training and providing experience in deci- sion making.
From McGinnis P: Rural Policy Development: A Community Leadership Development Approach, Kansas City, MO, 2003, National Rural Health Association.
The steps in the COPHC process include the following: • Define and characterize the community. • Identify the community’s health problems. • Develop or modify health care services in response to the community’s
identified needs. • Monitor and evaluate program process and client outcomes.
BOX 19-8 Community-Oriented Primary Health Care (COPHC): A Partnership Process
Partnership models, such as case management and COPHC, have proven to be highly effective in areas with scarce resources and an insufficient number of health care providers. Individuals and communities who are informed, active participants in plan- ning are more likely to develop consensus about the most appropriate solution for local problems. Subsequently, involved participants are more likely to use and support that system after it is implemented. Partnership models enhance the ability of rural communities to do what they historically have done well (i.e., assume responsibility for the services and institutions that serve their residents). Knowledge about partnership models and the skills to effectively implement them are useful for nurses who coordinate services that are accessible, available, and acceptable for rural populations in their catchment area.
438 PART 4 Issues and Approaches in Population-Centered Nursing
P R A C T I C E A P P L I C A T I O N Mrs. Jones, an 89-year-old widow, was diagnosed over 10 years ago with progressive congestive heart failure. She continues to live in her beloved home of 60+ years in spite of being on con- tinuous oxygen the last 3 years. She also has “bad knees” and gets around her house and yard with the use of a walker. Her husband of more than 60 years suddenly died 4 years ago of a heart attack while working on their farm. Their two married daughters live in California and Arkansas. The Midwestern town where she lives has about 1000 residents. The nearest hospital is more than 60 miles away from this town. Mrs. Jones’s 82-year-old widowed sister, Lydia Thomas, lives a few blocks from her. Their 76-year-old brother recently entered the county nursing home located in a town 20 miles away.
Even with her dyspnea and physical limitations, Mrs. Jones is able to live alone with her dog and cat, and insists that she will not relinquish her independent lifestyle as has her brother. Yet, in the past year she has been hospitalized three times: for a bad chest cold, for a kidney infection, and after a neighbor found her lying unconscious by the picnic table in her yard. Her doctor says this episode was related to a “heart problem.”
Upon being discharged from the hospital, Crystal Moore, the local home health nurse, was assigned to visit Mrs. Jones. Ms. Moore’s office is based in the County Senior Center near the nursing home where the brother is a resident. He is also a client of Ms. Moore and she visits him every Wednesday. The nurse provides outreach services to all the residents in the county referred to her by a large homehealth agency located in the city 70 miles away. As a case manager, she works closely with the hospital’s discharge planners to arrange a continuum of care for clients in the county. Nursing-related activities
include coordinating formal and informal services for clients, including biomedical supplies, oxygenation, nutrition, hydra- tion, pharmacological care, arranging for personal care, home- maker assistance, writing checks, home maintenance, emergency respite services, and home delivery of meals. A. Describe the nursing roles that Ms. Moore uses in coordinat-
ing a continuum of care for Mrs. Jones in terms of nutrition, oxygenation, pharmaceutical and biomedical equipment, transportation, and homemaker assistance.
B. Identify formal health care and support resources that can be accessed for Mrs. Jones.
C. Identify informal support resources that might be available in the small community that could help to ensure that Mrs. Jones is safe.
D. Identify three outcomes for Mrs. Jones that can be achieved by using nursing care (case) management.
E. Select a rural community in your geographic area. Create hypothetical situations, or select real clients with real health problems (e.g., an older adult with Alzheimer’s disease, a middle-aged person with cancer requiring end-of-life care, a child who is dependent on technology as a result of a farm accident). Prepare a list of services and referral agencies in that community that could be used to develop a continuum of care for each of these cases. How are these the same as, or different from, the case described in this chapter?
F. How could a public or home health nurse who is new to the community learn about formal and informal resources that could be accessed to develop a continuum of care for a rural resident for whom she cares?
Answers can be found on the Evolve site.
K E Y P O I N T S 1. There is wide diversity in the demography, economy, and
geography of rural communities. 2. Not all rural communities are based on an agricultural
economy; most are not! 3. Although many are struggling, not all rural communities
are suffering economically. Some rural communities only need more extensive economic development for sustainability.
4. Some rural towns are located in urban counties. 5. There are wide variations in the health status of rural popu-
lations, depending on genetic, social, environmental, eco- nomic, and political factors.
6. There is a higher prevalence of working poor in rural America than in more populated areas.
7. There are rural-urban health disparities. Rural adults 18 years and older overall are in poorer health than their urban counterparts; nearly 50% have been diagnosed with at least one major chronic condition. However, they average
one less physician visit each year than healthier urban counterparts.
8. More than 26% of rural families are below the poverty level; more than 40% of all rural children younger than 18 years of age live in poverty.
9. General practitioners and nurse practitioners are usual pro- viders of care for rural adults and children.
10. Rural residents must often travel more than 30 minutes to access a health care provider.
11. Nurses must take into consideration the belief systems and lifestyles of a rural population when planning, implement- ing, and evaluating community services.
12. Barriers to rural health care include the lack of availability, affordability, accessibility, and acceptability of services.
13. Partnership models, particularly case management and community-oriented primary health care (COPHC), are effective models to provide a comprehensive continuum of care in environments with scarce resources.
439CHAPTER 19 Population-Centered Nursing in Rural and Urban Environments
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C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S • Compare and contrast the terms urban, suburban, rural,
frontier, farm, non-farm residency, and metropolitan and micropolitan areas.
• Describe residency as a continuum, ranging from farm resi- dency to core metropolitan residency.
• Discuss economic, social, and cultural factors that affect rural lifestyle and the health care–seeking behaviors of resi- dents who live there.
• Identify factors that affect the accessibility, affordability, availability, and acceptability of services in the health care delivery system.
• Compare and contrast the health status and lifestyle behav- iors of rural and urban residents.
• Summarize key nursing concepts in terms of practice in the rural context.
• Examine the characteristics of rural community nursing practice and describe how these might differ from those of practice in more populated settings.
• Compare and contrast challenges, opportunities, and benefits of living and practicing as a nurse in the rural environment.
• Evaluate case management and community-oriented primary care as partnership models that can help nurses enhance the continuum of care for clients living in an envi- ronment with sparse resources.
• Propose potential areas for rural nursing research activities. Specify research questions that focus on the professional and clinical concerns of public health nurses who practice in the rural context.
440 PART 4 Issues and Approaches in Population-Centered Nursing
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20 Promoting Health Through Healthy
Communities and Cities
Jeanette Lancaster, PhD, RN, FAAN Dr. Lancaster is Professor and Dean Emerita of Nursing at the University of Virginia. She has edited this book with Dr. Marcia Stanhope through its previous eight editions.
Ms. Loren Kelly is a Clinician Educator at the University of New Mexico College of Nursing. She is also the Interprofessional Education Coordinator for the College at the University of New Mexico Health Sciences Center. She earned her BA in Political Science from the State University of New York at Potsdam; the Associate degree in Nursing at Castleton State College in Castleton, CT, her MSN in Community Health Nursing from the University of New Mexico, College of Nursing.
A D D I T I O N A L R E S O U R C E S Evolve website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz
• Case Studies • Glossary • Answers to Practice Application
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Discuss the history of the Healthy Communities and Cities
movement. 2. Discuss the Centers for Disease Control and Prevention
Healthy Communities Program. 3. Describe the core concepts and principles that guide the
development of a healthy community program.
4. Describe the steps used when working with communities in the Healthy Communities and Cities process.
5. Apply the steps in working with Healthy Communities and Cities to the concepts of health promotion.
6. Explain the role nurses can assume in working with Healthy Communities and Cities.
K E Y T E R M S appropriate technology, p. 444 Community Health Promotion Model, p. 450 community participation, p. 444 equity, p. 444 health promotion, p. 444 Healthy Communities and Cities (HCC), p. 442
healthy public policy, p. 445 international cooperation, p. 444 multisectoral cooperation, p. 444 primary health care, p. 444 —See Glossary for definitions
Loren Kelly, RN, MSN
442 PART 4 Issues and Approaches in Population-Centered Nursing
C H A P T E R O U T L I N E History of the Healthy Communities and Cities Movement Definition of Terms Assumptions About Community Practice Healthy Communities and Cities in the United States
Healthy Communities and Cities Around the World: Selected Examples
Developing a Healthy Community Models for Developing a Healthy Community
The Healthy Communities and Cities (HCC) initiative, or movement, began with the World Health Organization (WHO) in 1986 with the signing of the Ottawa Charter for Health Pro- motion. The initiative has grown and changed since 1986. This initiative, originally called Healthy Cities, has assumed a healthy communities focus in recent years. Some locales use the term healthy communities and cities, whereas other locales talk about healthy municipalities and cities, and still others use the term healthy communities. The Centers for Disease Control and Prevention (CDC) in the United States initiated work in this area in 2003, and called their program the steps program. The CDC program is now called Healthy Communities. The term healthy communities is used in this chapter; however, reference is made to other terms in order to describe the history of the movement and to refer to specific programs that use a term other than healthy communities and cities. The goal of this movement is to promote health through community engage- ment and collaboration to activate and diffuse local changes that support good health. The premise is that community members must be involved in identifying the need for health programs and in developing programs to meet those needs. Building healthy communities relies on broad-based participa- tion to make systems change in communities that can improve the health of the residents. The overall goals are to build com- munity capacity, prevent chronic diseases, reduce health risk factors and attain health equity.
This chapter provides an introduction to the history of the HCC movement and to the basic terminology related to the movement. It describes various models in which communities have structured their programs both in the United States and selected other countries. Key facilitators and barriers to the Healthy Communities process are discussed, as is the role for nurses in supporting the development and sustainment of healthy communities.
HISTORY OF THE HEALTHY COMMUNITIES AND CITIES MOVEMENT HCC is found in many regions of the world. The movement began in 1986 when the WHO’s Ottawa Charter became the first worldwide action plan for health promotion. At that time, the delegates to the conference declared that the following broad categories were prerequisites to health: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity. This is a much different approach to viewing health than the individualistic approach that holds that each person is responsible for his or her own health. Although 1986 seems to be in the distant past, the
areas for action that were determined by the Ottawa Charter for Health Promotion are highly relevant today (WHO, 1986). They are as follows: • Building healthy public policy: Many countries around the
world have begun to recognize the need to integrate health considerations into policy making and programming across sectors to achieve better health and health equity. One example of this is the Health in All Policies (HiAP) approach to improve population health. What this means is that health and equity must be embedded into governmental decision making at local, state, and national levels for collaboration across all of the sectors that influence health. Intersectoral collaboration includes policies in the areas of education, housing, transportation, land use, and neighborhood safety to promote health equity.
• Creating supportive environments: For example, when com- munities are being revitalized or developed, places should be designated as “green areas,” and made accessible to the public with parks, walking or bike paths, and fitness facilities. Both work and leisure should be a source of health for people. See Chapter 17, Integrating Multilevel Approaches to Promote Community Health for a discussion of how the environ- ment, especially the built environment affects health.
• Strengthening community action: The Ottawa Charter states (and this continues to hold true) that health promotion is most effective in communities when residents are fully engaged in the development and implementation of pro- grams. This requires a “tried and true” public health approach in which nurses listen to and respond to the needs of the community. Community members need to be involved in setting priorities, making decisions, planning strategies, and implementing them in order to attain better health.
• Developing personal skills: This includes providing informa- tion and teaching people the skills that they need in order to be healthy, such as regular and competent hand washing, choosing the right foods, engaging in regular age-appropriate exercise, and learning to avoid risk factors and increase their protective factors. This step increases the options available to people so they can have more control over their own health and their environments.
• Reorienting health services: This involves health care systems emphasizing health promotion and prevention, beyond pro- viding clinical and curative services. Individuals, community groups, health practitioners, health care institutions, and the government share responsibility for health promotion (WHO, 2010). The following Quality and Safety Education for Nurses box describes the importance of safety in com- munity care.
443CHAPTER 20 Promoting Health Through Healthy Communities and Cities
and Egypt. Other regional networks have been developed in Francophone Africa, Latin America, Southeast Asia, and the western Pacific. Particular attention is given later in the chapter to Healthy Municipalities and Communities in the Pan Ameri- can Health Organization (PAHO) region, since PAHO’s work is long-standing and well developed and has demonstrated effec- tive results.
Some claim that the concept of a healthy community or city is not new (Hancock, 1993). It is based on the belief that the health of the community is largely influenced by the envi- ronment in which people live and that health problems have multiple causes: social, economic, political, environmental, and behavioral. The HCC process has been applied to rural and metropolitan areas. The HCC process engages local resi- dents in action and is based on the premise that when people have the opportunity to work out their own locally defined health problems they will find sustainable solutions to those problems. This concept is integral to good public health prac- tice, which is to engage those for whom programs are being developed in the identification of need for, planning, imple- menting, and evaluating the programs. The Healthy People 2020 process is consistent with the way healthy communities and cities have developed their priorities and plans. One of the four goals of Healthy People 2020 is to create physical and social environments that promote good health for all. This goal relies on an ecologic perspective that says that health and health behaviors are determined by many influences including personal, organizational, environmental, and policy factors. Many of the goals of Healthy People 2020 will be challenging to meet in light of the poor economic conditions in the United States and many other countries. For example, it is difficult to increase the income of low-income persons in an era in which people continue to lose their jobs and where unemployment, especially unemployment of youth, is high. See the Healthy People 2020 box for objectives that relate to healthy communities and cities.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES As described in earlier chapters of the text, including Chapter 2: History of Public Health and Public Health Nursing, there are six Quality and Safety in Nursing competencies. All of the competencies could easily apply to Healthy Communities and Cities. However, safety is especially important for a healthy community program. Safety is an important competency for public health nurses who work in rural, suburban, and urban areas and for nurses who care for clients and communities in developed and less-developed countries. Aspects of community safety include but are not limited to the following: 1. Knowledge: Learn about the potential threats to safety including from the
physical and social environments including those at home, school, and at worksites.
2. Skills: If a safety threat is identified, such as toxic materials from a factory being channeled into a water source, organize appropriate com- munity leaders, workers, and volunteers to work toward reducing the pollution.
3. Attitudes: Be aware of the various conflicting points of view and goals in a situation in which industrial pollution affects the health of the community.
Safety Question If you think that a particular industry is emitting noxious chemicals into the air or water of the community, how do you get specific information to inform your actions?
Answer: Start by going to the Environmental Protection Agency (EPA) website (http://www.epa.gov) and search for pollutants by categories including ZIP code, address, or facility name. See Envirofacts Multisystem Search User Guide at http://www.epa.gov/enviro/facts/multisystem_user _guide.html.
As discussed in Chapter 17, health promotion is a process designed to help people increase control over, and improve, their health. Health promotion is not just the responsibility of the health sector but rather includes individuals, families, groups, and communities. Strategies and programs should be customized to meet local needs and take into account different cultural needs, economies, customs, resources, and priorities. The original goals of the Ottawa Conference continue to be areas of concern, and work must continue to achieve the goals. Chapter 4 also addresses, from a global health perspective, the need for a healthy community approach in selected countries around the world.
HCC began in the United States in 1988, with Healthy Cities Indiana and the California Healthy Cities project. Healthy Cities Indiana adapted the European experiences to the American context. The concept of Healthy Communities was used to include localities that were not cities but rather smaller com- munities such as towns or counties. In recent years, many U.S. communities have initiated the HCC process with the result that thousands of communities have taken local action to promote health. Several of these communities are featured in the chapter as examples of what a focus on health promotion at the community level would look like.
In other parts of the world, HCC has different names, includ- ing Healthy Islands, Healthy Villages, and, in Latin America, Healthy Municipalities and Communities. In addition, national networks have developed in Australia, Canada, Costa Rica, Iran,
HEALTHY PEOPLE 2020
• ECBP-8: Increase the proportion of worksites that offer a comprehensive employee health promotion program to their employees.
• ECBP-9: Increase the proportion of employees who participate in employer- sponsored health promotion activities.
• ECBP-11: Increase the proportion of local health departments that have established culturally appropriate and linguistically competent community health promotion and disease prevention programs.
• PA-13: Increase the proportion of trips made by walking. • PA-1: Reduce the proportion of adults who engage in no leisure-time physi-
cal activity. • PA-4: Increase the proportion of the nation’s public and private schools that
require daily physical education for all students. • OSH-9: Increase the proportion of employees who have access to work-
place programs
Selected Goals That Pertain to Healthy Communities
From U.S. Department of Health and Human Services, Healthy People 2020, Washington, DC, 2010, U.S. Government Printing Office.
444 PART 4 Issues and Approaches in Population-Centered Nursing
ASSUMPTIONS ABOUT COMMUNITY PRACTICE There are different models of community practice, and the assumptions that professionals have about communities shape the implementation of the HCC process. The classic work of Rothman and Tropman (1987) describing these different models and some of the key assumptions continue to be rele- vant today, as shown in the examples used in this chapter. The key models for community practice include the following: 1. Locality development is a process-oriented model that
emphasizes consensus, cooperation, and building group identity and a sense of community.
2. Social planning stresses rational-empirical problem solving, usually by outside professional experts. Social planning does not focus on building community capacity or fostering fun- damental social change.
3. Social action, on the other hand, aims to increase the problem-solving ability of the community with concrete actions that attempt to correct the imbalance of power and privilege of an oppressed or disadvantaged group in the community. Effective models of community practice use a partnership
between citizens and professionals in which there is delegated power and citizen control (Rothman and Tropman, 1987). A partnership approach, considered a bottom-up approach, incorporates the concepts of a multisectoral approach as well as community participation. A partnership approach contrasts with the top-down approaches in which professionals and experts tell the citizens what to do rather than involve and ask them.
HEALTHY COMMUNITIES AND CITIES IN THE UNITED STATES In the following paragraphs, HCC initiatives in various regions of the United States are discussed. These examples show the different models of community practice that are being imple- mented. Specifically, the CDC’s Healthy Communities Program emphasizes policy, systems, and environmental changes that focus on chronic diseases and that encourage people to be more physically active, eat a healthy diet, and not use tobacco. The rationale is based on the fact that about 50% of Americans are affected by chronic disease, and these diseases account for 7 of the 10 leading causes of death in the country. Also, there are many direct and indirect costs associated with being obese and overweight. Many chronic diseases are preventable. By prevent- ing a chronic disease from occurring, people can enjoy a higher quality of life, communities have a decreased burden of illness, and both the state and federal governments are able to reduce the amount they spend on health care (CDC, 2011). Some examples of chronic diseases cited by the CDC include the fact that heart disease and stroke account for 30% of all deaths in the United States; that nearly 26 million Americans have diabetes; and one of every 3 adults and 1 of 5 children aged 6-19 in the United States are obese (CDC, 2011, p. 2). The CDC said also that more than half of all adults fail to meet
DEFINITION OF TERMS There are many definitions of a healthy community. The Healthy People 2010 document described a healthy community as one that included those elements that enable people to maintain a high quality of life and productivity (USDHHS, 2000). To expand on this definition, consider what was stated in the docu- ment Healthy People in Healthy Communities: A Community Planning Guide Using Healthy People 2010: that a healthy com- munity would include access to health care services that include both treatment and prevention for all community members; the community would be safe; and there would be adequate roads, schools, playgrounds, and other services to meet the needs of the people in the community; and that the environment would be healthy and safe (USDHHS, 2001).
The CDC defines a healthy place as one that is “designed and built to improve the quality of life for all people who live, work, worship, learn, and play within their borders—where every person is free to make choices amid a variety of healthy, avail- able, accessible, and affordable options” (CDC, 2014, p. 201). The CDC also points out that a healthy community is one that continuously creates and improves both the physical and social environments and expands community resources to enable people to mutually support each other in carrying out essential life functions as well as in developing to their maximum poten- tial. A healthy community seeks to improve the quality of life of its people and does this through collaboration, partnerships, diverse and extensive citizen ownership, and partnership in the process.
The principles of primary health care (WHO and UNICEF, 1978) and the Ottawa Charter for Health Promotion (WHO, 1986) were instrumental in the development of the Healthy Cities movement. Primary health care refers to meeting the basic health needs of a community by providing readily acces- sible health services. Because health problems transcend inter- national borders, international cooperation is important to ensure health. The principles of primary health care include equity, health promotion, community participation, multisec- toral cooperation, appropriate technology, and international cooperation.
Equity implies providing accessible services to promote the health of populations most at risk for health problems (e.g., the poor, the young, older adults, minorities, the homeless, and immigrants and refugees). As discussed in Chapter 17, health promotion and disease prevention focus on providing community members with a positive sense of health that strengthens their physical, mental, and emotional capacities. Individuals within communities become involved in health promotion through community participation, whereby well- informed and motivated community members participate in planning, implementing, and evaluating health programs. Multisectoral cooperation is the coordinated action by all parts of a community, from local government officials to grassroots community members. Appropriate technology refers to affordable social, biomedical, and health services that are relevant and acceptable to individuals’ health, needs, and concerns.
445CHAPTER 20 Promoting Health Through Healthy Communities and Cities
professionals but also can be used by community leaders. The Task Force on Community Preventive Services continually updates its recommendations. See www.uspreventiveservicetask force.org. The current task force is called the U.S. Preventive Services Task Force (USDHHS, 2014). This guide provides health professionals with an authoritative source for making decisions about preventive services. The guides build on a socio-ecological model that recognizes that social and physical environments affect health and health behavior. This model divides the environment into five areas that affect health behav- ior: individual, interpersonal, organizational, community, and policy. Using the Handbook relies on the same process used in the assessment of a community. In other words, before deciding which of the five areas to target in your work, follow these steps: 1. Conduct a needs assessment and set health priorities. 2. Find out what social and environmental factors may affect
each health priority as well as what options are available for dealing with the chosen health priorities.
3. Think about the acceptability (to the community) and the feasibility (are resources available, etc.) to implement the project(s). As you work with the action guides, remember to take small
steps and do first things first; involve the appropriate people and do not be reluctant to make changes as you go based on what you learn and the outcomes you have (Partnership for Preven- tion, 2008).
HEALTHY COMMUNITIES AND CITIES AROUND THE WORLD: SELECTED EXAMPLES As mentioned earlier, PAHO in collaboration with the WHO has a long-standing involvement in developing healthy com- munities that they call the Healthy Municipalities and Com- munities Movement. The mission of this movement is to “strengthen the implementation of health promotion activities at the local level, making health promotion a high priority of the political agenda; fostering the involvement of government authorities and the active participation of the community, sup- porting dialogue, sharing knowledge and experiences and stim- ulating collaboration among municipalities and countries” (PAHO, 2012). Other key concepts in their approach include multisectoral partnerships to improve social and health condi- tions and advocacy for developing healthy public policy, main- taining healthy environments, and promoting healthy lifestyles. PAHO believes that creating a healthy municipality involves a process that relies on strong political commitment and support that is aligned with equally strong communities who are deter- mined to achieve their goals and who participate actively in the process of goal achievement (PAHO, 2012).
PAHO recommends a participatory development framework to gain commitment from the mayor, local government (all sectors), and representatives of community groups and organi- zations. PAHO has found this process to be the most effective in the Americas. The phases are as follows: 1. Aspects in the initial phase of the process
• Meet with local government authorities and community leaders to gain their perspectives about such things as
recommendations for aerobic physical activity based on the 2008 Physical Activity Guidelines for Americans; that tobacco is the single most preventable cause of disease, disability, and death; and that excessive alcohol use is the third leading cause of death related to lifestyle (CDC, 2011, p. 2).
These chronic disease facts support the priority that the CDC has placed on funding projects that will interrupt chronic diseases in communities around the country. Since 2003, the CDC’s Healthy Communities Program has funded more than 330 rural, urban, and tribal communities to support their goals. Specifically, their programs include Strategic Alliances for Health Communities, ACHIEVE (Action Communities for Health, Innovation, and EnVironmental ChangE), REACH U.S., Pioneering Healthy Communities (in collaboration with the YMCA of the USA), and Steps Communities (CDC, 2014). Also, Communities Putting Prevention to Work (CPPW) is a locally driven program that supports 50 communities as they tackle obesity and tobacco use. The CDC (2014) says that over 50 million people, or one in six Americans, live in a city, town, county or tribal community that benefits from these programs.
The CDC has also developed a set of “tools for community action” that can be used in developing healthy communities. Some of these tools are as follows: 1. Community Health Online Resource Center: formerly the
Community Health Resources Database: see http://cdc.gov/ DCH_CHORC/ to find assistance in planning, implement- ing, and evaluating community health interventions and programs that address their focus on chronic disease.
2. The Community Guide: see http://www.thecommunity guide.org/index.html to find evidence-based public health and community health interventions.
3. Community Health Assessment and Group Evaluation (CHANGE) Tool: Community leaders can use this tool to see what local policy, systems, and environmental strategies are currently in place in their communities and identify areas where health strategies are needed. CHANGE assists communities to define and prioritize areas for their own improvement. See http://www.cdc.gov/nccdphp/dch/ programs/healthycommunitiesprogram/tools/change/pdf/ changeactionguide.htm. Accessed August 15, 2014.
4. Action Guides: The Community Health Promotion Hand- book: Action Guides to Improve Community Health (Partner- ship for Prevention, 2008). In collaboration with the Partnership for Prevention program, the CDC has developed a set of “how-to” guides for five community-level health promotion strategies related to its chronic disease preven- tion target areas of diabetes self-management, physical activ- ity, and tobacco-use cessation. See http://www.prevent.org/ Initiatives/Action-Guides.aspx for a listing of specific guides. Also, see the CDC website for the other five guides to help communities develop health programs. Given the usefulness of the CDC Community Health Promo-
tion Handbook, further discussion is warranted here. The rec- ommendations for the five guides that the CDC chose came from the Task Force on Community Preventive Services (TFCPS, 2005). The handbooks primarily target public health
446 PART 4 Issues and Approaches in Population-Centered Nursing
academics, policy makers, youth, and seniors. They include rural and regional communities (www.communitybuilders .nsw.gov.au).
• Association for Community Health Improvements: This orga- nization’s website includes many healthy community tools and organizations in the United States and internationally. Similarly, www.healthycommunities.org hosts a website with valuable information about healthy communities and exten- sive links to other sites. Selected examples of healthy communities in the United
States are discussed later in this chapter. Also see Chapter 4 for examples of Healthy Cities Toronto, Canada, and Chengdu, China.
DEVELOPING A HEALTHY COMMUNITY What do people want from a healthy community? We know that each community is different and its challenges, goals, resources, competencies, problem-solving skills, and practices are differ- ent. As discussed throughout the chapter, many organizations in the United States and other countries have worked to help communities become healthier (Figure 20-1). One of these organizations in the United States is the National Civic League (2007). (See www.communitycommons.org/tag/nation-civic- league). In 2014, the National Civic League partnered with Community Commons to celebrate 25 years of Healthy Com- munities and to spread the ideas and insights in published and new online media. They emphasize the complexity of develop- ing healthy communities and have identified five principles that they think should be applied in community work if the goal is to find solutions using a broad-based inclusive process. These principles are as follows: 1. A broad definition of health that goes beyond the absence of
disease to address the root problems in communities and
healthy spaces and health promotion and to request that they make a public statement as well as a joint declaration of their commitment.
• Create an intersectoral, community planning committee. • Conduct a needs assessment including analysis of prob-
lems and needs. • Build consensus and decide on priorities for action.
2. Steps in the planning process • Train the committee and task forces to ensure that they
understand the concept of healthy community, the set- tings approach to health promotion, and participatory methods including needs assessment, planning, evalua- tion, and health education.
• Develop an action plan. • Mobilize resources needed to implement the plan and
develop a detailed work plan. 3. Moments in the consolidation phase of the process
• Implement activities that are included in the plan. Exam- ples might be establishing health-promoting schools, workplaces, markets, hospitals, and other healthy environments.
• Evaluate the results as well as the quality of participation. • Share knowledge and experiences with others. PAHO notes that the steps that work in its region may be
somewhat different from those that have been successful in Canada, the United States, and Europe. Later in this chapter, the 20 steps that PAHO says have been used by these other countries are cited as a way for nurses and other public health workers to develop a healthy community strategy. Interestingly, PAHO has found that it must start its process by gaining support from the mayor of the community and from other community leaders. These individuals must understand the concept of health pro- motion and the healthy municipalities process before they will offer their support. PAHO has also found that it must have a strong and knowledgeable support group who can envision a healthy municipality and convey that vision to opinion leaders (PAHO, 2012).
There are many excellent examples of Healthy Communities and Cities around the world. PAHO says that in some countries in their region, such as Mexico, Costa Rica, Chile, and Cuba, national networks have been established and been producing good results for many years (PAHO, n.d.). A few examples are highlighted here with information on how to locate their web- sites and learn more about the work being done around the world. • Ontario (Canada) Healthy Communities Coalition: They
focus on “What makes a healthy community.” Their website, www.ohcc-ccso.ca, is filled with useful resources.
• Horsens, Denmark: One of their key foci is on “safe com- munity Horsens.” Their website, www.horsenssundby.dk, is in Danish, but the button to choose English is clearly marked and they provide an overview of the work they are doing.
• Community Builders of New South Wales, Australia: They have an interactive electronic clearinghouse for persons involved in community level, social, economic, and environ- mental renewal, including community leaders, community and government workers, volunteers, program managers,
FIGURE 20-1 Community participation for developing a healthy community involves a representative community planning com- mittee. (From CDC, Pulsenet News, 2004. Available at: http:// www.cdc.gov/pulsenet/newsletter/Spring_2004.htm. Accessed January 10, 2011.)
447CHAPTER 20 Promoting Health Through Healthy Communities and Cities
same question before looking at Box 20-1 and see how close your replies are to those of the respondents.
This chapter indicates that a healthy community has involve- ment, inclusiveness, cooperation, and collaboration, among other qualities. Collaboration can help make the best use of resources, reduce duplication and competition, increase effec- tiveness, and develop more sustainable resources. It is like a recipe in that each agency in the collaboration brings one or more ingredients to the product. Putting all the ingredients together leads to a better product. Collaboration involves doing things differently than in the past and developing different kinds of partnerships and relationships. Organizations that work together effectively have generally achieved three things: 1. High levels of trust 2. Serious time commitment from the partners 3. A diminished need to protect their own turf (Torres &
Margolin, 2003) Collaboration requires the same mix of behaviors and goals
as those associated with the development of a healthy community—that is, a group of participants including those who are paid and volunteers who bring different skills and talents to the process and who work together to do the following: 1. Address a specific problem or opportunity 2. Work on a broad agenda of mutually beneficial goals 3. Provide a forum to discuss and respond to community con-
cerns, interests, and resources 4. Recognize that there are roles in a partnership and they will
be different from the role the person had in the parent organization. As mentioned earlier, Indiana and California have the longest
history of Healthy Communities and Cities in the United States. Healthy Cities Indiana began as a pilot program in 1988 with a grant from the W.K. Kellogg Foundation as a collaborative effort among Indiana University School of Nursing, Indiana Public Health Association, and six Indiana cities. On the basis of this project’s success, the W.K. Kellogg Foundation funded the dissemination phase, called CITYNET-Healthy Cities, in cooperation with the National League of Cities through their network of 19,000 local officials (Flynn, Rider, & Ray, 1991). This was an extensive project that initially involved six cities (Gary, Fort Wayne, New Castle, Indianapolis, Seymour, and Jeffersonville). Activities in these cities focused on problems of diverse populations. For example, actions were consistent with local priorities that included problems of children, teen parents, the homeless, access to health care, crime and violence, and older adults. Action was also taken on the broader environmen- tal policy issues, including management of solid waste and pro- motion of air quality. For each of these projects, the Community Health Promotion process was followed, thereby providing a broad base of community participation at all stages of com- munity planning. This was a process developed at Indiana Uni- versity School of Nursing, and it was consistent with many of the other U.S. and international processes for implementing healthy community initiatives.
An early example of the use of the Community Health Pro- motion process was the New Castle Healthy City community
includes economy, education, parks and recreation, arts, mental health, and community spirit and unity.
2. A collaborative, consensus-based approach to problem solving that involves a diverse group of citizens from the community.
3. An assets-based approach to problem solving that defines people and relationships by their skills and abilities rather than their needs and deficits.
4. Addressing challenges at a systems level in the community rather than implementing another short-term, low-impact project.
5. Creating a shared vision for the future that captures the hopes and dreams of the community and that guides col- laborative work. Other principles will guide the development and implemen-
tation of a healthy community. Examples of useful principles include the following: • The whole is greater than the sum of the parts; in other
words, most communities have limited resources, and no one agency can do all that is needed. However, if agencies work together, the outcome of the whole can be much bigger than the outcome of the aid provided by one agency.
• A change in one part of the system affects the others. For example, if the public transportation workers in a large city go on strike and there is no public transportation for many days, many areas of the community will be affected.
• Collaboration is central to the development of a healthy community.
• All systems have feedback loops whereby information from one area is fed back to the whole and provides an opportu- nity for change or “course correction.” For example, you might establish a helping program for dependent older adults where daycare is provided at low cost. This would enable the family members with whom the elder lives to provide safe care while they worked. However, if the family has no transportation of their own and the facility is not accessible by public transportation, the program would not be as helpful as hoped. The National Civic League also asked hundreds of commu-
nities across the country “What would your community look like if it were a really healthy place to live?” The replies shown in Box 20-1 come as no surprise. You might ask yourself that
• A clean and safe environment • A diverse and vibrant economy • Good housing for all • Good roads and good public transportation • Parks, playgrounds, and recreational facilities • People who respect and support each other • A place that promotes and celebrates its cultural and historical heritage • A place where citizens and government share power and where citizens
feel a sense of belonging • A place that has affordable health care for all • A place that has good schools • A place that has and supports strong families
BOX 20-1 What Is a Healthy Community?
448 PART 4 Issues and Approaches in Population-Centered Nursing
levels of unhealthy behaviors, such as cigarette smoking and inadequate exercise, compared with the Healthy People 2000 national objectives.
They used the survey results to determine the focus of their Healthy City initiatives. Using the data, they testified before the county commissioners about the need for health education and to support the employment of a health educator in the local health department. The cigarette smoking results were used by the committee to testify before the city council in support of an ordinance banning smoking in city buildings. The committee also sponsored community health awareness programs includ- ing a family fitness walk, safety checks of bicycles, and presenta- tions on healthy food preparation emphasizing reduced fat and salt in meals.
New Castle has expanded its focus and is now known as Healthy Communities of Henry County. They focused on devel- oping a network of walking trails throughout the county on the Trans-Indiana National Road Heritage Trail (NRHT) (Figure 20-2). Their 15th Annual Raintree Ride was held Septem- ber 2014. (See www.hchcin.org for more details on this worthy project and the implied enthusiasm for its accomplishment.) The process for the walking trails initiative, which began in 2002, is consistent with that of other successful healthy community proj- ects. Specifically, consultants worked with the committee to conduct a feasibility study and write a grant. Over the years, the committee obtained broad community support and cooperation, not only in defining local problems, but also in setting priorities and implementing their initiatives. Their interventions integrated individual lifestyle changes and policy changes aimed at promot- ing supportive environments for health.
FIGURE 20-2 Walking trails in Indiana help people engage in health-promoting exercise. (From indianatrails.org, 2010. Cour- tesy of Beverly Matthews. Available at: http://www.indianatrails .org/NRHT/photos.htm. Accessed January 12, 2011.)
Sanneh EJ, Hu AH, Njai M, et al: Making basic health care accessible to rural communities: A case study of Kiang West District in rural Gambia, Public Health Nursing 31(2):126–133, 2013.
This case study examined how lack of access to basic health care affects the health of poor, rural people in Gambia and what strategies including extensive use of nurses can help alleviate some of the health problems. Although this study was carried out in an African country, the information learned by the researchers has application in any country in which people live in rural areas and have difficulty accessing health care. The authors point out that poor people in developing countries tend to suffer “from a phenomenon known as the poverty penalty (the additional cost paid for goods and services by the poor relative to the more affluent)” (Sanneh et al, 2013, p. 126).
Sub-Saharan Africa, including Gambia, has a higher under-five mortality rate than anywhere else in the world. The 2007-2020 National Health Policy Frame- work of Gambia, entitled “Health is Wealth” aimed to address health issues through both preventive and curative services. They developed a health pyramid that placed primary care (village health services) at the base; second- ary care (minor and major health centers) as the next two types of care delivery moving up the pyramid; and tertiary care (hospitals) at the peak of the pyramid.
Their case study took place in Kiang West, in the Lower River Region of Gambia, which has a 50% poverty rate among its population ratio of 30,000 people per primary health care facility. Roads are not well developed and there is little economic activity. This was the work of a multistakeholder group including representatives from the government, Medical Research Council, World Health Organization, and the United Nations International Children Emergency Fund. The representatives of the health sector and a range of stakeholders initiated various activities to improve care, including improving staffing at the Karantaba Health Centre with more traditional birth attendants and village health workers who worked with the community health nurses to provide primary health care. They expanded programs for immunizations, providing children with two high doses of Vitamin A (which is critical to child health and immune function), surveillance of infectious disease, and mid- wifery services. Nurses play a key role in health care in this country. They documented improvements in the primary care services that they increased.
Nurse Use What the collaborators in the multistakeholder group learned is that “no single organization, sector, nor approach can provide answers for underdevelopment, poverty, and ill health.” They noted that “the importance of cooperation, both within a specific sector and across sectors, cannot be stressed enough” (p. 132).
EVIDENCE-BASED PRACTICE
assessment. The community committee found that there were high death rates in the community from cancer, chronic obstructive pulmonary disease, and heart disease. The commit- tee asked the following questions: Why were rates higher in this area than in the state and the nation? What were the lifestyle choices of people in the community? What in the environment supported or inhibited healthy choices?
The committee worked with the staff at Indiana University School of Nursing to develop a survey to obtain baseline data on health behaviors in the community. Staff at the University trained local volunteers in survey data collection. They distrib- uted 1000 door-to-door surveys using a system that ensured appropriate geographic coverage in the community. The response rate of 50% demonstrated the community’s interest in health concerns. They then compared their findings with the national health objectives (USDHHS, 1991). They found high
449CHAPTER 20 Promoting Health Through Healthy Communities and Cities
that led the school district to reduce fat calories in school lunches. The initiative was expanded to increase awareness of cardiovascular risk factors among elementary school students, and the work is ongoing.
In California, Building Healthy Communities is a ten-year comprehensive community effort to help Californians think about and support the health of the community. This work is funded by the California Endowment Building Healthy Com- munities fund. The Endowment distributed $1.7 billion in its first decade of operations. The Endowment thinks that a spe- cific focus helps them have a great impact, and they are focusing on healthy community building. Specifically, they are targeting “a nexus of community, health, and poverty to advance a ‘pre- vention movement’ in California” (California Endowment, 2010, p. 1). The Endowment plans to focus on this area for the next decade to develop “places where children and youth are healthy, safe and ready to learn” (California Endowment, 2010, p. 2). They think that the health of children is a primary indica- tor of the health of its communities (Figure 20-3). For news and information about Building Healthy Communities. See www.calendow.org/healthycommunities/building-healthy -communities/.
Another example in Indiana is the Healthy Communities Initiative in Bartholomew County. The Initiative began in 1994 with a goal of improving health and quality of life for residents of the county. They have remained true to their origi- nal concept of collaboration across the community. Their Guiding Principles are as follows: • Collaboration • Community Ownership • Inclusive/Broad Based • Benchmark & Measure Outcomes • Long-Term Commitment • Continuous Learning • Positive Motivation
The current collaboration is between Columbus Regional Hospital, schools, businesses, local government, churches, and others working together to address identified health needs. See more at http://www.crh.org/community-involvement/healthy -communities.aspx#sthash.vUfQc1D7.dpuf. They have action teams in community medication assistance, caring parents, domestic violence, Proyecto Salud, healthy lifestyles, tobacco awareness, volunteers in the medicine clinic, and a breast feeding coalition (Columbus Regional Hospital, 2014).
The second state to be featured is California. The California Healthy Cities and Communities (CHCC) is a program of the Center for Civic Partnerships, a part of the Public Health Insti- tute. For the past 25 years, the Center has assisted and supported over 100 cities and communities in the state to develop community health improvement initiatives (Center for Civic Partnerships, 2014). They work with communities of varying sizes and have developed strategies to curtail exposure to tobacco, increase opportunities for physical activity, encourage better nutrition, and improve public safety. This network is built on the premise of shared responsibility among community members, local officials, and the private sector. Community participation is the cornerstone of the projects, and the mission is to reduce inequities in health status that exist among diverse populations in communities. They publish a newsletter called Connections that can be accessed on their website: http://www.civicpartnerships.org/#!ca-healthy-cities -and-communities-progra/cjhg.
In 1989 Pasadena became a charter city of the California Healthy Cities project and produced a quality-of-life index with extensive input from residents, technical panels, and neighbor- hood groups. The index included over 50 indicators affecting community life, such as safety, education, substance abuse, rec- reation, economy, and housing. The index guided policy devel- opment in tobacco control, alcohol availability, and infant health education. It also assisted city and community agencies in planning, priority setting, resource development, and bud- geting. In 2008, Pasadena engaged a consulting group to help them update these indicators so they might continue their growth as a healthy city.
Another example of California Healthy Cities and Commu- nities is in Chico. A Healthy Chico Kids 2000 community-wide initiative was started, focusing on nutrition and health promo- tion. Nutrition education was provided for students in kinder- garten through sixth grade. A dietary assessment was conducted
FIGURE 20-3 Supportive communities provide playgrounds where children can play and exercise in a safe location. (From Metro Regional Government, 2010. Available at: http:// www.oregonmetro.gov/index.cfm/go/by.web/id/149. Accessed January 10, 2011.)
450 PART 4 Issues and Approaches in Population-Centered Nursing
Box 20-2 describes principles of community engagement that need to be considered in the community engagement process.
3. Develop a structure in the community for health promotion. This step is similar to the PAHO stage of assembling a steer- ing committee that will plan and coordinate the work. Some ways to collaborate and get the work done that support the HC process are (1) the whole local partnership deliberates and shares information, but subgroups make decisions and implement them; (2) the local partnership serves as a single advisory board for multiple agencies; and (3) the whole local partnership makes decisions, but subgroups take action together (Veazie et al, 2001). The steering group might develop and communicate a clear vision and mission that is broadly understood by all participants and not just by health professionals. The mission should define the problem and acceptable solutions in such a way as to engage (not blame) those community members most affected and not to limit the strategies and environmental changes needed to address the community-identified concern. Ongoing action plan- ning should identify specific community and system changes that can lead to widespread behavior change and community health improvement. The committee should develop wide- spread leadership, engaging a broad group of members and
There are thousands of Healthy Communities and Cities programs in the United States seeking local solutions to complex problems. Nurses often play key roles in the work of Healthy Communities and Cities programs.
MODELS FOR DEVELOPING A HEALTHY COMMUNITY There are many models to guide the development of a healthy community. The models have a considerable amount of com- monality. This section discusses how a nurse could either lead or be part of a team responsible for designing, implementing, and evaluating a healthy community. As has been seen, most of the successful healthy communities or cities establish priorities that are identified after careful assessment and enormous amounts of community involvement. Nearly 20 years ago, faculty at the Indiana University School of Nursing under the leadership of Beverly Flynn developed a Community Health Promotion Model by adapting the European model of cities to the United States. This section discusses the key steps needed to develop a healthy community and compares them to the model developed at Indiana University. The steps of a general model that PAHO describes as common to models in the United States, Canada, and Europe are as follows (PAHO, 2012):
1. Build a local support group 2. Know about the Healthy Cities idea 3. Know the city or community 4. Gain financial support 5. Decide where the organization for the project will be
located 6. Develop the proposal 7. Appoint a project steering committee 8. Analyze the environment in which the project will take
place 9. Define clearly the work of the project
10. Set up the project office 11. Plan a long-term strategy 12. Build project capacity 13. Establish accountability mechanisms
Now compare the previous 13-step model to the nine steps in the Community Health Promotion Model (Produced by the Institute for Action Research for Community Health/Indiana University, 1994) (Flynn, 1997): 1. Orient the community to the idea of community health
promotion. For example, meet with formal and informal leaders to identify persons in the community who have an interest in and the capability to support the community development process. You could hold an informational com- munity forum, or establish a task force to plan. The key is to find people who are committed to the process.
2. Build the partnership. Learn who the formal and informal community leaders are so you know who is listened to in the community. Be sure to have broad-based representation on your planning committee. Remember that people participate when they think there is a need, feel a sense of community, see their involvement as helpful and worth their time, and think the benefits outweigh possible costs (CDC, 1997).
Before starting a community engagement effort: • Be clear about the purposes or goals of the engagement effort, and the
populations and/or communities you want to engage. • Become knowledgeable about the community in terms of its economic
conditions, political structures, norms and values, demographic trends, history, and experience with engagement efforts. Learn about the com- munity’s perceptions of those initiating the engagement activities.
For engagement to occur, it is necessary to: • Go into the community, establish relationships, build trust, work with the
formal and informal leadership, and seek commitment from community orga- nizations and leaders to create processes for mobilizing the community.
• Remember and accept that community self-determination is the responsi- bility and right of all people who comprise a community. No external entity should assume it can bestow on a community the power to act in its own self-interest.
For engagement to succeed, you need to: • Partner with the community to create change and improve health. • Recognize and appreciate all aspects of community engagement and
respect community diversity. In order to effectively design and implement approaches for community engagement, be aware of the various cultures and other areas of diversity of a community.
• Realize that you can only sustain community engagement by identifying and mobilizing community assets, and by developing capacities and resources for community health decisions and action.
• Be prepared to turn over control of actions or interventions to the community, and be flexible enough to meet the changing needs of the community.
• Make a long-term commitment to the engaging organization and its partners.
BOX 20-2 Principles of Community Engagement
From Centers for Disease Control and Prevention: Principles of community engagement, Atlanta, 1997, CDC. Available at http://www.cdc.gov/phppo/pce. Accessed April 4, 2010.
451CHAPTER 20 Promoting Health Through Healthy Communities and Cities
motorcycle helmet laws, handgun laws, and immunization policies for school-age children. Providing information is a way to serve as an advocate. Nurses may be asked to testify or assist others to prepare testimony that will give the city council, county commissioners, or other members of plan- ning groups the information they need to promote the devel- opment of healthy public policy.
9. Monitor and evaluate the progress. This step is similar in all problem-solving processes. You must watch the progress, make sure you stay on track, or make a course correction if needed and then evaluate the outcome. As can be seen, both models use a problem-solving approach,
and the latter is clearly similar to the use of the nursing process in the community with a goal of promoting health. In the fol- lowing box a brief case illustrates how a model such as the ones listed previously are used to guide the development of a healthy community.
allies in the work of the community organization, mobiliza- tion, and change (Roussos & Fawcett, 2000). The member- ship of the working group should be diverse and clearly reflect the community’s composition.
4. Determine who will lead the health promotion work. You may need to provide some leadership development work at this stage, such as sending members to conferences or work- shops or using consultants or online training programs.
5. Assess the community. The steps here follow those in the chapter on community assessment. Start by clarifying the purpose of the assessment and what you will do with the data you collect. The assessment provides the frame of reference for identifying the community’s strengths, needs, and resources.
6. Plan for community-wide health. Many of the skills for working with groups that are discussed in Chapter 16 will be used in this step of the process, as will models for plan- ning in Chapter 25 that discusses program management.
7. Develop community action for health. The interventions at this stage should be designed to achieve the outcomes cited in Box 20-3. These nine areas can guide the selection of actions and provide a focus for the evaluation.
8. Provide information based on data to policy makers. Effec- tive development of public policy relies on dialogue between those making the policies and the members of the public who will be affected by them. The aim is to link policy makers, professionals, and citizens together to achieve com- monly agreed on health goals. Examples of healthy public policies include seat belt legislation, no-smoking policies,
HOW TO Work with a Healthy Community Initiative: A Case Example The Crooked Creek Quality of Life Initiative (CC QOLI): A Commu- nity Development Experience took place in Indianapolis, Indiana. The purpose of the initiative was to improve the quality of life of residents of a geographically defined neighborhood in an Midwest- ern city in the United States. An advisory board provided oversight for a comprehensive assessment conducted by nursing students. The assessment results were used for developing a proposal that funded an advisory group appointed by the mayor of the city. The PAHO Healthy Cities and Municipalities model was used to bring diverse sectors of the community together to collaborate in order to address the conditions responsible for health and well-being. Organizations involved included a hospital, social service agency, housing development agency, and university.
The goal of the CC QOLI was to improve the quality of life of Crooked Creek residents through: 1. Revitalization of built environments (such as in commercial and
community buildings, housing, roads, and sidewalks) 2. New collaborations among health, education, and social service
organizations 3. Engagement of the residents in community improvement
Initiatives implemented to achieve these goals were investment in a housing program for low- and moderate-income residents; con- struction of a Family Pavilion to address the civic, social, intergenera- tional, cultural, and recreational needs of Crooked Creek individuals and families; and a School Health Program for area students. Results Achieved The Fay Biccard Glick Family Pavilion at Crooked Creek was con- structed and now provides a wonderful space for community gath- erings, youth and family activities, recreation, and an affordable venue for wedding receptions, family reunions, graduation ceremo- nies, open houses, and religious services. The School Health Program moved health care delivery beyond traditional hospital walls and is now part of a broader vision to build healthier communi- ties. School corporations have adopted healthier school policies and are able to address chronic issues of asthma, obesity, and absen- teeism. Investments in housing have resulted in completion of three congregate living homes providing a home for 12 disabled residents, and the most recent home uses “green” building prac- tices. Additional results have been the provision of costly repairs to the homes of 33 elderly homeowners; education of 60 potential homebuyers about the home-buying process; and down payment
• Health education: Health knowledge, attitudes, motivation, intentions, behavior, personal skills, and effectiveness
• Influence and social action: Community participation, community empowerment, social standards, and public opinion
• Healthy public policies and organizational practices: Political stat- utes, legislation, and regulation; location of resources; organization prac- tices, culture, and behavior
• Healthy living conditions and lifestyles: Use of tobacco, availability of food and food choices, physical activity, consumption of alcohol and drugs, relationship between protective factors and risk factors in the physical and social environment
• Effectiveness of health services: Delivery of preventive services, access to the health services, and quality of services
• Healthy environments and spaces: Restricted sale of tobacco and alcohol; restrictions on illicit drug use; positive environments for children, young people, and older adults; and sanctions for abuse and violence
• Social results: Quality of life, social support networks, positive discrimi- nation, equity, development of life skills
• Health outcomes: Reduction of morbidity and mortality, disability, and avoidable mortality; psychosocial and life skills
• Capacity building and development: Measures of sustainability, com- munity participation and empowerment, human-resources development
BOX 20-3 Designing Interventions and Evaluating Results of Healthy Municipalities and Cities
From Pan American Health Organization: Healthy municipalities and communities: mayor’s guide for promoting quality of life, Washington, DC, n.d., World Health Organization, p 24. Available at http://www.paho .org/english/ad/sde/hs/mayorsguide.htm. Accessed January 21, 2011.
452 PART 4 Issues and Approaches in Population-Centered Nursing
LINKING CONTENT TO PRACTICE
Health promotion using the healthy community model relies on key public health skills and core competencies. Such an approach includes the core functions of assessment, policy development, and assurance, which is making sure that there is a competent workforce available to meet the needs of the community. See Chapter 1 for details on the public health core functions.
Specifically, the Public Health Nursing: Scope and Standards uses a community-focused problem-solving process that is consistent with the steps in developing a healthy community (ANA, 2013). Throughout the Quad Council Public Health Nursing Competencies document are competencies that also fit this process. For example, in many of the domains, there is an emphasis on collaboration with others for determining health priorities and in using the policy-making process to achieve health goals (Quad Council, 2011). Also, the steps in healthy community development are congruent with the Intervention Wheel discussed in Chapter 9.
assistance for 12 first-time buyers who purchased homes in Crooked Creek. Factors Affecting and/or Hindering Success A major barrier occurred when the contractor for the Family Pavilion project walked off the job midway through the project, resulting in an 8-month delay and cost overruns. Another contractor was hired and funds were raised to complete the project. The School Health Program became more complex when partners realized that the unique nature of each school required that interventions be tailored for each particular school’s student population. The investments in housing programs found the cost of projects were sustainable only to the degree that the organization continued to successfully compete for public and private funds to underwrite projects. Summing Up Lessons learned across initiatives include: 1. Collaboration makes individual organizations stronger—a new
organization without a track record benefits from partnering with an established organization, which gives others “permission” to be supportive. Established organizations benefit from the energy and entrepreneurial aspects of start-ups.
2. Having a good plan based on good data is crucial to securing funding and support.
3. Program operators need to ensure that senior leaders (senior execu- tives and board members) stay informed and engaged over time in order to sustain initiatives over the long term. Otherwise they risk being replaced by the next new (and not necessarily better) thing.
Authors: Alicia Chadwick with Crooked Creek Northwest Community Development Corporation, Helen Lands with Fay Biccard Glick Neighborhood Center, Mary Beth Riner with Indiana University School of Nursing, and Marty Rugh with St. Vincent Health.
Because nurses naturally work with community people from different walks of life and are respected health professionals in the community, they are well suited to promote Healthy Com- munities (HC). Look for opportunities within existing com- munity partnerships that you work with and that are also interested in promoting the community’s health. Plan how to introduce them to the HC process, and work together to find ways to initiate the process with your combined network of contacts to develop activities that support improved health.
Nurses may work with the healthy community process in a variety of ways and in many stages. It is important to remember that evaluation and research are important parts of the process. Specifically, nurses may initiate, coordinate, or be part of a research team conducting program evaluation research. Provid- ing data relevant to changes in health status through short-term impact evaluation and long-term outcome evaluation is valu- able in creating the knowledge base for validating the field of community health promotion. The following How To box describes the steps to use in organizing a community meeting to plan a healthy community.
The Linking Content to Practice box applies many of the key public health documents to the work of developing a healthy community. Remember that the ultimate goal is to promote the community’s own leadership for health. In other words, the nurse must not do for the community what it can do for itself. The role of the nurse and of other health professionals in Healthy Communities is to work in partnership with commu- nity leaders (Flynn, 1997). John Ashton (1989), one of the
founders of the European Healthy Cities project, summarizes the role of health professionals in Healthy Cities as being “on tap, not on top.” The Levels of Prevention box provides sugges- tions for how to foster community education and action, and the How To box describes how to organize a community meeting related to the HC model.
LEVELS OF PREVENTION
Primary Prevention Develop a community forum to initiate communication about health promotion.
Secondary Prevention Assess needs and strengths in the community to detect ways to address health problems.
Tertiary Prevention Initiate community action when problems have occurred and evaluate and monitor progress of programs and policies.
Healthy Communities
HOW TO Organize a Community Meeting About Healthy Communities 1. Identify who should be included in the community meeting. It is
critical that all sectors and population groups in the community be involved.
2. How will they be invited to the meeting? Who will invite them? Allow at least 2 weeks so people can arrange their schedules.
3. Who will convene the meeting? 4. Set the date and time for the meeting and arrange for a neutral
meeting place. 5. Plan the meeting agenda:
a. Introduction of participants b. Introduction to Healthy Communities (HC) c. Identification of community people who should be there
(“Whom did we miss?”) d. Questions and discussion about HC, and about community
issues that are important e. Commitment to the HC process f. Formation of the HC committee (obtain names and addresses
of those interested) g. Other suggestions
453CHAPTER 20 Promoting Health Through Healthy Communities and Cities
P R A C T I C E A P P L I C A T I O N Because nurses work in partnership with the community in Healthy Communities, the examples of outcomes of HC initia- tives reflect that partnership rather than a specific nursing inter- vention. An example of an outcome of a HC initiative that used the Community Health Promotion process is Fort Wayne, Indiana, Healthy City.
Committee members of the Fort Wayne, Indiana, Healthy City project collaborated in a community-wide program to address the fact that only 65% of Fort Wayne preschool children were immunized. Access to immunization services was expanded to five sites throughout the city at three different times in a program called Super-Shot Saturday.
A nurse, along with other members of the Fort Wayne, Indiana, HC committee, would be using which of the following principles of health promotion to provide access to immuniza- tions for preschool children? A. Promoting healthy public policy B. Creating supportive environments C. Strengthening community action D. Reorienting health services E. Improving personal skills
Answers can be found on the Evolve site.
K E Y P O I N T S 1. Although Healthy Cities began in 1986 in Europe, it is now
an international movement of communities and cities focused on mobilizing local resources and political, profes- sional, and community members to improve the health of the community.
2. The principles of primary health care and health promo- tion guide the Healthy Communities movements.
3. The name used for the Healthy Community activity varies from one locale to another.
4. The models of community practice most frequently found in the Healthy Communities movement are that of working with the local people to plan via community partnerships that will best meet their needs.
5. Community participation can be gained in many ways; it is often helpful to have a local person on the planning com- mittee to advise on how to best enlist the aid and support of the residents.
6. The CDC has become involved in the Healthy Communi- ties work in its efforts to reduce the amount of chronic illness.
7. The CDC has developed a wide range of tools to help com- munities improve their health; these tools are available on its website at no charge.
8. The concept of healthy communities is used in the United States as well as in many other nations. One region that has a well-developed set of programs is that covered by the Pan American Health Organization (PAHO). The steps that are used in PAHO countries are included in the chapter.
9. The steps for developing a healthy community including the use of the PAHO model or the Community Health Promotion model developed at Indiana University School of Nursing can be used by nurses working with communi- ties to improve their health capacity.
10. The first two states to develop Healthy Community projects were Indiana and California. These two states have ongoing active and responsive programs; some are discussed in the chapter.
11. The Healthy People 2020 objectives incorporate many of the key concepts of healthy communities including providing access to health services; combating chronic illnesses, and providing safe food, a safe and healthy environment, oppor- tunities for fitness, immunizations, and reduction in inju- ries and violence, to name a few.
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. In collaboration with a community group, conduct a com-
munity assessment. Identify the community’s assets and problems.
2. Evaluate the effectiveness of a current approach to a health problem in your community (e.g., teen pregnancy). Describe how the approach would change if you were to use the steps in developing a healthy community such as the Community Health Promotion process.
3. Discuss the role of the nurse in health promotion within a healthy community model.
4. Identify city council members, the president of the chamber of commerce, the director of family services, the mayor, a religious leader, and other community leaders who are the
“movers and shakers” in getting things done. Generate a list of questions that will help these leaders describe the major assets and problems of the community. Interview several local leaders and summarize their responses.
5. You are asked by the health commissioner to organize a com- munity coalition for orientation to the Healthy Communi- ties process. Outline the steps you would take.
6. Describe your philosophy of community leadership develop- ment for health promotion.
7. Discuss ways in which the Healthy People 2020 objectives can incorporate community participation. Select one topic area within Healthy People 2020 and outline a community inclu- sive approach that you could use.
454 PART 4 Issues and Approaches in Population-Centered Nursing
REFERENCES American Nurses Association: Scope
& Standards of Practice, ed 2. Silver Springs, MD, 2013, Public Health Nursing, ANA.
Ashton J: Creating Healthy Cities, paper presented at Healthy Cities Indiana Network Session. Seymour, IN, May 1989.
California Endowment: Overview Strategic Vision 2010-2020: Building Healthy Communities. 2010, author. Available at: www.csun.edu/alliance/Wellness- Coreteam/Documents/CA%20 Endowment%20Building%20 Healthy%20Communities.pdf. Accessed August 15, 2014.
Center for Civic Partnerships: CA Healthy Cities and Communities Program. 2014. Available at: http:// www.civicpartnerships.org/#!ca -healthy-cities-and-communities -progra/cjhg. Accessed August 16, 2014.
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21 The Nurse-led Health Center: A Model for
Community Nursing Practice
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Describe key characteristics of nurse-led center models. 2. Explain community collaboration. 3. Identify interventions that address Healthy People 2020
goals.
4. Determine the feasibility of establishing and sustaining a nurse-led center.
5. Describe the roles and responsibilities of the advanced practice nurse in a nurse-led center.
6. Discuss the future of population-centered nursing practice, education, and research.
K E Y T E R M S advanced practice nurses, p. 457 business plan, p. 465 community collaboration, p. 456 comprehensive primary health care, p. 459 convenient care clinics, p. 464 cost-effectiveness, p. 467 evidence-based practice, p. 467 feasibility study, p. 465
federally qualified health centers, p. 459 grants, p. 463 multilevel interventions, p. 456 National Nursing Centers Consortium, p. 459 Nurse-Family Partnership, p. 459 nurse-led health center (NLHC), p. 456 nursing models of care, p. 456 organizational framework, p. 463
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz • Case Studies • Glossary • Answers to Practice Application • Resource Tools
• Resource Tool 21.A: Factors Influencing the Success of Collaboration
• Resource Tool 21.B: The Evolution of Nursing Centers • Resource Tool 21.C: Nursing Center Positions • Resource Tool 21.D: Outline of Essential Elements in
Nursing Center Development • Resource Tool 21.E: WHO Priorities for a Common
Nursing Research Agenda • Resource Tool 21.F: Principles for Nursing Center
Research
Katherine K. Kinsey, PhD, RN, FAAN Dr. Katherine K. Kinsey is the Nurse Administrator and Principal Investigator of the Philadelphia Nurse-Family Partnership (NFP), the Mabel Morris Family Home Visit Program, and other special projects including early childhood initiatives. Dr. Kinsey earned the BS from Millersville University in Pennsylvania and the BSN and MSN from the University of Pennsylvania School of Nursing. She earned the PhD from the Graduate School of Educa- tion with a speciality in Health Professions Education also from the University of Pennsylvania. Dr. Kinsey previously directed a nationally recognized academic-based nurse-managed health center. She is a past chairperson of the American Public Health Association, Public Health Nursing Section. Dr. Kinsey serves on several nonprofit boards and is the president of the Kingsley Family Foundation, which is dedicated to improving the well-being of vulnerable, underserved populations.
Dr. Mary Ellen T. Miller is an Associate Professor at De Sales University School of Nursing in Center Valley, PA, and teaches in the undergraduate, graduate, and doctoral nursing programs. She earned the BSN and MSN from LaSalle University and the PhD from Temple University. Both universities are in Philadalphia, Pennsylvania. Dr. Miller serves as Chair of the Wellness Center Committee of the National Nursing Center Consortium. Previously, she served as the Associate Director of Public Health Programs for an academic nursing center. Dr. Miller has published works about nurse-managed centers and presents regionally and nationally on topics related to her work, as well as about student involvement with community service and learning, and about nurse-managed wellness centers.
Mary Ellen T. Miller, PhD, RN
456 PART 4 Issues and Approaches in Population-Centered Nursing
C H A P T E R O U T L I N E What Are Nurse-Led Health Centers?
Overview and Definition Nurse-led Models of Care
Types of Nurse-Led Health Centers Wellness Centers Special Care Centers Comprehensive Primary Health Care Centers
The Foundations of Nurse-Led Center Development Community Collaboration Community Assessment Multilevel Interventions
The Team of a Nurse-Led Center Director: Nurse Executive Advanced Practice Nurses Other Staff Educators, Researchers, Students, and Other Members
The Business Side of Nurse-Led Health Centers: Essential Elements
Start-up and Sustainability Evidence-Based Practice
Evidence-Based Practice Model Health Insurance Portability and Accountability Act
(HIPAA) Outcomes and Quality Indicators Quality Improvement Technology and Information Systems
Education and Research Program Evaluation
Positioning Nurse-Led Health Centers and Advanced Practice Nurses for the Future
K E Y T E R M S — cont’d outcomes, p. 456 Patient Protection and Affordable Care Act, p. 460 prevention levels, p. 463 primary health care, p. 458 program evaluation, p. 471 public health nurses, p. 459 quality care, p. 467
reimbursement systems, p. 458 special care centers, p. 459 stakeholders, p. 461 strategic planning, p. 461 sustainability, p. 463 wellness centers, p. 458 —See Glossary for definitions
Considerable data document that nurse-led health centers (NLHC) improve health outcomes. The nurse-led health center (NLHC) model increases access to care; provides a more comprehensive approach to health and illness; decreases racial, ethnic, and geographic disparities in health status; and can potentially reduce the overall costs of health care. NLHCs, as safety net providers, reach out to and engage underserved, vul- nerable populations in public health and primary health care initiatives. This chapter describes NLHCs and their origins, evo- lution, and future directions. Emphasis is placed on the Healthy People 2020 framework, community collaboration, and multi- level interventions to improve access and reduce health dis- parities. This chapter describes nursing roles and responsibilities in delivering client-centered, community-based services, man- aging center operations, and expanding initiatives for practice, research, and education in public health and primary care set- tings. Economic, social, political, national health care reform, and global factors influencing NLHC operations and population- centered nursing practice are discussed.
WHAT ARE NURSE-LED HEALTH CENTERS? Overview and Definition The terms nurse-led health center, nursing center, nurse- managed health center, and nurse-managed health clinic are interchangeable in this chapter and are used to describe this model of health care. The citations in this ninth edition of Public Health Nursing: Population-Centered Health Care in the
Community include historical references noted in earlier edi- tions and current references regarding the evolution of NLHCs. The references frame the decades-long NLHC movement. However, the ways in which we gain knowledge is changing. The introduction of new Internet-based technology and communi- cation venues regarding public health programs and NLHCs will grow exponentially (Khan et al, 2010). Access to NLHCs initiatives, public health practice examples, and career oppor- tunities are now featured on social media websites, wikis, and blog communities. These venues, and others still in the research and development phases, will add rich content as NLHCs con- tinue to transition into mainstream health care provider status.
In the past, the most frequently cited and referenced defini- tion of nurse-led health centers was the one developed by the American Nurses Association (ANA) Nursing Centers Task Force in the mid-1980s and shown in Box 21-1. However, the Nurse-Managed Health Clinic Investment Act of 2009 (Senate Bill 1104/House of Representatives Bill 2754) of the 111th Con- gress provides a more current and functional definition of nurse-managed health clinics with an amendment to Title III of the Public Health Service Act (42 U.S.C. 241 et sez.) as seen in Box 21-2.
NLHC provide unique opportunities to improve the health status of individuals, families, and communities through direct access to nurses and nursing models of care (Lancaster, 1999). All NLHCs possess characteristics that reflect the values, beliefs, and scientific knowledge and skills inherent in nursing models of care. Furthermore, each is guided, managed, and primarily
457CHAPTER 21 The Nurse-led Health Center: A Model for Community Nursing Practice
health disparities by providing access to comprehensive primary health care and health promotion and disease prevention ser- vices (Hansen-Turton, Miller, & Greiner, 2009). Interdisciplin- ary staff achieves success through shared vision, positive attitudes, and respect for team members (Phillips, 2009). Social determinants of health (Wilensky & Satcher, 2009) as well as the integration of time, tact, talent, trust, caring, personal respect, equity, and social justice perspectives serve as the foun- dation from which health is viewed as essential for everyday life (Plowfield, Wheeler, & Raymond, 2005). Efforts of the center focus on enhancing people’s capacity to meet their personal, family, and community responsibilities and interests and typi- cally include the following: • Community-based culturally competent care that is accessible,
acceptable, and responsive to the populations being served • A holistic approach to care based on complex and interrelated
bio-psychosocial factors • Interorganizational and interdisciplinary collaboration that
crosses health and human service systems and increases opportunities for comprehensive and seamless services among care providers, agencies, and payers
• Multilevel interventions that acknowledge organizational, environmental, health, economic, and social policy contri- butions to health, health problems, and issues of access to care
• Community partnerships in establishing and supporting the center’s health efforts
• Relationship-based practice with individuals, families, orga- nizations, and communities that fosters understanding of context, interests, and needs for health care Nurse-led center models combine people, place, approach,
and strategy in everyday life to develop appropriate health interventions. Advanced practice nurses (APNs) work in close partnership with the communities they serve to provide public health programs, community-wide health education, and primary health care services. They establish relationships with families, community representatives, policy makers, and others in designing, implementing, and evaluating appropriate health intervention strategies, services, and programs (Zimmerman, Mieczkowski, & Wilson, 2002; Hansen-Turton, Miller, & Greiner, 2009).
A nurse-led center’s health and community orientation builds strong connections to the population served. These strong rela- tionships with community leaders, residents, and clients foster a deep awareness of local factors that influence daily life (Lundeen, 1999). This orientation builds on Lillian Wald’s community work more than a century ago. Wald’s work to establish The Henry Street Visiting Nurse Service and a cadre of public health nurses who treated social and economic problems—not just infections, diseases, and providing care to the chronically ill—is part of the nursing center legacy (Fee & Bu, 2010). Figure 21-1 depicts the opening of a nurse-led center.
TYPES OF NURSE-LED HEALTH CENTERS There are many types of nurse-led centers. Each has a “person- ality” of its own (Gerrity and Kinsey, 1999). A center should be
staffed by nurses, thus ensuring that decision making and ulti- mate accountability for this model of care rest with professional nurses (Kinsey and Gerrity, 2005).
The NLHC is supported by the ANA seminal position paper titled Health Promotion and Disease Prevention (ANA, 1995). The paper recognizes health promotion strategies as pivotal points of any health care system designed to control costs and reduce human suffering. It acknowledges nursing’s scope of practice and underscores its efforts to focus on disease preven- tion interventions (ANA, 1995).
Nurse-led center models combine human caring, scientific knowledge about health and illness, and understanding of family and community characteristics, interests, assets, needs, and goals for health promotion, disease prevention, and disease management. NLHC models de-emphasize illness-oriented and institutional care that has dominated health care since World War II and subscribe to a holistic perspective on improving personal, community, and societal well-being.
Nurse-led Models of Care NLHCs are strategically positioned to improve the health and well-being of vulnerable populations (Kinsey, 1999) and reduce
Nurse-led centers—sometimes referred to as nursing centers, community nursing organizations, nurse-managed centers, nursing clinics, and community nursing centers—are organizations that give the client direct access to profes- sional nursing services. Using nursing models of care, professional nurses in these centers diagnose and treat human responses to actual and potential health problems, and promote health and optimal functioning among target populations and communities. The services provided in these centers are holistic and client centered and are reimbursed at the reasonable fee level. Accountability and responsibility for client care and professional practice remain with the professional nurse. Overall accountability and responsibility remain with the nurse executive. Nurse-led centers are not limited to any particular organizational configuration. Nurse-led centers can be free-standing businesses or may be affiliated with universities or other service institutions such as home-health agencies and hospitals. The primary characteristic of the organization is responsiveness to the health needs of the population.
BOX 21-1 American Nurses Association Nursing Centers Task Force: Nurse-led Center Definition
From Aydelotte MK, Barger S, Branstetter E, et al: The nursing center: concept and design, Kansas City, MO, 1987, American Nurses Association, p 1.
The term “nurse-led health center or clinic” or “NLHC” means a nurse-practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and is associated with a school, college, university, or department of nursing, feder- ally qualified health center, or an independent nonprofit health or social ser- vices agency.
BOX 21-2 Nurse-Managed Health Clinic (NMHC) Investment Act of 2009 Definition
Source: Nurse-managed Health Clinic Investment Act of 2009. Senate Bill 1104 and House of Representatives bill 2754. For exact language see Title V, section 2512 of the House bill (HF 3962) and Title V, Subtitle c, section 5208 of the Senate bill (HR 3590).
458 PART 4 Issues and Approaches in Population-Centered Nursing
2009). Public health education and support programs may include smoking cessation (Lakon, Hipp, & Timberlake, 2010) and management of chronic conditions such as diabetes, asthma, and hypertension. Many centers also provide dental, behavioral health, environmental health risk reduction, and parenting education (Hansen-Turton, Bailey, Torres, & Ritter, 2010). “Enabling” services help people access language transla- tion, registration for entitlement programs, transportation vouchers, and specialty services. Healthy People 2020 goals and objectives provide direction to services planned, implemented, and evaluated through the wellness center model.
These centers complement existing primary care services. The staff maintains strong relationships with local health care providers in community health centers, clinics, private prac- tices, long-term care facilities, and other organizations. In general, financial support for center programs comes from public health department and other service contracts, founda- tion grants, fee for services, voluntary contributions, and shared resources from affiliated organizations (Hansen-Turton, Miller, & Greiner, 2009). In addition, these centers often serve as venues for community service learning activities for graduate and undergraduate students from multiple disciplines. Nursing centers extend learning beyond the classroom and into the com- munity, providing a legitimate experience whereby students apply theoretical content to a community setting (Miller & Guigliano, 2006).
based on community assets and perceived needs with a clearly stated mission and vision as well as its commitment to com- munity well-being, contributing to its profile (Hansen Turton, Miller, & Greiner, 2009). Organizational structure (academic, non-academic), federal tax status (profit or nonprofit), and reimbursement systems (fee for service, sliding scale fee rates, or no charge) also define centers. Other types will evolve as a result of national health care legislation. The legislative initia- tives include maximizing federally qualified health center ser- vices; increasing access to primary health care for people of all ages; introducing new public health, preventive health, and home visiting programs; and implementing and using elec- tronic medical records. To date, most nurse-led centers fit into the types described in Box 21-3.
Wellness Centers Wellness centers focus on health promotion, disease preven- tion, and management programs. APNs and others provide outreach and public awareness services, health education, immunizations, family assessment and screening services, home visiting, and social support (Hansen-Turton, Miller, & Greiner,
FIG 21-1 Donna Torrisi, MSN, Nurse-Managed Health Center Director with community leaders at the 2008 Grand Opening of the Family Practice and Counseling Health Annex, Philadelphia, PA. (From Family Practice and Counseling Network Clients, Philadelphia, PA.)
Service Model • Wellness centers: Provide health promotion and disease prevention
programs • Comprehensive primary care centers: Provide health-oriented primary care
and public health programs • Special care centers: Provide programs targeting specific health conditions
(such as diabetes) or population groups (such as the frail elderly)
Organizational Structure • Academic nurse-led center: Housed within a school of nursing • Free-standing center: Independent center with its own governing board • Subsidiary: Part of larger health care systems, home-health agencies, com-
munity centers, senior centers, schools, and others • Affiliated center: Legal partnership association with health, human ser-
vices, or other organization
Internal Revenue Service Designation • 501(c)3: Non-profit business • Proprietary: Incorporated as a for-profit business
Reimbursement Mechanism • Fee-for-service: Payment at time of service; may include sliding-fee scale • HMO provider: Payment at contracted rates by health maintenance
organization • Federally Qualified Health Center (FQHC): Federal designation that allows
cost-based reimbursement per encounter • Third-party reimbursement: Client billing to public program or commercial/
private insurance • Contributions: Individual donations, philanthropic gifts, fund-raising activi-
ties to support a program
BOX 21-3 Nurse-led Center Typologies
459CHAPTER 21 The Nurse-led Health Center: A Model for Community Nursing Practice
protocols, quality improvement strategies, and client satisfac- tion measures (Sherman, 2005). Nursing centers must meet standards established by government, insurers, health mainte- nance organizations, and other payers.
Increasingly, the Bureau of Primary Health Care (BPHC) of the U.S. Department of Health and Human Services (USDHHS) designates nurse-led primary health centers as federally quali- fied health centers (FQHCs). Their purposes are to (1) provide population-based comprehensive care in medically underserved areas and (2) maintain the appropriate mission, organizational, and governance structure according to the FQHC designation. These designations include community health center, public housing center, homeless center, or school-based center.
The FQHC designation is important from a number of per- spectives. Most importantly, it supports a primary care center’s efforts to serve low-income and uninsured populations and remain fiscally solvent. FQHCs receive federal grant funds from the Health Resources and Services Administration (HRSA) to support operational expenses. They also receive cost-based payment for services provided to Medicare and Medicaid patients, Federal Tort Claim coverage, and 340b drug pricing, and they have the option to participate in the National Health Services Corps.
Many nurse-led centers need to overcome internal and exter- nal organizational hurdles to initiate the FQHC application process and receive funding approval (Torrisi & Hansen-Turton, 2005). The National Nursing Centers Consortium (NNCC), with offices in Pennsylvania, Washington, DC, and California, provides regional training for the FQHC application processes. The recent passage of the Nurse-Managed Health Clinic Invest- ment program by the 111th Congress holds great potential for additional NLHC-affiliated academic institutions to be eligible for FQHC status.
Many NLHCs are in nonprofit academic settings. They are housed within or closely affiliated with schools of nursing. These NLHCs actively integrate service, education, and research in their model. They build on public health and primary care nurse practitioner educational programs, draw on the knowl- edge and skills of faculty, and provide rich learning experiences for nursing students at all levels. Furthermore, they use the knowledge, skills, and resources of other schools of health professions, business, communications, and law to expand the center’s service capacity (Shiber & D’Lugoff, 2002). Academic nursing centers have documented benefits to communities served, specifically regarding the strengths of nurse practitioners and the centers’ ability to provide outreach to the community (Pohl et al, 2007).
One example of an academic nurse-led center is the Lewis and Clark Community College Nurse-Managed Health Center located in Godfrey, Illinois. The college also has a mobile health unit. This NLHC was the first to open to the public on a U.S. community college campus. The center provides nonemergency, low-cost primary care services and partners with the Southern Illinois Healthcare Foundation for referrals and specialty care. Nursing students have clinical rotations through the NLHC and its mobile unit. Students and faculty are involved in client educa- tion and illness prevention services. This model introduces
FIG 21-2 Investing in the future: public health nurses and pro- grams like Nurse-Family Partnership, Early Head Start, Parents As Teachers, and others improve family health and mother- child (or maternal–child) well-being. (Used with permission of Philadelphia Inquirer Copyright © 2010. All rights reserved.)
Special Care Centers Some nurse-led centers focus on a particular demographic group or on those with special health care needs. Special care centers provide services and specialized health knowledge and skills to a particular group, and they are an adjunct to compre- hensive primary health care models. Examples of special care centers are those that focus on the needs of people with diabetes or HIV/AIDS, adolescent mothers, the frail elderly, and support services for people with mental disorders (Alakeson, Frank, & Katz, 2010). Other centers are the hub for public health nursing practice in home and community settings. These include Nurse- Family Partnership models across the nation as well as other early childhood home visiting models including Parents As Teachers and Early Head Start.
Comprehensive Primary Health Care Centers In many communities, nurse-led centers offer comprehensive primary health care. In addition to the health and wellness programs described previously, these centers also serve as the primary care (medical) home for families in the communities where they are located. In the centers, nurse practitioners, other advanced practice nurses, and allied health professionals provide both physical and behavioral health care services. These centers address the needs of individuals and families across the life span, ensuring access to specialized health care as indi- cated. Public health nurses and community workers provide outreach, social support, and an array of public health pro- grams. Public health programs include health education, screening, immunizations, lead poisoning prevention, home visitation such as in the Nurse-Family Partnership, environ- mental health initiatives, and other preventive community- based health services (Figure 21-2).
Comprehensive primary health care centers face the chal- lenge of establishing systems for documenting clinical care and utilization patterns. These systems include demographic pro- files, accounting support, billing mechanisms, reimbursement
460 PART 4 Issues and Approaches in Population-Centered Nursing
The Consortium often links members with potential members to share expertise and consult on program design and imple- mentation. See the Linking Content to Practice box.
students to the expanding roles and responsibilities of APNs in community settings and career options (Weller, 2010).
Other centers may be affiliated with freestanding organiza- tions, subsidiaries of health care or other human services orga- nizations, or sponsored by an affiliate of such entities. Each of these organizational arrangements requires carefully estab- lished legal agreements. To conduct business, these organiza- tions must become incorporated; apply to the Internal Revenue Service (IRS) for a tax status designation; and receive a State- ment of Tax Status Determination. Organizations are generally categorized as a nonprofit (501(c)3) entity or some form of proprietary (for-profit) organization. The majority of nursing centers are with nonprofit organizations; others fit within a proprietary business model, and others operate as subsidiaries of established organizations. In all cases, staff must be familiar with the particular laws and regulations associated with the IRS tax status under which they operate.
Another way to describe nurse-led centers involves the health care system’s financial reimbursement methods that support services and programs. These include fee-for-service, desig- nated HMO provider, Medicaid provider, Medicare provider, and FQHC status. Each designation requires a center to possess certain characteristics, meet a set of standards, and possess identification numbers that allow them to participate in billing and reimbursement systems.
Regardless of the type of center, a wide array of social deter- minants, personal, social, educational, economic, and environ- mental concerns, indicate the need for and expansion of nursing centers. Increasing population density and diversity, challenging community conditions, and long-standing and emerging health problems indicate the role such models of care can play (Kinsey, 2002). The 2010 national health reform law, the Patient Protec- tion and Affordable Care Act, holds the potential for NLHCs to work with like entities to help improve the nation’s health. This law and the 2013-2014 “roll-out” focuses on reforming the health care system, increasing disease prevention initiatives and access to services, and containing or reducing health care expen- ditures (Thorpe & Ogden, 2010). The national commitment to build integrated delivery systems offers nurse-led centers and academic health systems new opportunities to demonstrate effectiveness, efficiency, and cost savings (Dentzer, 2010).
With the anticipation of NLHCs expansion grants, it is essential to work with like-minded individuals and groups to share knowledge, resources, and lessons learned. Several orga- nizations dedicated to the promotion and sustainability of NLHCs are in place to support its members through these expansion phases. The NNCC is one nationally recognized organization dedicated to this work. As of 2014, NNCC repre- sents more than 250 members and is the largest national reposi- tory of member nurse-led health centers. Its members represent organizations, programs within parent organizations, free- standing entities, and individuals invested in the nurse- managed center model. (A current membership list is available at http://www.nncc.us). Members have the benefits of NNCC monthly newsletters, grant updates, current legislative and advocacy work, and its Annual National Conference. NNCC reaches out to nonprofit organizations and individuals inter- ested in establishing or expanding a nurse-led (clinic) model.
THE FOUNDATIONS OF NURSE-LED CENTER DEVELOPMENT The foundations for integrating primary care and public health services through the NLHC model include the perspective of the World Health Organization (WHO) and the Healthy People 2020 systematic approach to improving individual and com- munity health. The WHO’s definition of health and its frame- work to address global health supports an NLHC’s integration of primary care and public health services in community settings (WHO, 1978).
The Healthy People initiative has framed the nation’s health promotion and disease prevention agenda since 1980. Its frame- work, vision, mission, goals, and objectives are developed to achieve better health for all by 2020. Healthy People represents a collaborative federal, public, and stakeholder process and accounts for global and national environmental, social, demographic changes, and trends such as the increasing older populations. Healthy People accommodates the escalating tech- nological influences on personal and population health status, and incorporates anticipated changes in the U.S. sickness- oriented health system. Chapter 2 describes the history of Healthy People, and chapters throughout the text apply the
LINKING CONTENT TO PRACTICE
This chapter discusses the ways in which nurses provide primary care and public health services within the context of a nurse-led center. The skills of assessment, planning, implementation, evaluation, and policy development are integral to this role. In order to effectively practice in a nurse-led center, nurses use the standards of nursing practice from many specialty areas as well as the core competencies for both public health nursing and public health. Specifically, the nurse working in this setting would incorporate the following core competencies from the Quad Council of Nursing (QCN) Public Health Nursing (2011) and the American Association of Colleges of Nursing (AACN), supplement to the 2010 Essentials of Baccalaureate Nursing Education for Professional Nursing Practice titled Recommended Baccalaureate Competen- cies and Curricular Guidelines for Public Health Nursing (2013). The QCN competencies are built on those of the Council on Linkages (PHF, 2014) and their core competencies for public health professionals. For example, Domain #1 in both documents describes analytic assessment skills and Competency #1 is “conducts thorough health assessments of individuals, families, communities and populations.” There are 10 additional skills that nurses would use from this domain in nursing centers. As has been discussed throughout this chapter, nurses working in nursing centers use the policy process in providing care. Domain #2 is that of policy development/program planning skills and each of the 11 competencies/skills are used in a nursing center. The AACN supplemental competencies are based on the nine essen- tials from the original AACN recommendations and focus on primary and secondary prevention strategies in population health, including interprofes- sional collaboration.
From Public Health Foundation, Council on Linkages: Core competencies for public health professionals, Washington DC, 2009, PHF; Quad Council: Domains of practice, 2009. Available at http:www.sphtc.org/phncompetenciesfinalcomb.pdf. Accessed July 29, 2010.
461CHAPTER 21 The Nurse-led Health Center: A Model for Community Nursing Practice
people and organizations serve as the foundation for the col- laborative process and for community change. Relationships begin with introductions and open discussion to listen to and learn from one another. From this, relationships grow toward a collective willingness to work together toward a common purpose, sharing risks, responsibilities, resources, and rewards along the way. The seminal definition of collaboration devel- oped by Mattessich and Monsey (1992) describes the work involved; they view collaboration as a relationship entered into by two or more groups to achieve common goals that are well defined and beneficial to all. There must be a respectful com- mitment to these goals with mutual accountability and author- ity that allows for shared responsibilities, resources, and successes. See Resource Tool 21.A: Factors Influencing the Success of Collaboration.
Nurse-led center staff needs to have skills in networking, coordination, and cooperation in order to collaborate (Hansen- Turton, Miller, & Greiner, 2009). A number of basic agreements and interview strategies help set the stage for a long-term process of discussion, decision making, and action (Rollnick, Miller, & Butler, 2008). Once established, they are reviewed and rigorously adhered to throughout the life of the collaboration. These agreements are as follows: • Regular meetings where diverse perspectives are heard and
respected • A mutually agreed on decision making process • Consistent and accurate communications so all participants
have the necessary information to make decisions • Agreement by all participants to support collaborative deci-
sions once they are made—within the groups or organiza- tions they represent and publicly in the community Mattessich and Monsey (1992) have identified six criti-
cal elements that contribute to the success of a collabora- tive endeavor: the environment, membership characteristics, process and structure of the group, communication patterns, purpose of the collaboration, and resources within and outside the group.
Perhaps the most important feature in community collabo- ration is the capacity of those involved to enhance the capacity of another person, group, or organization to achieve the common purpose. For instance, rather than the nurse-led center serving as the lead organization, different participating organi- zations will serve from time to time in the leadership role, or hold greater responsibility, or perhaps receive additional funds to achieve the common purpose to which they all have sub- scribed. This cooperation allows participants to achieve a mutual benefit (Goffee & Jones, 2001).
Each nurse-led center develops its philosophy, goals, and activities through a process of community collaboration, com- munity assessment, and strategic planning. Strategic planning recognizes multiple levels of intervention required for bringing about and sustaining change. Often, community collaboration and assessment are concurrent activities.
Community Assessment Nurse-managed centers must conduct periodic community assessments. This chapter reemphasizes the importance of data and analysis of community needs and assets in determining the
objectives of Healthy People 2020 to their content. The concept of Healthy People 2020 builds on shared responsibility to improve the nation’s health. Communities, individuals, and systems have the potential for change, yet no one person or organization can do this alone. Powerful, productive partner- ships among diverse people and groups and long-term commit- ments to community collaboration are needed to achieve Healthy People 2020 goals. NLHCs can help to achieve the goals and objectives of Healthy People 2020 and would emphasize those goals and objectives that fit the target populations’ needs. For example, an NLHC associated with an elementary school where more than 40% of the students are obese would select Healthy People 2020 objectives relative to childhood nutrition, physical activity, and exercise. The NLHC would also imple- ment communication strategies that address the need to reduce childhood obesity in school-age children.
Community Collaboration Nurse-led centers and APNs are well positioned to guide and facilitate community collaboration and engagement (Keefe, Leuner, & Laken, 2000; Bechtel & Ness, 2010; Thompson & Feeney, 2004). Productive collaboration requires staff expertise and commitment from many to change communication pat- terns, professional agendas, and speak in a common voice to generate positive community transformation (Cross & Prusak, 2002). The community transformations occur through policy, legislative, and funding changes that improve the health status of many and help design the patient-centered medical homes that include NLHCs (Landon et al, 2010).
Individuals, families, groups, organizations, policy makers, and staff are involved in the process. Referred to as stakeholders, each entity brings a unique perspective. Their particular knowledge and skills enhance the community’s efforts to address critical needs, solve problems, and recognize unique strengths and resources. Stakeholders facilitate or undermine strategic efforts to improve health. It is impossible to fully know and address issues and concerns in a community without having all perspectives heard and every stakeholder respectful of different opinions and experiences (Bechtel & Ness, 2010). The following Healthy People 2020 box lists a sample of goals that affect nurse-led centers.
Collaboration takes time, effort, and resources. It requires nurturing and support to make it work. Relationships among
HEALTHY PEOPLE 2020
The following objectives are examples that pertain to the work of nurses in nurse-led centers: • ECBP-3.3: Advocating for personal, family, and community health (skills). • HC/HIT-2: Increase the proportion of persons who report that their health
care providers have satisfactory communication skills. • AHS-7: Increase the proportion of persons who receive appropriate
evidence-based clinical preventive services. • MICH-10: Increase the proportion of pregnant women who receive early
and adequate prenatal care. • MICH-21: Increase the proportion of infants who are breastfed.
From U.S. Department of Health and Human Services: Healthy People 2020: understanding and improving health, Washington, DC, 2010, U.S. Government Printing Office
462 PART 4 Issues and Approaches in Population-Centered Nursing
Multilevel Interventions As the community and the center work together for compre- hensive community health, a multilevel approach is needed. Some behavioral decisions or changes occur at the individual and family level. However, for comprehensive community health improvement, strategies are needed at organizational, community, and sociopolitical levels. Nursing center staff may focus their efforts on system issues, community capacity, and family and individual health care access concurrently. Alterna- tively, the staff may concentrate programmatic efforts solely at the individual or family level and later address system and com- munity issues. There is no one approach. Figure 21-4 presents the “big picture” perspective that the majority of center inter- ventions take place in community rather than institutional set- tings. In the twenty-first century, innovative and disruptive preventive health models are challenging the status quo of insti- tutionally driven primary care practices (Lawrence, 2010).
type of nursing center to establish or expand. Through the assessment process, nurses learn both the community’s formal and informal infrastructure and the communication networks through which everyday life takes place (Baker, White, & Lichtveld, 2001). Neighborhood walks, bus rides, car trips, and discussions with elected officials, administrators of health care systems, public health department staff, and community members provide insight into the community’s health and the many other influencing factors. Figure 21-3 depicts a nurse doing a neighborhood walk. Also, historical, ethnographic multimedia news features add context to the community assessment (Anderson, 1999).
Assessment activities identify community assets and health problems. For example, there may be a rich network of block captains who serve as leaders and communication liaisons with the community. There may be a local community college that can provide space and support for meetings. If high rates of childhood asthma are discovered, there may be human service organizations that can help in disease prevention and manage- ment efforts (Kawachi & Berkman, 2003).
As nurses conduct individual interviews and focus groups, develop surveys, review health care data, and examine social determinants of health (social, educational, employment, economic, housing, and others), they gather detailed infor- mation about the overall well-being of the community. These sources of information build an understanding of the community and its traditions, strengths, interests, concerns, problems, needs, and preferences. The assessment process includes sharing current health data, historical trends, and future projections with the community. Center staff can discuss the findings, share perspectives and ideas, and encourage involvement in the collaborative process. From this, the nursing center’s overall direction, services, and programs emerge (Anderko, 2000).
FIG 21-3 Neighborhood walks provide insight into the community’s health.
FIG 21-4 Multilevel intervention model.
Individuals and Families
Sociopolitical systems
463CHAPTER 21 The Nurse-led Health Center: A Model for Community Nursing Practice
service organizations, schools, churches, public housing facili- ties, and others (Bellack & O’Neil, 2000). Although there con- tinues to be no historical or current databank regarding the absolute number of nursing centers that have been developed, NNCC surveys document that models have been developed in every state, and in urban, suburban, and rural communities. Some nurse-managed centers have curtailed services or closed because of factors such as funding challenges, changes in insti- tutional commitment, scarcity of qualified advanced practice nurses, and population losses resulting from natural catastro- phes (Pohl et al, 2010).
Resource Tool 21.B highlights the evolution of nursing centers over the past century, and lists educational, political, legislative, and funding factors that have influenced the devel- opment and sustainability of nursing centers. This evolution- ary trend will be altered with the implementation of the Patient Protection and Affordability Care Act and committed funding to NLHCs.
THE TEAM OF A NURSE-LED CENTER Nurses, including APNs, other health and allied health profes- sionals, support staff, and the community at large, comprise the nurse-led center team. The center type and its services deter- mine staff patterns and roles, responsibilities, and reporting lines. Every center must have an organizational chart that clearly shows staffing positions and reporting responsibilities. The organizational framework must be dynamic in nature and adaptive to new community-focused initiatives.
A fundamental premise to any NLHC is that the community in which the model is placed has the most power and influence on model development and team composition. The demand for services will be community driven. A rural NLHC model may have different staff needs than one situated in a distressed urban area (Jacobson, 2002).
A center’s success also relates to how well the team works together to ensure the delivery of high-quality health care to target populations (Heifetz & Linsky, 2002). Positive collegial and professional relationships set the tone for the work. Critical center clinical and management positions are briefly high- lighted in the following section. Resource Tool 21.C presents actual or potential nurse-led center positions and extensive descriptions of staff and adjunct roles.
Director: Nurse Executive The director or nurse executive is an APN who is committed to the NLHC model. The roles and responsibilities of the nurse executive are dynamic and diverse. The director has a current knowledge of the target community, the ability and willingness to work with many community organizations and groups, and a background in organizational planning, administration, and fiscal management. The nurse executive is responsible for over- sight of contracts and grants, annual reports, and development of the advisory board or board of directors. Other responsibili- ties include hiring and retention of highly qualified staff.
Directors are visionary leaders and planners. They con- stantly use data, collaborative feedback, existing resources, and
APNs involved in public health and nurse-managed center ser- vices are strategically positioned to communicate, adapt, and influence change to improve and support individual, popula- tion, and community health outcomes (Vermeulen, Puranam, & Gulati, 2010). The multilevel intervention approach helps people enter the health care system earlier, with greater ease and confidence, and continue in care long enough to realize positive outcomes (Berkman & Lochner, 2002). This approach also rec- ognizes that one size (static, rote services) does not meet all the needs and interests of the target population.
Nurses keep in mind the prevention levels that improve the health of the public. Primary, secondary, and tertiary prevention are not terms the general population understands. In fact, the idea of prevention at different levels requires thoughtful inves- tigation and analysis. One of multiple national resources regard- ing prevention levels and agendas is Partnership for Prevention (www.prevent.org). The Levels of Prevention box is one example that a NMHC might use.
LEVELS OF PREVENTION
Primary Prevention Assess home for lead dust; educate family on lead poisoning prevention strategies.
Secondary Prevention Conduct blood lead level screenings on a regular basis for children younger than age 6.
Tertiary Prevention Treat child who has an elevated blood lead level with appropriate therapies and eliminate environmental lead toxicity exposures.
Nursing Center Application
The foundations of nursing center development are rooted in public health nursing history and the evolution of the nursing profession (Fee & Bu, 2010). Other chapters in this text provide historical details and factors that have influenced nursing edu- cation, practice, service, and research throughout the twentieth century.
Most nursing center models as currently known emerged from academic nursing programs in the 1970s through 2000s. At that time, opportunities did not exist within the traditional health care system for faculty or their nurse practitioner students to apply their knowledge and skills in a nursing frame- work of care. Bold ideas in the schools of nursing at the University of Wisconsin-Milwaukee, Arizona State University, Columbia University, and others established practice settings that simultaneously provided health care to the community and learning experiences for students. Many of the academic centers focused on the underserved populations in nearby com- munities. Over time, centers have achieved national recognition as essential safety net providers to vulnerable populations (Sherman, 2005).
The success of these early efforts supported the establish- ment of other academic nursing centers across the nation. Inter- est in this model of practice grew rapidly among community
464 PART 4 Issues and Approaches in Population-Centered Nursing
practice in primary care and public health settings. These set- tings include FQHCs, local and state health departments, NLHCs, and convenient care clinics (retail clinics).
National health reform legislation supports increasing the advanced practice workforce in primary care patient–centered medical homes. As discussed in Chapter 5, on March 23, 2010, the Patient Protection and Affordable Care Act was signed into law. The act makes a significant investment of $50 million to expand nurse-managed health centers to serve vulnerable, at-risk populations. In addition, it also supports faculty scholar- ship programs to expand nursing school enrollment and student loan repayment programs.
Other Staff Community health workers are essential staff in many NLHCs. Typically, they are neighborhood residents who have completed high school or 2-year associate degree programs and who want to work with others in their community. The workers are trained in community outreach, family case management, or on-site services (Rosenthal et al, 2010).
The operations of any center require support staff. Staff members include a business or operations manager and data operations personnel. A parent organization may dedicate a portion of staff lines, including human resources and public relations, to assist the director and senior staff. The operations manager handles contracts and grant budgets, advertising for staff, personnel hires, and billing. Personnel management, staff- ing patterns, and site management including data collection are also responsibilities of an operations manager.
Data operations personnel are essential. Client-based and population-based outcomes are necessary for program evalua- tion, proposal development, and funding purposes. Rapid changes in technology related to billing and reporting requirements, and federal regulations regarding protection of information about an individual’s health care status, require data operations personnel on site or as consultants. In today’s litigious society, the operation of any NLHC involves ensuring privacy of client records and securing access to computerized data.
At present and into the future, information systems (IS) and technology support (TS) personnel must be in place to meet the escalating expectation to institute and effectively use a computerized client-centered database. Computerized systems require upgrades and maintenance. Also, as hardware and soft- ware programs become obsolete and new programs are intro- duced, staff will need training and support to adapt to new data systems.
Staff may also be needed for public relations and multimedia campaigns to gain support as the center expands. Other multi- disciplinary providers are engaged in nursing center work and share responsibility in outreach and educational campaigns. Provider representation is diverse. Staff includes physician col- laborators, family therapists, mental health counselors, stu- dents, faculty, administrators, and clinical social workers. Other professionals include dentists, podiatrists, lactation specialists, and clinicians with interests in holistic health (Lutz, Herrick, & Lehman, 2001).
partnerships to modify and adjust the overall direction of the nursing center (Salmon, 2007; Torrisi & Hansen-Turton, 2005). As NLHCs have evolved and third-party reimburse- ment opportunities for nurse practitioner services increase, APN practitioners have assumed leadership positions in center practices. Likewise, advanced practice public health nurses have led the NLHC movement and employed nurse practitio- ners as advanced practice providers. For the most part, public health nurse directors have implemented a holistic service model. This model incorporates public health service and community-based programs that complement the primary care services.
There are NLHCs that started with public health programs and then established primary health care services. These public health programs include maternal–child home visitation funded by Title V federal funds, Nurse-Family Partnership (NFP), and Environmental Protection Agency (EPA) grants focusing on lead poisoning prevention, asthma triggers prevention, and many others. Other centers started with primary health care services at one location and later on incorporated client- centered public health services.
Advanced Practice Nurses Advanced practice nurses (APNs) have additional education and training beyond their basic nursing program and are certi- fied or licensed in a specialty area such as women’s health nurse practitioner. They provide an expanded level of health services to individuals and families. These nurses are responsible for the oversight of clinical staff as well as program services and outcome measures.
Nurses with advanced preparation in community or public health nursing are essential to the advancement of NLHCs and integrated health services (Dentzer, 2010). These nurses use nursing and public health principles to promote and sustain the health of populations in neighborhood and community set- tings. Their work is diverse. Nurses are responsible for assessing populations’ needs and interests in health care, developing grant proposals to expand services, and managing contracts for pre- ventive and early intervention programs in community settings. Nurses implement group health education classes and screen- ings, and provide individual case management in community and home settings. Health advocacy is an essential component of their work (ANA, 2007).
In comprehensive primary care centers, nurse practitioners provide on-site services. As APNs, nurse practitioners can be generalists (i.e., family nurse practitioners who provide services to people of all ages) or specialists. The specialist nurse practi- tioner has skills with particular age groups (e.g., pediatric, ado- lescent, or geriatric) or skills developed to meet the interests and needs of particular population groups such as women’s health; menopausal health; and wound, ostomy, and continence man- agement (Horrocks, Anderson, & Salisbury, 2002).
Naylor and Kurtzman’s article in Health Affairs (2010) dis- cusses nursing workforce issues, and the need to support the work of APRNs in primary care settings. In 2008, APRNs represented about 8% of the 3.1 million licensed registered nurses in the United States (ANA, 2011). The majority of APNs
465CHAPTER 21 The Nurse-led Health Center: A Model for Community Nursing Practice
Start-up and Sustainability In planning and establishing a nursing center (Schultz, Krieger, & Galea, 2002), nurses and others need to seek expert advice and support. This includes having financial advisors. It is important to remember that this work is a business enterprise in which the art and science of nursing is practiced. Final deci- sions about establishing a nursing center are made after explo- ration of the following essential areas: 1. Organizational goals, commitments, and resources 2. Community interests, assets, and needs 3. Feasibility study, internal and external to the parent
organization 4. Strategic plan 5. Business plan 6. Information management plan and resources 7. Existing social policy and health care financing 8. Legal and regulatory considerations 9. Mission, vision, and commitment of the lead organization
The initial work of assessing the interests, resources, and capacity of an organization to undertake the nursing center model is interrelated yet separate. For example, conduct a fea- sibility study before developing a business plan and incorporate elements of the feasibility study into the business plan. A stra- tegic plan builds on feasibility data as well as economic prin- ciples and practices. Planners must also consider workforce needs, personnel management, public information and out- reach campaigns, community capacity, and the health care envi- ronment relative to funding streams. In 2015 and beyond, any feasibility study must analyze the national health care reform legislation dollars committed, and funded programs. As a cau- tionary note, dollars committed do not guarantee funding at that level. Regardless of the federal funding level, there will be widespread competition for program support.
Feasibility Study A feasibility study identifies the strengths, limitations, and capacity of an organization and the community to support the establishment and continuation of a nursing center. It requires interviews with key individuals, surveys and data collection, focus groups, and community forums. It is necessary to con- sider epidemiologic, environmental, and other community assessments as well as data from public health agencies. Local agencies and tertiary care institutions can provide data about health needs and gaps in care for targeted groups. The study must consider legal and regulatory policies. States vary in their regulations for APNs, particularly nurse practitioners. The planners must investigate required professional credentialing, site accreditation, state Medicaid waivers, physician collabora- tive agreements, and any local or state requirements (Naylor & Kurtzman, 2010). The overall processes of community collabo- rations, assessment, and feasibility studies support the develop- ment of business plans, strategic plans, and timelines.
A sound business plan considers all aspects of establishing a nursing center and describes the development and direction of the nursing center and how goals will be met (see the How To Develop a Business Plan box). A business plan is built on the
Educators, Researchers, Students, and Other Members The education and research roles held by faculty, staff, and consultants are essential if the NLHC model is to advance in today’s health care system (AACN, 2002). The opportunity for faculty involvement through clinical training of students as well as community-focused research programs is evident and prom- ising for community collaboration and well-being (Greiner & Knebel, 2003).
NLHC programs are client and student oriented. Nursing students can learn about the intersection of health care eco- nomics, service, education, and research (Thies & Ayers, 2004). Students also have opportunities to promote social justice while engaging in community service learning activities with under- served, vulnerable populations (Hansen-Turton, Miller, & Greiner, 2009; Thompson & Feeney, 2004). If the center is part of a school of nursing, faculty roles include clinical oversight of graduate and undergraduate students assigned to the center or involved in related community projects, such as adult influenza inoculation campaigns.
Other members include community advocates, board of directors/advisory board members, and organizational part- ners. Community advocates are frequently known as key stake- holders. Community voices are often the most influential and listened to by elected officials and their staff.
Every NLHC should have a board of directors or advisory board. The organizational structure of a center as part of a larger institution or a freestanding entity dictates the type of board members that govern or advise staff on the direction of the center. A board of directors has oversight responsibilities, including fiscal management, for the NLHC model. An advisory board guides the work of an NLHC but holds no fiduciary or voting responsibilities. The board should represent diverse pro- fessions and occupations and be knowledgeable about the target community and its residents.
In addition, organizational partners are valued members. Centers that develop and maintain organizational relationships will benefit through service agreements and contracts with one or more of the partners.
THE BUSINESS SIDE OF NURSE-LED CENTERS: ESSENTIAL ELEMENTS Nurses who work in nursing centers are committed to working with diverse people in noninstitutional settings. The nurses use community characteristics, population profiles, health indexes, epidemiologic findings, and positive working relationships with professionals and the public at large to develop the model (Hansen-Turton, Miller, & Greiner, 2009). The model requires careful planning and structure to be a successful education, service, and business enterprise. During the planning and implementation phases, interrelated elements must be consid- ered. Resource Tool 21.D outlines essential elements in nursing center development. These elements serve as an annual check- list to measure growth of a nursing center and guide sound decisions regarding sustainability and future planning.
466 PART 4 Issues and Approaches in Population-Centered Nursing
the staff move the center in the appropriate direction? (5) How will staff process and handle change?
Feasibility studies, business plans, and strategic plans lay the foundation for strong nursing centers. These components are crucial to the day-to-day functioning of a newly opened nursing center and reflect the abilities of the management team to build community coalitions and collaboratives. In addition, the management team must be knowledgeable about federal regulations, acts, and funding changes, especially Medicaid and Medicare reimbursement, and grant opportunities. One resource tool that should be on site for reference is the NNCC Guide: Nurse-Managed Wellness Centers: Developing and Main- taining Your Center, a National Nursing Center Consortium Guide and Toolkit (Hansen-Turton et al, 2009).
Once the community assessment, feasibility study, business plans, and organizational networking are completed, it is important for key people to ask the following questions: • Why would the organization want to do this? • What will be the immediate and long-term outcomes for the
organization and the community at large? • Can the investment (that is, staff, money, time, and space)
be made? • Does the community truly want and need a nursing center
model? The organization cannot drive the desire for the nursing
center. The center must be person- and community-centric, not provider-centric. If the establishment of a nursing center is solely done from the organization’s vantage point, the possibil- ity of long-term sustainability may be jeopardized. The final question is the most critical one: Does the community truly want and need a nursing center model? No assessment, study, or plan can ignore this question. If the answer is not clear, more time must be invested to find out if there is a match in need, interest, and a center’s potential capacity. For example, if the community is focused on helping young women move from public assistance into jobs and the immediate need is daycare, a nursing center that offers linkages with daycare providers and on-site physical examinations and childhood immunizations will be an essential community resource. However, if the nursing center offers only senior citizen services, the immediate and expressed community need was ignored.
The establishment of a nursing center is warranted if the model reflects the needs, interests, and strengths of the target population and is economically feasible. There should be long- term commitments by all involved in the planning process, including any parent organization. The parent organization’s mission, vision, and commitment influence the viability of the nursing center model. Planners must determine the support of the parent organization before investing the time, effort, and collaborative work necessary to develop the model. If there is uncertainty at the administrative level, it is foolhardy to move forward until there is strong and documented commit- ment from the organization that matches the community commitment.
It is challenging for those involved in the planning process to forecast programs, determine service patterns, integrate outcome measures, and project costs. The planning process over
known or more predictable sources of funding at the time the plan is developed. In today’s uncertain economic health care environment, it may be necessary to modify the business plan at a moment’s notice (Torrisi & Hansen-Turton, 2005). Legislative changes and reimbursement regulations can signifi- cantly alter the business plan. In addition, no grant allocation should ever be included in the business plan until the grant is awarded.
HOW TO Develop a Business Plan 1. Cover page includes date, name, address, and phone number(s)
of the person(s) responsible for the nursing center and any consultants to the business plan.
2. Executive summary. This is a one- or two-page overview of the center and the plan.
3. Table of contents. 4. Description of the business plan that details what the center is
and what services it will provide. 5. Survey of the industry. This summarizes the past, present, and
future of the local and regional health care market. 6. Market research and analysis. This description outlines existing
competition and the potential market share and identifies target groups.
7. Marketing plan. This details how the center will reach its tar- geted clients.
8. Organizational chart with a description of the management team.
9. List of supporting professional staff (e.g., accountants). 10. Operations plan. This describes how and where services will
be provided. 11. Research and development. This projects program improve-
ment and opportunities for new initiatives. 12. Overall schedule. The timeline establishes the start date and
development phase of the nursing center. 13. Critical risks and problems. This examines the internal and
external threats to the center and how these will be addressed. 14. Financial plan. The fiscal projections for the first 3 to 5 years
are presented. A budget, cash flow forecast, and break-even point are included.
15. Proposed funding. Specific sources are listed that can provide funding.
16. Legal structure of the center. This describes the status of the center, such as free-standing, a corporation, or part of a larger organization.
17. Appendixes and supporting documents
The strategic plan complements the business plan. A strate- gic plan looks into the future and guides the work of the nursing center in that direction. Strategic plans have a regular timeline and may change as indicated by local, national, and global events. Strategic planning meetings are periodically scheduled to review and refine the plan. The plan includes goals, objec- tives, and target timelines for implementation and evaluation of projected and ongoing services. The strategic plan should answer these questions: (1) What resources will the center need after start-up? (2) What economic and legislative factors may influence center productivity and sustainability? (3) What will be the center’s core functions in 5, 7, and 9 years? (4) How can
467CHAPTER 21 The Nurse-led Health Center: A Model for Community Nursing Practice
example would be a city health department that issues a contract to a nursing center to immunize 100 adults against influenza for a specified sum per vaccine. Each nursing center may have one or many contracts and agreements; however, a nursing center should enter into each arrangement with clear understanding of the business side of the model. Any contract or agreement should be fiscally sound and not deplete center resources.
EVIDENCE-BASED PRACTICE Evidence-based practice represents the clinical application of particular nursing (health care) interventions and documented client and population outcome data over time (Deaton, 2002). Trends in health care services, client responses, and changes in community characteristics must be documented and summa- rized periodically (Oros et al, 2001). Assessments of sources of ill health, including noncommunicable conditions, and com- munity influences on economic, environmental, behavioral, and physical health are conducted periodically and reported (Lancaster, 2005). Outcome measurements include client use of on-site services, childhood and adult immunizations patterns, pregnancy outcomes, emergency department and hospital use, and other health indexes including client satisfaction and quality-of-life measures.
The cost of collecting and documenting outcome measures must be included in the NLHC budget (Tudor, 2005; Bates & Bitton, 2010). Measurement instruments require technological support and staff expertise and ongoing monitoring and analyses (Garrett & Yasnoff, 2002; Browne et al, 2010). The Patient Protection and Affordable Care Act includes the preven- tion and wellness national strategy to fund and support evidence-based and community-based services. This act should provide support to NLHCs with defined outcome measures and electronic medical records (EMRs) in place (Forrest & Whelan, 2000).
Defined outcome measures (evidence) will enable NLHC staff to determine program effectiveness and cost savings associated with clinical outcomes (Resick et al, 2011). The chal- lenge is how to define the criteria, develop measurements and collection methods, compare the evidence with broader com- munity findings, interpret the data to funders, and disseminate findings to the wider health care community. Nursing center staff can use a variety of forums to share findings including professional conferences and publications, popular press, mul- timedia venues, and testimonies at public hearings (Callahan & Jennings, 2002).
Evidence-based Practice Model In the twenty-first century health care market, research focusing on evidence-based practices demonstrating meaningful client and family outcomes will drive grant calls and investment deci- sions by public and private entities. An outstanding example relevant to advanced practice nurses and nurse-led models of care was published online July 7, 2014 in the Journal of the American Medical Association (JAMA) Pediatrics. Dr. David Olds et al reported on the Effect of Home Visiting by Nurses on Maternal and Child Mortality. He and colleagues found that the
time can be difficult. Planners may not devote sufficient time to the matter of nursing center revenue sources (Torrisi & Hansen-Turton, 2005). If money matters are not thoroughly considered, any nursing center’s future will be compromised and may not withstand the stresses of changing funding streams, political decisions, and policy changes (Kinsey & Gerrity, 2005).
The business plan provides information that forecasts the minimum funding necessary to begin a nursing center and project income 1, 3, and 5 years from inception. A break-even analysis is essential. A business plan must be periodically modi- fied when legislation regarding Medicaid and Medicare reim- bursement rates occurs. In addition, a business plan must accommodate a state’s reimbursement parameters for APNs.
Potential income sources include fee-for-service, commer- cial reimbursement, and self-pay. Fee-for-service may be the most viable of economic strategies. Commercial reimburse- ment includes private health care insurers with established fee schedules. Clients without a source of health insurance are characterized as self-pay. Costs and charges for services must be established. Nursing centers located in medically underserved areas or working with medically underserved populations (migrants) have sliding-fee schedules based on published federal poverty guidelines. Managed care contracts with par- ticular insurance companies, particularly Medicaid contractors, are other sources of income; however, the monthly Medicaid reimbursements do not cover the cost of providing health care to the most vulnerable and underserved in society (Torrisi & Hansen-Turton, 2005). Cost-effectiveness and quality care are key concerns as providers deal with the instability of reimburse- ment rates and the variable number of underinsured people seeking a medical home.
Financial support for nursing centers may also come from foundations, charitable contributions, private giving, and fund- raising. Fund-raising can take the form of direct mailings, pledges, and events that raise money. Grants are a source of initial and ongoing funding. The funding organization gener- ally releases guidelines of what the organization will fund. The guidelines are frequently released as a request for proposals (RFP). A proposal developed in response to the RFP specifies how the nursing center would meet the goals of the granting organization in the given timeline. The description of services and client outcomes must be presented in relation to the RFP guidelines.
Nursing centers have agreements and contracts in place for specific services. Agreements and contracts may have different language as well as reporting and fiscal management require- ments; however, the basic premise is similar. The nursing center enters into a written agreement to provide services to a select population group or develop a program that targets a spe- cific area. For example, a center may have an agreement with the American Cancer Society to develop a cancer education program for minority seniors in a low-income senior housing complex. The agreement is for a defined time period, has target goals and objectives, and outlines staff assignments and expec- tations, but there is no budget related to the program. A contract is a legal document that lists the purchase of services, report- ing requirements, invoicing, and expected client outcomes. An
468 PART 4 Issues and Approaches in Population-Centered Nursing
information is used and disclosed. According to current regula- tions, all staff must monitor and keep secure client records, have mechanisms to transfer client information securely and appro- priately, and strictly adhere to client confidentiality (Thorpe & Ogden, 2010).
Nurses in NLHCs are required to comply with HIPAA regu- lations, as well as be responsive to and report public health threats such as tuberculosis, disease outbreaks related to food contaminations, and influenza. Reference resources for staff include the HIPAA website of the Office for Civil Rights (http:// www.hhs.gov/ocr/hipaa/) (USDHHS, 2010b) and the CDC website on Privacy Rule guidelines (http://www.cdc.gov/privacy rule) (CDC, 2010b). Other chapters further detail public health responsiveness and HIPAA documentation challenges.
Outcomes and Quality Indicators Quality health indicators and related performance measures are priorities in any type of nursing center (Stryer, Clancy, & Simpson, 2002). These data are presented to the nursing center’s board, funders, and the community at large and document the center’s contributions to the health and welfare of the commu- nity. Outcome measures and quality indicators can be preset, or staff may determine that there are outcome measures that were not predetermined, but at time of review have meaningful results. For example, the nurse practitioners may have set up a callback system that improves timely use of primary care ser- vices. This can now be documented through client satisfaction, adherence to advised health practices, and changes in health behaviors. Such outcomes can be considered quality indicators that emerged from the day-to-day practices.
Center staff must carefully consider and determine what outcome measures and quality indicators have meaning for the community and the health care system. Despite a staff tendency to want to measure everything, begin with particular indicators and measures and incrementally add as information is indi- cated. Excessive measures consume staff time and resources and valid measurements may not emerge.
The Quality Care Task Force of the NNCC has developed Guidelines for Quality Management for Nursing Centers with Standards for Community Nursing Centers. This publication is a vital tool for staff and can be accessed at www.nncc.us. The standards assist nursing centers to assess growth and develop- ment and areas that need improvement. The standards also include quality indicators, population groups, performance targets, and measures. The indicators are grouped into the areas of prevention, utilization, client satisfaction, functional status, symptom severity, and others.
Utilization of the standards and select indicators and associ- ated processes enable a nursing center to document evidence- based practice. References used to develop the standards include the National Committee for Quality Assurance (NCQA) (Gingerich, 2000). An example of evidence-based practice follows; also refer to Table 21-1.
The Philadelphia Nurse-Family Partnership (NFP) serves first- time low-income parents and their children through an intensive public health nurse home visit model. This replication model is based on the most rigorously tested program of its kind
Nurse-Family Partnership reduces preventable death among both low-income mothers and their first-born children living in urban, disadvantaged neighborhoods. Primarily African American low-income mothers and children residing in Memphis, Tennessee, were engaged in a randomized, clinical trial of this early intervention program for more than two decades (1990-2011). In earlier studies, mothers participating in the NFP program, when compared with those in the control group, were found to have received better prenatal care; reduced short-interval second pregnancies; decreased use of public assistance programs; and had less substance abuse. Their nurse- visited children, compared to children not receiving nurse home visits, were less likely to be hospitalized with injuries through age two years; more likely to be school ready; and less likely to reveal depression, anxiety, and substance abuse at age 12. This study reports on the findings that mothers in the control groups who did not receive nurse home visits were nearly three times more likely to die than mothers receiving nurse home visits. The relative reduction in maternal mortality was even greater for deaths related to external causes including drug overdose, suicide, and homicide. Children in the control group not receiving nurse home visits had a mortality rate of 1.6% for preventable causes such as sudden infant death syn- drome, unintentional injuries, and homicide. There were zero preventable deaths among nurse-visited children.
For more than 37 years, Dr. Olds and colleagues continued to study the long-lasting maternal and early childhood out- comes of those involved in Nurse-Family Partnership. NFP is the most rigorously studied maternal and early childhood health program of its kind. The data demonstrate that NFP public health nurse home visitors, in partnership with their enrolled mothers, contribute to multigenerational health and family stabilization. These outcomes also have measurable eco- nomic and societal benefits that reduce long-term social service expenditures. The Nurse-Family Partnership National Service Office (www.nursefamilypartnership.org) helps communities and nurse-led models of practice implement and sustain this evidence-based public health program. The Philadelphia Nurse- Family Partnership is highlighted later in this chapter.
Health Insurance Portability and Accountability Act (HIPAA) Staff committed to evidence-based practice, outcome measures, EMRs, data collection, and analyses must be knowledgeable about the Health Insurance Portability and Accountability Act (HIPAA). HIPAA, which is Public Law 104-191 passed by the 104th Congress to protect the privacy of individually identified health data referred to as protected health information (PHI). The regulations took into consideration the shift to paperless, electronic medical records. Electronic records increase the potential for individuals to access, use, and disclose sensitive personal health data. The act enables consumers to have more control over their health information, establishes boundaries about the use and release of health records, sets safeguards about provider protection of private health information and penalizes violations of same, and enables consumers to obtain and/or make informed decisions about how their health
469CHAPTER 21 The Nurse-led Health Center: A Model for Community Nursing Practice
violence during pregnancy. Seventy-five percent of mothers initi- ated breastfeeding with 13.5% breastfeeding at 12 months of infancy. Upon graduation when children turn 2 years, 93% of the toddlers were fully immunized. Of the mothers who entered the program without high school or GED diplomas, 60% were still in school and 40% completed education, with 17% pursuing higher education. Philadelphia NFP mothers during the first year post- partum entered the workforce earlier than national counterparts and remained employed. The Mabel Morris Family Home Visit program complements the NFP model as it uses the Parents As Teachers curriculum and enrolls pregnant and parenting families and follows the youngest child until age 5. This program enables graduating NFP families to continue with home visit services if needed. Nurse home visitors also staff this program and are involved in extensive Parents As Teachers training. This model focuses on positive parenting education emphasizing parents as the child’s first teacher and school readiness at age five for each child.
The Philadelphia NFP reflects NFP National Service Office findings across the nation. It is a cost-effective nurse home visit program proven to be of great benefit for low-income, first-time at-risk mothers and their first-borns (NFP, 2014). Dr. Ted Miller of the Pacific Institute for Research and Evaluation prepared a report analyzing to date NFPs costs, outcomes and return from investment. NFP programs in Pennsylvania have an average cost per family of $8,327 and Miller’s model predicts that by a child’s 18th birthday the benefits to society of NFP are estimated to be $59,972, which represents a $7.20 return on investment for every dollar invested in Nurse-Family Partnership (Maternal and child health program, 2014).
The momentum to support evidence-based home visitation programs will continue beyond this decade. Forty-nine states, the District of Columbia, and five territories were awarded funds to create and support successful home visiting programs, such as Nurse-Family Partnerships and Parents As Teachers Home Visit models (USDHHS, 2010a).
(www.nursefamilypartnership.org). Philadelphia’s NFP was estab- lished July 1, 2001. It is the largest countywide site in the Com- monwealth of Pennsylvania and was formed to reduce child abuse and neglect in high-risk Philadelphia neighborhoods. Eligible low- income women are enrolled during pregnancy. Each woman receives intensive home visit services until the child reaches age 2 (program graduation). The Philadelphia NFP adheres to the national NFP model of nurse home visitation. NFP goals are to improve pregnancy outcomes, improve children’s health and development, and improve families’ economic self-sufficiency over time. NFP is based on the primary prevention and early intervention model developed by Dr. David Olds and colleagues (Eckenrode et al, 2010). Advanced practice public health nurses receive extensive education in NFP protocols, maternal-infant- toddler assessment measures, and motivational interviewing strat- egies. As of 2014, NFP nationally serves over 29,000 women in 43 states, the US Virgin Islands and six tribal communities.
On July 21, 2010, Health and Human Services Secretary Kath- leen Sebelius announced the Affordable Care Act Initial Funding for Maternal, Infant, and Early Childhood Home Visiting (MIECHV) State Grants to fund evidence-based home visiting programs that improve the well-being of families with young chil- dren. In 2012, Philadelphia NFP and its complementary Mabel Morris Family Home Visit Program received a MIECHV federal expansion grant award and increased enrollment from 400 preg- nant adolescent and adult women in any given year to 650. Data released in July 2014 summarize participant demographics and health and employment outcomes from 2001 to 2014 (N = 4012). Upon enrollment, the median age of clients was 18 years (range, 10 to 45 years). The median education was eleventh grade. Ninety- three percent of the population was unwed with 72% unemployed and from 2010 to present a decline in median annual incomes to $7,500. Ninety-two percent of the population was of African American or Hispanic heritage. Cumulative data document the following outcomes: there was a 19% reduction in smoking during pregnancy, a statistically significant (63%) reduction in marijuana use, and a statistically significant (62%) reduction in domestic
Indicator Population Performance Targets Measure
Prevention Annual influenza
vaccine High-risk groups: Age 65 or those with heart or
lung disease and other chronic conditions Healthy People 2020 = 90% age 65+ Healthy People 2020 = 60% high-risk ages
18-64 years
Client self-report and/or clinical records/audit
Utilization Mammogram within
past 2 years HEDIS: Women age 52-69 years Healthy People 2020: Women 40 years and older
HEDIS 2001 = 81% Healthy People 2020 = 70%
Client self-report and/or clinical records/audit
Client Satisfaction Client satisfaction,
annual 100 consecutive clients per quarter Performance targets to be determined by individual
nursing center and/or health care plan Surveys
Functional Status Quality-of-life
indicator Adults age 18 years and older Determined by individual nursing center and related
to baseline indicators and improvement goals Screen using Short
Form 12 or 36
TABLE 21-1 Examples of Quality Health Indicators for Nursing Centers
470 PART 4 Issues and Approaches in Population-Centered Nursing
Bohmer, & Kenagy, 2000; Naylor & Kurtzman, 2010). However, the staff must be as committed to data as to the provision of quality services. Data will enable the staff to clearly understand what goals are in place, and if areas are to be improved, they can develop action plans to improve services and client out- comes (Campbell, 2000). The concurrent emphasis on service and data can stress staff and the capacity of any nursing center to effectively and efficiently manage services and technology (Bates & Bitton, 2010). The Quality and Safety in Nursing Edu- cation box describes how to use data to improve care.
Technology and Information Systems Currently, technology and information systems are essential for data collection and analyses. Available technologies need to be used to collect, collate, and analyze data and to support the provision of quality health care services (Shortliffe, 2005; DesRoches, Campbell, & Vogeli, 2010). Technology and infor- mation systems will continue to change and adapt to accom- modate existing health care legislation, HIPAA, Healthy People 2020, public health mandates, and unfolding global and national events. Continual reinforcement about the confidentiality of client records is critical (Callahan & Jennings, 2002). Transfer of information must be carefully monitored, and the use of computers and the entering and retrieval of data by staff will be delineated by role and responsibility and passwords. One resource tool that should be on site for reference is the National
This is an opportune time for APNs interested in public health and prevention initiatives to explore employment options in NLHCs that host nurse-family partnerships and other maternal-child-family health services. Throughout the nation, there is great momentum in the health and economic sectors to create social impact bonds that would sustain early childhood initiatives demonstrating measurable, long-term personal and family outcomes. The cost savings to society are measurable and investors want to make wise investment decisions that have “payouts.” Nurses committed to prevention work in com- munity settings are on the cusp of new careers in early child- hood programs.
Quality Improvement The evidence-based practice application exemplifies what nurses can do to measure outcomes, strive to improve those outcomes given particular standards, and make meaningful contributions to the public’s health. Accurate data collection, measurement methods, summary statistics, and preparation of evidence-based practice reports are fundamental standards in any NLHC.
As the nursing center model continues to grow throughout the nation, the potential to collectively summarize data and outcomes will further strengthen this movement. Through col- laboration and the pooling of data, this model will continue to move into the mainstream health care system (Christensen,
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Quality Improvement Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
Important aspects of quality improvement include: • Knowledge: Recognize that nursing and other health professions students
are parts of systems of care and care processes that affect outcomes for patients and families
• Skills: Seek information about outcomes of care for populations served in care setting
• Attitudes: Value own and others’ contributions to outcomes of care in local care settings
Quality Improvement Question Nursing centers are established to address a specific health need in a commu- nity. You are a public health nurse who has been invited to help develop a new nursing center whose primary aim is to provide primary care to a newly insured group prevalent in your community: previously uninsured young adults. This population is newly insured because of the Affordable Care Act of 2010. As you begin to research this population, you come to appreciate the impor- tance of this target population. In your research you discover that an impor- tant aspect of the success of the Affordable Care Act is the inclusion of young adults (age 19 to 29). According to 2013 statistics collected by The Common- wealth Fund, this population has historically been uninsured at higher rates than any other age group, not because of a lack of desire for health coverage
but because they have lacked access to affordable health coverage—only 64 percent of young adults had health insurance coverage in 2010. Additionally, 41 percent of all young adults and 60 percent of uninsured young adults said they did not receive needed health care because of the cost of care. Half of uninsured young adults also reported medical debt or problems paying medical bills, while 29 percent of insured young adults reported these prob- lems due to the lack of sufficient health care coverage (Collins, Robertson, Garber & Doty, 2013).
The new Nursing Center is funded by a local large university (whose many graduates stay in the community), the local, large regional university hospital, and a large regional charity organization. Consider the following questions in the development of this important community-based resource: • Knowing that quality improvement is data driven work, what data will you
need to track to demonstrate an improvement in providing primary care to your target population?
• How will you gather data about current barriers to access to care for your target population?
• How might you involve your financial stakeholder partners in ensuring that your nursing center is providing more accessible care to your target population?
• Since ongoing monitoring of relevant data is vital to assessing whether a nursing center is meeting its stated goal for its target population, how will you educate the staff of the nursing center about the importance of these data? Develop bullet points for ongoing education/motivation of the nursing center staff.
Quality and Safety Focus
Collins SR, Robertson R, Garber T, Doty MM: Insuring the future: current trends in health coverage and the effects of implementing the Affordable Care Act, New York, 2013, The Commonwealth Fund. Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
471CHAPTER 21 The Nurse-led Health Center: A Model for Community Nursing Practice
psychosocial interventions inherent in nursing practice is being examined, such as listening to, supporting, and interpreting information for clients. Client satisfaction studies document the perceived value by those who use nursing centers. Factors associ- ated with access to services are being examined. These include availability, timeliness, acceptability, and affordability of ser- vices. Environmental conditions, such as housing, transporta- tion, criminal activities, and welfare-to-work transitions that influence health care access and use patterns are being examined. Resource Tool 21.F presents a template for research in NLHCs.
Program Evaluation Program evaluation is an essential organizational practice in NLHCs, and research questions emerge from program evalua- tion. The evaluation process is a systematic approach to improve and account for public health and primary care actions. Evalua- tion is thoroughly integrated in routine program operations. The process drives community-focused strategies, allows for program improvements, and identifies the need for additional services.
Program evaluation separates what is working from what is not and enables clinicians, faculty, and students to ask difficult questions and handle pressing challenges (Schultz, Krieger, & Galea, 2002). Resources are available to nursing center staff to enhance their understanding and application of program evalu- ation in their particular setting. Resources include courses offered through the Centers for Disease Control and Prevention (CDC) Public Health Training Network, The Community Toolbox (http://www.cdc.gov/eval/framework.index.htm), and other resources updated by the CDC Evaluation Working Group (2010a). These resources enable nursing center staff to imple- ment the six essential program evaluation steps in the context of their model and in their particular community. The essential steps are outlined in Box 21-4.
POSITIONING NURSE-LED HEALTH CENTERS AND ADVANCED PRACTICE NURSES FOR THE FUTURE The future for nurse-led health centers is promising. The advent of the Affordable Care Act and consumer demand is changing the traditional Western model of health care. NLHCs continue to be strategically positioned to meet these changing demands and needs. Consumers are seeking alternative sources of care such as acupuncture, meditation, and mindfulness training. They are also presenting with health stressors related to the
Nursing Center Consortium Guide: Community and Nurse- Managed Health Centers: Getting Them Started and Keeping Them Going (Torrisi & Hansen-Turton, 2005).
EDUCATION AND RESEARCH Nursing centers provide many education and research oppor- tunities. Clinical assignments through the nursing center model enable students at all levels to work with skilled clinicians, develop positive community collaboratives, and build their skills to become professionals. These students often develop an interest in working with underserved populations in medically underserved areas of the nation. Students are assets to the nursing center model. Faculty brings skills that enable nursing center staff to develop and implement programs that integrate faculty-student contributions and enable the programs to engage more of the target population.
It is necessary to carefully coordinate, supervise, and evaluate student education in nursing centers. A faculty liaison enables students to have a resource within the educational system as well as a link with the center. Student schedules must also be coordinated with nursing center timelines. A year-round nursing center that provides 24-hour coverage of services must accommodate academic schedules and students moving in and out of clinical assignments. Nursing center staff and faculty must work to maintain ongoing communication with clients and community agencies about student rotations, program assignments, and student projects. Students should be encour- aged to share their work with the community because learning is a mutual exchange of goods and services. In addition, in any nursing center model nothing is done in isolation (Shiber & D’Lugoff, 2002).
Research in nursing centers provides the opportunity to gain answers to questions and to share the findings with colleagues and the public (Sherman, 2005). It is important to answer ques- tions about individual and population health status, client outcomes over time, roles and capacities to address health pro- motion with the existing health system, and the value and affordability of care (Gladwell, 2005). Centers offer many opportunities for educational research.
Each center needs a research or program evaluation agenda. Resource Tool 21.E displays the WHO’s priorities for a common nursing research agenda. The research focus includes identifica- tion and clarification of client needs, particularly those not engaged in an existing health system; description of nursing interventions and linkages with consumer needs and resources; demonstration of effective interventions that produce appro- priate outcomes; and cost analysis and documented cost- effectiveness of services (Hirschfeld, 1998).
Over the past three decades, nursing center research has prin- cipally focused on the development and characteristics of nursing centers (Sherman, 2005). Descriptive data have been collected about clients, types of services, the financial supports, and com- munity relationships. However, more than descriptive clinical studies are needed. Research efforts are underway to capture and name the unique features of nursing models of care and link them with health outcomes. For example, the significance of
• Engaging stakeholders • Describing the program • Focusing the evaluation design • Gathering credible evidence • Justifying conclusions • Ensuring use and sharing lessons learned
BOX 21-4 Essential Program Evaluation Steps
472 PART 4 Issues and Approaches in Population-Centered Nursing
personal, family, and community need and interest. An article in the Harvard Business Review cited nurse-led centers as a disrup- tive and innovative approach to the delivery of health care ser- vices (Christensen, Bohmer, & Kenagy, 2000). A decade and a half later, NLHCs continue to be disruptive, innovative, and con- stantly in the forefront, identifying new opportunities to better address the needs and strengths of unique population groups.
There is no better time than the present to be a nurse and to advance the profession (Zysberg & Berry, 2005). Nurses in NLHCs are uniquely positioned to introduce nursing to com- munity members, to speak on behalf of the profession, and to introduce educational opportunities to those seeking a future in health care. They are and will continue to be front-line advo- cates for social justice and equality for all. Their work is a lasting legacy for those who follow (Figure 21-5).
The authors envision the following advancements within this decade and beyond: (1) a full complement of APNs, population-focused nurses, nurse practitioners, and other nurse experts who are the backbone of primary health care providers throughout the nation, and (2) an exponential expansion of the NLHC model, focusing on wellness and prevention initiatives. The practice application at the conclusion of this chapter exem- plifies the potential of nursing contributions to improve the health of one urban community.
enduring aftermaths of natural and man-made catastrophes such as hurricanes, droughts, and bioterrorism (Rottman, Shoaf, & Dorian, 2005). NLHCs and their community counter- parts must be prepared to meet the daily needs of people as well as any unexpected events that threaten society’s future (Fairbrother et al, 2010). In addition, health care providers must appreciate the societal and economic consequences of the “great recession” of 2008 that is predicted to influence American life for a decade or longer (Henig, 2010) as more public dollars will be consumed to support those in need (Lancaster, 2005).
Clinics in retail stores are often staffed by nurse practitioners and offer a convenient point of service.The clinics are typically located in high-volume retail businesses including grocery stores and pharmacies. These clinics have a limited scope of care that includes immunizations, routine school physicals, and common acute problems. The majority of retail clinics are owned by for-profit organizations whose management does not consider the clinics as NLHCs. In fact, there is concern that the retail clinic fragments care and threatens the viability of primary care provider services, including NLHCs (Pollack, Gidengil, & Mehrotra, 2010). In the future, market forces including the public’s interest in convenient and affordable care will deter- mine the growth of NLHCs and the demand for retail clinics as alternative sources of care.
Given the complexity of care in the twenty-first century, as well as the positioning of NLHCs to be the provider of choice, all staff should identify and join one or more professional orga- nizations such as the National Nursing Centers Consortium, the American Nurses Association and the American Public Health Association, Public Health Nursing Section. The NNCC website (www.nncc.us) provides an extensive overview of one member- ship organization service. Services include data warehousing, information systems, public policy development, health care advocacy, and monthly postings of relevant grant opportunities for education, service, and research initiatives.
Much has been noted about the nursing workforce issues that confront our nation and the world in this century. Legisla- tors, health care systems, the nursing profession, and educa- tional institutions as well as the public continue to focus on interrelated factors that contribute to the available pool of advanced practice nurses (Bingham, 2002; Donelan et al, 2008; Buerhaus, Auerbach, & Staiger, 2009). NLHCs and associated community-based initiatives need highly qualified and com- mitted nursing staff to contribute to this work. More profes- sional nurses are choosing public health or community-based practices, reporting their belief that they are making a positive difference in their communities as well as a high level of job satisfaction (University of Michigan Center of Excellence in Public Health Workforce Studies, 2013). The opportunities to make meaningful differences in the lives of people served and to shape an evolving practice model are appealing. Nurses attracted to this model often discover that they can be front-line advocates for people and have more opportunity to do policy development (Drevdahl, 2002).
Nurses involved in NLHCs focus on health disparities and access to care for all. They educate others about the NLHC as a model of public health and primary care services responsive to
FIG 21-5 Preparing for their future as advanced practice nurses in a nurse-managed health clinic. (From Mabel Morris Head Start Program, Philadelphia, PA.)
473CHAPTER 21 The Nurse-led Health Center: A Model for Community Nursing Practice
P R A C T I C E A P P L I C A T I O N Annual summaries of client use patterns and program outcome data document erratic patterns of client access and ongoing use of one nursing center’s services. The center, located in a public housing site, offers comprehensive primary health care to clients of all ages, a sliding-fee schedule so no one is turned away, managed care contracts, and a variety of public health and social services provided in home or community settings. The office is open 6 days a week with appointments available during day and early evening hours. The site is readily accessible by public or private transit, and it is less than a 5-minute walk for any public housing resident. A large, attractive sign is in the front of the site for adver- tising purposes. Monthly outreach is conducted to local busi- nesses, schools, social service agencies, and tertiary care centers. Outreach includes information such as the center’s services, hours, and location. Personal contacts, flyers, and posters advertising unique programs such as flu clinics are strategically placed within the housing complex and proximal neighborhoods.
Despite these efforts, data indicate that other strategies are needed. A focus group held with staff, public housing residents, and users of the health center services began. Client users candidly shared their need to have more flexibility in the
appointment schedule. Appointments made months in advance were often not kept because of conflicting schedules (such as work or school), despite the client’s best intent. Staff said that too many clients were “no-shows” and their work schedules were “too light.” Public housing residents were concerned about keeping their “business private.”
Consensus was reached to establish an “open access” appoint- ment model. Clients can schedule appointments or call the day before or day of a needed visit. Nurses would reinforce the open access model and the center’s confidentiality standards with clients. All staff would reinforce the option during client visits as well as prepare press releases and community presentations. Staff would review client access and use patterns quarterly. By the next quarter, client access and adherence to appointments increased by 50% and primary care staff reported greater satis- faction in their work responsibilities. Nurses noted that clients in public housing expressed positive comments on how the nursing center had helped them manage their appointment schedules better. Overall, the increased access and use of appro- priate primary health care services support the center’s goal to promote community well-being.
K E Y P O I N T S 1. NLHCs provide unique opportunities to improve the
health status of individuals, families, and communities through direct access to nursing care.
2. Nurse-led center models combine people, place, approach, and strategy in everyday life to develop appropriate health care interventions.
3. A nurse-led center’s health and community orientation builds strong connections to the community served.
4. A center is defined by its particular array of services and programs, such as comprehensive primary health care centers and special care centers.
5. The foundations for the nurse-led model include the per- spective of the World Health Organization and the Healthy People 2020 systematic approach to improving individual and community health.
6. Each center develops its philosophy, goals, and activities through a process of community collaboration, assessment, and strategic planning.
7. As the community and the center work together for health, a multilevel approach is used that includes individuals and expands to legislators.
8. Nurse-led center development is rooted in public health nursing history and the evolution of the nursing profession.
9. Most current nursing center models emerged from aca- demic nursing centers in the 1970s.
10. Nurse-led models support the skill development of advanced practice nurses, allied health professionals, and paraprofessionals.
11. Any nurse-led center must have a board of directors or an advisory board to guide program development, fund- raising, community networking, and other work.
12. The nurse-led center requires careful planning and struc- ture to be a successful education, service, and business enterprise.
13. Start-up and sustainability are based on a community- focused feasibility study, a sound business and financial plan, operational support, and resource management.
14. Evidence-based practice in nursing centers is essential and represents the clinical application of particular nursing interventions and documented client outcomes.
15. The Health Insurance Portability and Accountability Act will increase a center’s investment in administrative and oversight services.
16. Available technology and systems management must be used to collect, collate, and analyze center data.
17. Education, community service and learning, and research opportunities abound in this model.
18. Program evaluation is an organizational practice in nurse- led centers; research questions are developed from program evaluation.
19. Threats to the viability of nursing centers include the unin- sured or underinsured, erratic funding resources, commu- nity decline, and disenfranchised high-risk populations.
20. Nurses attracted to the nurse-led model discover profes- sional fulfillment in advocating for people in need and becoming involved in public policy change.
21. Nursing centers represent an innovative approach to the delivery of primary health care services.
22. Nurses involved in the nurse-led model are front-line advo- cates for social justice and equality for all.
474 PART 4 Issues and Approaches in Population-Centered Nursing
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work in an NLHC model? 3. What existing public policy might adversely affect the viabil-
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4. Why would APNs be attracted to this model of primary health care?
5. How many elected officials at the local level are familiar with the nurse-led center model and, if the majority is unin- formed, what could you do to educate the officials?
6. Where do you envision yourself professionally in 2020?
475CHAPTER 21 The Nurse-led Health Center: A Model for Community Nursing Practice
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Case Management
22
Ann H. Cary, PhD, MPH, RN, FNAP Dr. Ann H. Cary began practicing public health nursing as a home-health nurse in New Orleans, Louisiana, where she executed case management functions daily. She has served on national workgroups to establish the standards of practice for public health nurses and case managers and created certification examinations for case managers; authored numerous articles on case management issues, taught baccalaureate and graduate-level courses in case management, and directed graduate programs in case management and continuity of care. She is the Dean of the School of Nursing and Health Studies at the University of Missouri, Kansas City, MO. In Kansas City, she also serves on a variety of non-profit and interprofessional foundation and community boards whose missions are to increase access, coordinated care, and quality delivery for clients; and, to prepare health care leaders of the future to assure population health.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Define continuity of care, care management,
case management, care coordination, transitional care, integrated care, social determinants of health, and advocacy.
2. Describe the scope of practice, roles, and functions of a case manager.
3. Compare and contrast the nursing process with processes of case management and advocacy.
4. Identify methods to manage conflict, as well as the process of achieving collaboration.
5. Define and explain the legal and ethical issues confronting case managers.
K E Y T E R M S accountable care organizations, p. 477 advocacy, p. 489 affirming, p. 491 allocation, p. 493 amplifying, p. 490 assertiveness, p. 494 autonomy, p. 497 beneficence, p. 497 brainstorming, p. 492 care coordination, p. 481 care management, p. 478 care maps, p. 485 case management plans, p. 485 case manager, p. 485 clarifying, p. 491 collaboration, p. 494 cooperation, p. 494 coordinate, p. 481
critical pathways, p. 478 dashboard indicators, p. 477 demand management, p. 479 disease management, p. 478 distributive outcomes, p. 493 fidelity, p. 497 information exchange process, p. 490 informing, p. 490 integrative outcomes, p. 493 justice, p. 497 life care planning, p. 486 Medical/Health Home or Patient/Client-Centered Medical
Home model, p. 481 negotiating, p. 493 nonmaleficence, p. 497 patient engagement, p. 483 population management, p. 477 problem-purpose-expansion method, p. 492
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks • Quiz
• Case Studies • Glossary • Answers to Practice Application
477CHAPTER 22 Case Management
integrated systems to realize the following important conse- quences on the focus of care: • Emphasis is on population health management across
the continuum, rather than on episodes of illness for an individual.
• Management has shifted from inpatient care as the point of management to primary care providers as points of entry.
• Care management services and programs provide access and accountability for the continuum of health.
• Successful outcomes are measured by systems performance and pay for performance for providers to meet the needs of populations. The contemporary focus of integrated health systems defines
the nature of the client as a population in addition to that as an individual. In these systems, population management involves the following activities: • Assessing the needs of the client population through health
histories (and, in the future, genograms), claims, use-of-service patterns, and risk factors; and communicating through interop- erable information systems to ascertain patterns, trends, and responses to health programming in a population
• Creating benefits and network designs to address these needs • Selecting dashboard indicators to measure performance • Prioritizing actions to produce a desired outcome with avail-
able resources • Selecting evidence-based programs related to wellness, preven-
tion, health promotion, and demand management; patient/ client engagement; and educating the population about them
• Instituting evidence-based care management processes that assure transitional and coordinated care across the health continuum for a population aggregate
• Deploying case managers within a variety of delivery and insurance systems to clients and providers
• Evaluating provider patterns of performance and client dashboard indicators for impact Establishing a relationship between financing, managing,
delivering, and coordinating services is critical to reach the goal
Since the Patient Protection and Affordable Care Act (ACA) was initiated in 2010, the health care industry continues to re-evaluate systems that attempt to integrate financing, management, quality, and service delivery models. Challenges abound for clients and providers as they attempt to coordinate care, transition clients among providers and systems, access and share information and documentation about clients and communities, and navigate the complexity of integrated care to optimize quality and access while managing costs. The new models of health care financing provide incentives to value care outcomes over the volume of care provided. Delivery of care is now organized through a network of providers, such as negotiated contracts with hospitals and other levels of care, physicians, nurse practitioners, pharma- cies, ancillary health services, and outpatient centers.
Managing the health of populations served by the integrated systems is essential (Newman et al, 2014). These include account- able care organizations (ACOs). Nurse case managers and nurse care managers will play a pivotal role in innovative systems of delivery (Institute of Medicine [IOM], 2011). Population man- agement includes wellness and health promotion, illness preven- tion, acute and subacute care, chronic disease, rehabilitation, end-of-life care, care coordination, and community engagement. Case managers are at the core of population health strategies to improve the community outcomes (Noonan, 2014). Population health management can maintain and improve the physical and psychosocial status of clients through cost-effective and custom- ized solutions, such as coordinating and transitioning of care to reduce gaps and costs; supporting evidence-based practices; selecting quality care that is culturally competent; and providing disease management and self-management educational pro- gramming (Case Management Society of America [CMSA], 2009; Noonan, 2014). Examples include planning and health delivery strategies for adolescents in a school system or the chronic disease management of elderly in a rural community (Huber, 2010; McKesson Corporation, 2014).
Like the earlier concept described by the American Hospital Association (AHA, 2003-2004), the ACA endorses the use of
K E Y T E R M S — cont’d problem solving, p. 492 risk-sharing, p. 485 social mandate, p. 478 supporting, p. 491 transitions of care, p. 481
utilization management, p. 478 veracity, p. 497 verifying, p. 491 —See Glossary for definitions
C H A P T E R O U T L I N E Definitions Concepts of Case Management
Case Management and the Nursing Process Characteristics and Roles Knowledge and Skill Requisites Tools of Case Managers
Evidence-Based Examples of Case Management Historical Evidence Contemporary Evidence
Essential Skills for Case Managers Advocacy Conflict Management Collaboration
Issues in Case Management Legal Issues Ethical Issues
478 PART 4 Issues and Approaches in Population-Centered Nursing
DEFINITIONS Care management is a health care delivery process that helps achieve better health outcomes by anticipating and linking populations with the services they need more quickly (CMSA, 2010). It is an enduring process in which a population manager establishes systems and processes to monitor the health status, resources, and outcomes for a targeted aggregate of the popula- tion. The population manager is the tactical architect for a population’s health in the delivery system. According to a report by McKesson Corporation (2014), nurse care managers are pre- dicted to hold the primary responsibility for the care manage- ment process in health systems. Building blocks that are used by the manager include risk analysis; data mapping; predictive modeling; dashboard indicators; monitoring for health pro- cesses, indicators, and unexpected illnesses; epidemiologic investigation of unexpected illnesses; development of multidis- ciplinary action plans and programs for the population; and identifying case management triggers or events (e.g., when dra- matic results are obtained by prevention or early intervention) that indicate the need for early referrals of high-risk clients (ANA, 2013; Stricker, 2014).
Care management strategies were initially developed by health maintenance organizations (HMOs) in the late 1970s to manage the care of different populations. The purpose was to promote quality and ensure appropriate use and costs of ser- vices. Typically these involved clients with reduced self-care capacity and whose diseases and treatments were intense (Michaels and Cohen, 2005). Care management strategies include utilization management, critical pathways, case man- agement, disease management, and demand management. Utilization management attempts to promote optimal use of
services to redirect care and monitor the appropriate use of provider care/treatment services for both acute and community/ambulatory services. Providers are offered mul- tiple options for care with different economic implications. Through the use of utilization management, clients who have repetitive readmissions (i.e., they fail to respond to care) are often referred to care management programs.
Critical pathways and maps, which were initiated in the early 2000s, are tools that specify activities providers may use in a timely sequence to achieve desired outcomes for care. The outcomes are measurable, and the pathway tools strive to reduce variation in client care. Today, agencies are more likely to call these clinical paths, evidence-based practice protocols, clinical decision supports or guidelines, or case management plans of care.
Care management services are used for clients with specific diagnoses who may have high-use patterns, noncompliance issues, cost caps (e.g., no more than $10,000 to $20,000 can be spent on their case), or threshold expenses.
Disease management constitutes systematic activities to coor- dinate health care interventions and communications for populations with disease conditions in which client self- care efforts are significant (CMSA, 2010). For example, dia- betes, asthma, and depression are typically targeted by providers and insurers. These programs have evolved largely
of population management—that is, achieving health outcomes at the population level. The Healthy People 2020 goals are to attain both quality of life and increase years of healthy life, achieve health equity and eliminate health disparities, and create social and physical environments as a social mandate for health care. In the second decade of the twenty-first century, case management will be an essential intervention to positively influence the leading health indicators, chronic disease out- comes, and focus areas of Healthy People 2020 (USDHHS 2010).
Establishing evidence-based strategies for all functions is critical to the success of case management for individuals and populations. Using the current best evidence blended with clin- ical expertise is a critical skill of the case manager (American Nurses Association [ANA], 2013; Lamb, 2013; CMSA, 2010). In their practice, nurse case managers have the following core values: increasing the span of healthy life, reducing disparities in health among Americans, and promoting access to care and to preventive services. Many of the interventions nurses use with clients and health care systems will further the Healthy People 2020 objectives. These include case management inter- ventions to minimize fragmented care and promote quality transitions of care; incorporate standardized practice tools and adherence guidelines; improve safety of care; and use interpro- fessional teams to deliver services.
In the Intervention Wheel model for public health nursing practice, the nursing actions of case management, collabora- tion, and advocacy comprise 3 of 17 evidence-based interven- tions for individuals, families, and populations served by public health nurses (Keller et al, 2004; and see Chapter 9). These three concepts and practice arenas for public health nurses are more fully described in this chapter. Case management incorporates many of the Quad Council Competencies for Public Health Nursing (Quad Council, 2011) because it involves individual and family care as well as community resources, population health, interprofessional teams, and policy implementation.
HEALTHY PEOPLE 2020
Case management strategies offer opportunities for nurses to help meet the following Healthy People 2020 objectives for target populations:
Access to Care • AHS-2: Increase the proportion of insured persons with coverage for clini-
cal preventive services • AHS-3: Increase the proportion of persons with a usual primary care
provider • AHS-6: Reduce the proportion of individuals who experience difficulties or
delays in obtaining necessary medical care, dental care, or prescription medications
• ECBP-14 and -14.1: Increase the inclusion of clinical prevention and popu- lation content in undergraduate nursing, including counseling training for health promotion and disease prevention
• SA-9: Increase the portion of persons who are referred for follow-up for substance abuse problems
AHS, Access to health services; ECBP, educational and community-based programs; SA, substance abuse. From USDHHSS: Healthy People 2020: A roadmap for health, Washington, DC, 2010, U.S. Government Printing Office.
479CHAPTER 22 Case Management
transitions among health care facilities, such as wellness and prevention, and interprofessional teams. The complexity of care and the publishing of the ICD-10s bring more in-depth docu- mentation requirements to the scope of the case manager’s activities but the essence remains: accountability, collaboration, advocacy, care coordination, and professionalism (Owen, 2014).
Case management is provided by the disciplines of nursing, social work, and rehabilitation counseling, to name a few. Research by Park and colleagues (2009) found that common knowledge exists for case management providers from the disciplines of nursing, social work, and rehabilitation counseling: case recording and documentation, conflict resolution strategies, negotiation, ethics, relevant legislation, interpersonal communication, and roles and functions required in various settings. Figure 22-1 illus- trates the unified knowledge domains for professionals in case management and emphasizes the fluidity of common knowledge used by case managers regardless of discipline.
Treiger (2013) indicates that the challenges of academic preparation for future case managers will be to prepare them in interprofessional case management programs rather than through the lens of a particular clinical practice. In addition, case managers in case management programs are expanding their clinical expertise to embrace the process of disease man- agement, a successful strategy for population outcomes. Spe- cialty case management in advanced nursing practice is a critical
as initiatives in managed care organizations (Huber, 2010) and will be a focus of accountable care organizations (ACOs).
Demand management seeks to control use by providing clients with correct information and education strategies to make healthy choices, to use healthy and health-seeking behaviors to improve their health status, and to make fewer demands on the health care system (Tufts Managed Care Institute, 2011). In contrast to care management—which was developed as a
population approach to manage care after the aegis of indi- vidual case management—case management comprises the activities implemented with individual clients/families in the system. In the latest Standards of Practice for Case Management, case management is defined as “a collaborative process of assessment, planning, facilitation, care coordination, evalua- tion, and advocacy for options and services to facilitate an indi- vidual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes. Related activities…include care coor- dination; complex condition management; population health management through wellness, disease and chronic care man- agement; and promoting transitions of care services” (CMSA, 2010, p. 224).
The case manager builds on the basic functions of the tradi- tional nurse’s role and adapts new competencies for managing
FIG 22-1 Evidence-based knowledge of case managers from disciplines of nursing, social work, and rehabilitation counseling. (Courtesy of Ann H. Cary.)
Health care management d elive
ry,
and transitions
P r i n
c i p l
e s a n d C o n c
e p
t s
Negotiation
Common Knowledge domains and statements
of case manager disciplines:
Nursing, social work, rehabilitation counseling Case recording
documentation, data management,
data analytics
Conflict resolution strategies
Interpersonal communication (group dynamics, relationship building, team building)
Health Care and disability-related legislation
Roles and functions of case managers in various settings
Ethics and professional conduct
480 PART 4 Issues and Approaches in Population-Centered Nursing
case management as a “set of logical steps and process of inter- acting within a service network which ensures that a client receives needed services in a supportive, effective, efficient and cost-effective manner” (p. 4). Case management was defined by the American Hospital Association (1986) as the process of planning, organizing, coordinating, and monitoring services and resources needed by clients, while supporting the effective use of health and social services. Secord (1987) defined case management as a systematic process of assessing, planning, and coordinating the service, referrals, and monitoring that meets the multiple needs of clients. Bower (1992) described the con- tinuity, quality, and cost containment aspects of case manage- ment as a health care delivery process, the goals of which are to provide quality health care, decrease fragmentation, enhance the client’s quality of life, and contain costs.
A focus on collaboration is important in the National Case Management Task Force definition. The definition emphasizes a collaborative process between the case manager, the client, and representatives of other agencies and provider groups. The process includes assessments, plans, implementation, coordina- tion, monitoring, and the evaluation of options and services to meet an individual’s health needs. Effective communication is essential to identify available resources to promote quality, cost- effective outcomes (CMSA, 2010; Mullahy, 2010; Stricker, 2013).
As a competency, case management was defined in the public health nursing literature as the “ability to establish an appropri- ate plan of care based on assessing the client/family and coor- dinating the necessary resources and services for the client’s
role in this field (Treiger, 2013). In implementing case manage- ment, advance practice nurses work with clients or community aggregates as well as systems managing disease and outcomes, whereas nurses with bachelor’s degrees more often focus on care at the individual level. Treiger (2013) also observes that there are many individuals working under the title of case manager who fail to perform the full scope of roles and functions, leading to the question of title protection for case managers.
This chapter describes the nature and process of case man- agement for individual and family clients. Case management has a rich tradition in public health nursing as practiced by Lillian Wald and now is frequently found in hospitals, transi- tional and long-term care, home and hospice care, and health insurance companies. Case management is at the top of the care management pyramid, reserved for a subset of the population. In Figure 22-2, Coggeshall Press (2008) illustrates a case man- agement model pyramid that recognizes the tenets of risk strati- fication and case finding, coordination, and ultimately case management of a smaller proportion of clients in the popula- tion. This model recognizes the interchange of public health and populations at risk for service intensity resulting from eco- nomic or care integration needs.
CONCEPTS OF CASE MANAGEMENT Reviewing multiple or historical definitions of case manage- ment helps to demonstrate the complex process and the concept of case management over time. Weil and Karls, in 1985, described
FIG 22-2 Case management model. (From Coggeshall Press: Case Management Model. Coralville, IA, 2008, Coggeshall Press; as cited in Huber, 2010.)
Risk identification and stratification on measures of health and well-being.
Uses principles of primary prevention for lifestyles and behavioral change
Care coordination of those identified as at risk
Case management
of the 10%-20% of the population
needing economic or care integration case management
481CHAPTER 22 Case Management
post–acute care follow-up, and decreasing gaps in care by the use of a single consistent provider (cited in ANA, 2013, p. 19). To advance knowledge on the outcomes of transitions of care, NTOCC has developed a number of tools and resources for case managers to assure effective communication between clients, caregivers, and providers, and published a compendium of tran- sition models in practice that provides evidence of cost savings and lower 30-day hospital readmission rates and emergency room visits. The Transitional Care Bundle includes seven essen- tial interventions: medication management, transition planning, client/family engagement and education, information transfer, follow-up care, provider engagement, and shared accountability across providers (Lattimer, 2013). Research indicates that the models employing the “Transitions” concept are currently ensur- ing higher quality and health care savings (http://www.ntocc.org/ portals/0/Tangiblesavings.pdf).
Case management differs between urban and rural settings. In the rural setting, where the distance between populations is more expansive, there are fewer organized community-based systems and communication and distance are often a greater challenge. Furthermore, the economics, pace and style of life, values, and social organization all differ. In a study referenced in Stanton and Dunkin (2009), rural residents identified four barriers to access to care that confront case managers in rural areas: lack of proximity to providers, limited services, scarcity of providers, and reduced availability of emergency and acute care services. Transportation, both for nurses and for clients, and lack of health insurance and benefits were documented challenges to rural clients of case managers.
In a study of rural Veterans Affairs (VA) mental health patients who received case management services, Mohamed, with Neale and Rosenheck (2009) and Mohamed, with col- leagues Rosenheck and Cuerdon (2010) found that intensive case management services were characterized as slightly less frequent, less intensive, and less recovery oriented than services delivered to the urban VA population. Travel distances and times were longer for rural case managers. Case management service intensity was related to premature termination of ser- vices for the veteran populations. Because case management is part of a transitional care model and coordination of care can reduce readmissions and promote safety, appropriate delivery of case management is essential to support The Joint Commis- sion’s National Safety Goals (2009) as well as the National Quality Strategy (AHRQ, 2013).
Case Management and the Nursing Process The nurse views the process of case management through the broader health status of the community. Clients and families receiving service represent the microcosm of health needs within the larger community. Through a nurse’s case manage- ment activities, general community deficiencies in quality and quantity of health services are often discovered. For example, the management of a severely disabled child by a nurse case manager may uncover the absence of respite services or parenting support and education resources in a community. While managing the disability and injury claims within a cor- poration, the nurse may discover that alternative care referrals
benefit” (Muller and Flarery, 2003, p. 230). Case management has been a term prevalent in the social work literature as well as in public health nursing beginning in the mid-1900s. Knowl- edge and skills required to achieve this competency include the following: • Knowledge of community resources and financing
mechanisms • Written and oral communication and technology-enhanced
documentation • Proficient negotiating and conflict-resolving practices • Critical-thinking processes to identify and prioritize prob-
lems from the provider and client viewpoints • Application of evidence-based practices and outcomes
measures Case management practice is complex as evidenced by the
need to coordinate activities of multiple providers, payers, and settings throughout a client’s continuum of care. Care coordina- tion, one function of case management, is the deliberate organi- zation of client care activities between two or more participants involved in a client’s care to facilitate the appropriate delivery of health care services…and involves the marshaling of personnel and resources to carry out all required patient care activities… managed by the exchange of information among participants for different aspects of care (McDonald et al, 2010). For example, in a contemporary model of primary care practice, the Medical/ Health Home or Patient/Client-Centered Medical Home model provides accessible, continuous, coordinated, comprehensive care and is managed centrally by a physician/nurse practitioner with the active involvement of nonphysician practice staff. Care pro- vided must be assessed, planned, implemented, adjusted, and evaluated on the basis of goals designed by many disciplines as well as goals of the client, the family, significant others, and com- munity organizations. Although likely employed and located in one setting, the nurse as case manager will be influencing the selection, monitoring, and evaluation of care provided in other settings by formal and informal care providers.
With the increased use of electronic care delivery through telehealth activities, case management activities are now handled via iTablets, phones, e-mail, and fax, and through video visits with the electronic monitoring of physiological status at a cli- ent’s residence from a case manager who is located elsewhere. Case managers may also deliver care to a global network of clients located in different countries. A challenging problem is the fragmentation of services and miscommunication handoffs, which can result in overuse, underuse, gaps in care, and mis- communication. These can result in costly client outcomes and quality issues in hand-offs and transitions from provider to provider. Health information technology and electronic health records are benefiting collaborative care team communication, real-time data, and timely adjustments in care.
Case management, including the care coordination function, is part of a wider concept of transitions of care illuminated by the National Transitions of Care Coalition (NTOCC, 2011). Transitional care services bridge the gaps among diverse services, providers, and settings through the systematic application of evidence-based interventions that improve communication and transfer of information within and across services, enhancing
482 PART 4 Issues and Approaches in Population-Centered Nursing
Characteristics and Roles Case management can be labor intensive, time consuming, and costly. Because of the rapid growth in the nature of complexity in clients’ problems managed by the case manager, the intensity and duration of activities required to support the case manage- ment function may soon exceed the demands of direct caregiv- ing. Managers and clinicians in community health are exploring methods to make case management more efficient including the use of providers who can perform to the limit of their licenses, auxiliary case management providers/services, and evidence- based practices. These provider characteristics, which incorpo- rate the four CMSA activities (previously noted in the Concepts of Case Management section), are used today (CMSA, 2010): 1. The technical/intellectual qualifications to understand and
evaluate specific diagnoses, generally requiring clinical credentials (and experience), financial resources, health information technology knowledge and analyses, and risk arrangements
2. Capability in language and terminology (able to understand and then to explain to others in simple terms)
3. Assertiveness, diplomacy, and negotiation skills with people at all levels
for home-health visits and physical therapy are generally unde- rused by the acute care providers in the community. Through a nurse’s case management of brain-injured young adults, the absence of community standards and legislative policy for helmet use by bicyclists and motorcyclists may be revealed, stimulating advocacy efforts for changing community policy. Case management activities with individual clients and families will reveal the broader picture of health services and health status of the community. Community assessment, policy develop- ment, and assurance activities that frame core functions of public health actions are often the logical next step for a nurse’s practice. When observing lack of care or services at the indi- vidual and family intervention levels, the nurse can, through case management, intervene at the community level to make changes. Clearly, the core components of case management and the nursing process are complementary (Table 22-1).
Secord’s classic illustration of case management (1987) remains an appropriate picture of the process that nurses use. The CMSA model (2010) is a contemporary illustration of the case manager’s process in the continuum of care (Figure 22-3) and Table 22-1 also compares the case management process and nursing process.
Nursing Process Case Management Process Activities
Assessment • Case finding • Identification of incentives for target population • Screening, selection and intake • Determination of eligibility • Assessment of challenges, opportunities, and problems
• Develop networks with target population • Disseminate written materials • Seek referrals • Apply screening tools according to program goals and objectives • Use written and on-site screens • Apply comprehensive assessment methods (physical, social,
emotional, cognitive, economic, and self-care capacity) • Obtain consent for services if appropriate
Diagnosis • Identification of problem/opportunity and challenges • Hold interprofessional, team, family, and client conferences • Determine conclusion on basis of assessment • Use interprofessional team
Planning for Outcomes • Problem prioritizing • Planning to address care needs • Identification of resource match
• Validate and prioritize problems with all participants • Select evidence-based interventions • Develop goals, activities, time frames, and options • Create case management plan • Gain client’s consent to implement • Have client choose options
Implementation • Advocating for client interests • Frequent monitoring to assess alignment with goals
and changing nature of client needs
• Contact providers • Coordinate care activities • Negotiate services and price • Adjust as needed during implementation • Document processes and monitor progress
Evaluation • Measuring attainment of activities and goals of service delivery plan
• Continued monitoring and follow-up of client status during service
• Reassessment • Bringing closure to care when client needs are
achieved or change • Appropriate discharge to ensure effective transitional
care and termination of case management processes
• Ensure quality of transitional communication and coordination of service delivery
• Monitor for changes in client or service status • Follow up as needed • Examine outcomes against goals • Examine needs against service • Examine costs • Examine satisfaction of client, providers, and case manager • Examine best practices and outcomes for this client
TABLE 22-1 The Nursing Process and Case Management
483CHAPTER 22 Case Management
4. The ability to assess situations objectively and to plan appro- priate case management services
5. Knowledge of available clinical evidence and resources as well as their strengths and weaknesses
6. The ability to act as advocate for the client and payer in models relying on third-party payment
7. The ability to act as a counselor or facilitator to clients to provide support, understanding, information, and intervention
8. Interprofessional team player In 1998, Cary described the roles of case managers in the
practice setting. These roles are clearly affirmed today by the CMSA (2010) (Box 22-1). The roles demanded of the nurse as case manager are greatly influenced by the forces that support or detract from the role. Figure 22-4 presents factors that demand the attention of both the nurse and the system during the case management process.
Knowledge and Skill Requisites Nurses, as in other disciplines, are not automatically experts in the role of case manager. First, they develop and refine the knowledge and skills that are essential to implementing the role successfully. Knowledge domains useful for nurses in systems desiring to implement quality case management roles are found in Box 22-2 (Cary, 1998; Stanton and Dunkin, 2009; Treiger, 2013).
When a nurse seeks a case manager position, some of the skills and knowledge will need to be acquired through
FIG 22-3 The continuum of care case management model. (From Case Management Society of America [CMSA]: Standards of Practice for Case Management. Little Rock, AR, 2010, CMSA, p. 5.)
TH E C
ONTINUUM
F IN
A N
CI AL
ETHICS & LE G
A L
S O
C IA
L S
UPPORT PR OV
ID
E R
S
C
ASE MANAGEM EN
T
C L IE
N T
-C E
N TE
RE D PATIENT-C
E N
T E
R E
D
M O
N ITO
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IMPLEMENT
C O
LL A
B O
R A
T E
ASSESS
P LA
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V A
LU A
TE
OF HEALTH CA RE
academic and continuing education programs, literature reviews, onboarding, orientation, and mentoring experiences. Basic nursing education may need to be updated, and practical experiences in case management may be required. Treiger (2013) recommends that case managers pursue advanced edu- cation in case management. In fact, professional development activities for case managers in public health have been demon- strated to contribute to job satisfaction (Schutt et al, 2010). Finally, title protection for case managers is an issue under discussion in the literature in order to ensure credibility of services provided by professional, skilled case managers.
Tools of Case Managers The six “rights” of case management are right care, right time, right provider, right setting, right price/value, and right out- comes. How does the nurse judge the effectiveness of case man- agement? Three tools are useful for case management practice: case management plans, disease management, and life care planning tools. An underlying principle for the use of each of these tools is the need to use robust evidence as the basis for the selection of activities; technology and health information systems and analytics are now the drivers of these tools.
Technology supports the delivery of processes used by the case manager. The technology sector is refining software in the areas of documentation, decision support, dashboard tools, predictive modeling, workflow automation, reporting capabili- ties, electronic health records, patient engagement strategies and social media, and remote monitoring (Carneal and Pock,
484 PART 4 Issues and Approaches in Population-Centered Nursing
• Broker: Acts as an agent for provider services that are needed by clients to stay within coverage according to budget and cost limits of health care plan
• Client advocate: Acts as advocate, provides information, and supports benefit changes that assist member, family, primary care provider, and capi- tated systems
• Consultant: Works with providers, suppliers, the community, and other case managers to provide case management expertise in programmatic and indi- vidual applications
• Coordinator: Arranges, regulates, and coordinates needed health care ser- vices for clients at all necessary points of services. Effectively participates and leads interprofessional teams
• Educator: Educates client, family, and providers about case management process, delivery system, community health resources, and benefit coverage so that informed decisions can be made by all parties
• Facilitator: Supports all parties in work toward mutual goals • Liaison: Provides a formal communication link among all parties concerning
the plan of care management • Mentor: Counsels and guides the development of the practice of new case
managers
• Monitor/reporter: Provides information to parties on status of member and situations affecting client safety, care quality, and client outcome, and on factors that alter costs and liability
• Negotiator: Negotiates the plan of care, services, and payment arrange- ments with providers; uses effective collaboration and team strategies
• Researcher: Accesses and applies evidence-based practices for program- matic and individual interventions with clients and communities; participates in protection of clients in research studies; initiates/collaborates in research programs and studies; accesses real-time evidence for practice
• Standardization monitor: Formulates and monitors specific, time-sequenced critical path and care map plans (see page 485) as well as disease manage- ment protocols that guide the type and timing of care to comply with pre- dicted treatment outcomes for the specific client and conditions; attempts to reduce variation in resource use; targets deviations from standards so adjust- ments can occur in a timely manner; uses dashboards and predictive modeling to anticipate outcomes
• Systems allocator: Distributes limited health care resources according to a plan or rationale
BOX 22-1 Case Manager Roles
FIG 22-4 Factors that require the attention of the nurse and client in the case management process. TQM, total quality management.
Clinical assessment
Research
Patient data
Point-of-care design
Best practice
Patient outcomes
Prespecification design
Clinician’s experiential knowledge
Research findings
TQM Evaluative
setting data
System management
System’s policies,
resources, and financing
• Standards of practice for case management • Evidence-based practice guidelines for specific health and disease conditions
and communities • Knowledge of health care financial environment and the financial dimension
of client populations managed by nurses • Clinical knowledge, skill, and maturity to direct quality timing and sequencing
of care activities • Care resources for clients within institutions and communities: facilitating
the development of new resources and systems to meet clients’ needs • Transition planning for ideal timing, sequencing, and levels of care • Management skills: communication, delegation, persuasion, use of power,
consultation, problem solving, conflict management, confrontation, negotia- tion, management of change, marketing, group development, accountability, authority, advocacy, ethical decision making, and profit management
• Teaching, counseling, and education skills • Program evaluation and research • Performance improvement techniques • Peer and team consultation, collaboration, and evaluation • Requirements of eligibility and benefit parameters by third-party payers • Legal and ethical issues • Information management systems: clinical and administrative • Health care legislation/policy • Technical information skills, interoperable information systems, dashboard
monitoring, data management and analysis, predictive modeling software, facile use of EHRs
• Outcomes management and applied research
BOX 22-2 Knowledge Domains for Case Management
EHRs, Electronic health records.
485CHAPTER 22 Case Management
2014; Stricker, 2014; Treiger, 2013). For example, health infor- mation technology (HIT) allows the case manager to access real-time data to improve timeliness of decisions or program changes for any number of adjustments in care protocols to ensure optimal outcomes. Data analytic software and dash- boards allow for rapid decisions for clinical, administrative, and financial outcomes. Dashboard functions typically include (1) manipulation of report data, (2) access to information, (3) observing individual/population trends, and (4) observing trends in large datasets (Stricker, 2014). These data-reporting tools can vary from off-the-shelf, to customized, to simple Excel spreadsheets—each with their own advantages and gaps.
Historically, case management plans have evolved through various titles and methods (e.g., critical paths, critical pathways, care maps, multidisciplinary action plans, nursing care plans). Regardless of the title given, standards of client care, standards of nursing practice, and clinical guidelines using evidence- based practices for case management serve as core foundations of case management plans. Likewise, in interprofessional action plans, core professional standards of each discipline guide the development of the standard process.
As early as 1985, the New England Medical Center (Boston, MA) instituted a system of critical path development to guide the case management process in the acute care setting. This method of designing structures and processes of care laid the groundwork for the critical paths, care maps, and clinical deci- sion tools now used in the industry. A critical path was described as a case management tool composed of abbreviated versions of discipline-specific processes; it was used to achieve a measur- able outcome for a specific client “case” (Zander et al, 1987). The critical path detailed the essential and sequential activities in care, so that the expected progress of the client was known at a point in time. Outcomes from critical paths included sat- isfaction, client competency, continuity of care, continuity of information, and costs and quality of care. However, one criti- cism was that critical paths may not be evidence based (Renholm et al, 2002).
At that time the prevailing method of establishing critical paths was by internal, “expert knowledge” from a specific insti- tution, the result being that they could not be applied generally or tested under systematic, scientific methods. In the New England model, key incidents included consults, tests, activities, treatments, medication, diet, discharge planning, and teaching. The paths showed the differences between clients’ progress. However, the paths were generally not revised unless a body of evidence was found to adjust the expected actions.
Care maps became the second generation of critical path- ways of care. Rather than give definitions, as early as in 2001 Brown discussed the “various types of evidence that must be accessed, interpreted, and integrated into care design” (p. 3). Brown proposed the best practice health care map (BPHM) as a model for providing quality clinical care within an interpro- fessional practice. This model discussed all the components of knowledge development and care planning activities that must occur to have positive client outcomes. The author noted that care designed in advance takes the form of “clinical guidelines, care maps, decision algorithms, and clinical proto-
cols for specified populations of clients” (Brown, 2001, p. 3). The “prespecification design” of the BPHM entailed these preplanning courses of care. Brown (2001) stressed the impor- tance of incorporating research findings and clinical experience when developing prespecified plans. Furthermore, the author emphasized that at the point of care, these prespecified plans must be adapted to the individual client or population. The Brown BPHM was (1) client centered, (2) scientifically based, (3) population-outcomes based, (4) refined through quality assessment and compared with other maps, (5) individualized to each client, and (6) compatible with the larger system of health care in the United States.
Such activities today are more likely referred to as case man- agement plans, care maps, and integrated clinical pathways and are the foundation for the methods to establish standardized, evidence-based case management plans. Clinical paths today are defined as structures of care based on interventions trans- lated from evidence for use with clients; include detailed steps in a course of care; are based on pilot applications; and are modified (Kinsman et al, 2010). In the electronic health record (EHR) critical paths become the centerpiece of communication and interprofessional team processes for the case manager (Hyde and Murphy, 2012). Care guidance formats (critical paths, care maps) are integrated into the EHR to be used by the case manager to provide clinical decision support. They may appear as prompts, checklists, references, for example, that will auto-populate a documented service and remind providers as to the array of procedures to be implemented. Case managers need to ensure that any “guidance care plans” embrace the unique needs of the client and care in order to optimize out- comes of care for clients.
Adaptation of any standardized case management plan to each client’s characteristics is a crucial skill for the process and outcome of care. These plans link multiple provider interven- tions to client responses and offer reasonable predictions to clients about health outcomes. Institutions report that sharing case management plans with clients empowers the clients to assume responsibility for monitoring and adhering to the plan of care. Self-responsibility by clients incorporates autonomy and self-determination as the core of case management. For the nurse employed as a case manager, ample opportunity exists to apply and revise critical path/map care guidance prototypes for a target population experiencing acute and chronic health problems.
Disease management is an organized program of coordi- nated health care interventions that use consensus-driven per- formance measures and scientifically based evaluations in clinical outcomes for populations with conditions in which client self-care efforts are critical (CMSA, 2010; URAC, 2014). This approach focuses on the natural progression of a disease in high-risk populations. Disease management programs may contain many of the following components (Disease Manage- ment Association of America [DMAA], 2008, 2010): • Selection of high-risk patients, with a focus on a singular
disease state (diabetes, asthma, congestive heart failure [CHF]) • Financial and risk-sharing arrangements between payers
and providers
486 PART 4 Issues and Approaches in Population-Centered Nursing
certifies and URAC accredits disease management organiza- tions and programs on the basis of their respective standards (see websites www.jointcommission.org and www.urac.org). This may influence the choice of programs a case manager selects to use with clients.
Opponents of the use of disease management programs cite the study by McCall and Cromwell (2011), which described a comparison of eight commercial disease management pro- grams used with Medicare populations and using a nurse call center approach. This comparative evaluation study revealed only modest improvement in quality of care measures with no significant reduction in utilization of acute care services or costs. Some of the possible explanations included that clients had complex comorbidities that required more than a singular disease approach; social determinants and environmental factors may not have been adequately addressed in the plans; and the inclusion of high-risk with low-risk patients could have diluted the significance of the results. Clearly, more research with innovative models that can capture the true nature and intensity of client needs in a disease management program will be necessary to inform the use or discontinuance of this approach in the future.
Life care planning is another tool used in case management. A life care plan assesses the current and future needs of a client for catastrophic or chronic disease over a life span. The life care plan is a customized, medically based document that provides an organized plan to estimate reasonable and necessary current and future medical and nonmedical needs of clients with associ- ated costs and frequencies of goods and services. Typically these needs incorporate medical, financial (income), psychological, vocational, built environment, and social costs during the remaining life of the client (Sambucini, 2013). Life care plans are typically used for clients experiencing catastrophic illness or adverse events resulting from professional malpractice or accidents/injuries or those who have sustained an injury when younger and subsequently have changes in requirements as they age. For example, conditions may include spinal cord injury, traumatic brain injury, chronic pain, amputation, cerebral palsy, and burns. Life care plans are also used to set financial rewards, which can be used to secure resources for care in the future and create a lifetime care plan. A systematic process like the nursing process is used and interprofessional input is required.
The American Association of Nurse Life Care Planners (AANLCP) has published a Code of Professional Ethics and Conduct for Nurse Life Care Planners with Interpretive State- ments (2012a) as well as the Nurse Life Care Planners Standards of Practice with Interpretive Statements (2012b). Nurse life care planners have access to academic course work, continuing edu- cation activities, and a published A Core Curriculum for Nurse Life Care Planning (Apuna-Grummer and Howland, 2013). There is also a certification examination for nurse life care plan- ners that awards the designation of Certified Nurse Life Care Planner (CNLCP) as a specialty designation (www.cnlcp.org).
The first phase of the plan is crafted to include a thorough assessment of the client, financial/billing agreements, an infor- mation release signed by the client, and a targeted date for report completion. Development of the plan is the second
• Programs for monitoring the use of clinical paths and evidence-based guidelines to assess outcomes and costs
• Protocols for clinical, financial, and administrative processes
• Services to educate clients and promote self-management skills, including the use of motivational interviewing techniques.
• Enhanced quality through evidence-based decision support and other registry technologies
• Support for provider/client relationships and plans of care • Evaluation of clinical, humanistic, and economic outcomes
to address the goal of improving overall health
HOW TO Apply Telehealth Interventions for Clients To learn more about telehealth interventions for clients, case man- agers can do the following: • Make it a point to learn how telehealth works in your community
and in the industry. • Examine the evidence base for telehealth as an option for the
types of clients you are servicing when considering available resources.
• Seek continuing education to prepare you on the art and science of telehealth application and client receptivity. Read the literature on e-communication and monitoring impact effectiveness.
• Be aware of the strengths and weaknesses of this delivery and plan to adjust the delivery model to optimize effectiveness for your clients.
• Seek networking opportunities with professional organizations and other case managers about the uses of telehealth.
• Examine the clinical guidelines and practice algorithms for tele- health adoption, application, and use.
• Sharpen your personal interaction and program evaluation skills to better assist in decision making about the use of telehealth services.
From Hagan L, Morin D, Lepine R: Evaluation of telenursing outcomes: satisfaction, self-care practices, and cost savings. Public Health Nurs 17:305–313, 2000.
The philosophy of disease management can give clients the tools needed to better manage their lives (Newman et al, 2014; CMSA, 2010). Clients with chronic diseases may benefit from a disease management approach. The goals are to interrupt the continued development of a disease and prevent future disease and complications through secondary and tertiary prevention interventions. Promotion of wellness is necessary for success. For specific client populations that consume a disproportionate share of resources, disease management programs allocate the correct resources in an efficacious manner. Disease manage- ment programs may reduce emergency department visits, result in fewer inpatient days and rehospitalizations, greater client satisfaction, and reduced school absences (NTOCC, 2011; Sidorov, 2010). As the science of disease management evolves to predict direct relationships between outcomes and protocols of care, case managers will need to demonstrate cost-effective, optimal clinical care across the continuum—a goal of care man- agement for populations. In fact, disease management is viewed as a top strategy by employers. The Joint Commission (TJC)
487CHAPTER 22 Case Management
All of these tools/programs, in coordination, constitute pop- ulation health management strategies to educate clients and promote self-management, provide nurse coaching support, promote safe care transitions, improve care management and coordination, and enhance quality (DMAA, 2010).
EVIDENCE-BASED EXAMPLES OF CASE MANAGEMENT Historical Evidence Carondelet Health at St. Mary’s Hospital in Tucson, Arizona, developed a community nursing network in which enrollees are distributed among a number of community health centers. Pro- fessional nurse case managers assisted older clients to attain healthier lifestyles and maintain themselves in the community. Nurses were successful in delivering economical services per month for Medicare enrollees. Through nurse case manage- ment services, this nursing HMO was reported to have reduced the number of inpatient days per 1000 enrollees by one third, at an average cost of $900 per day, for a savings of $300,000 for every 1000 enrollees (ANA, 1993; American Nurses Foundation [ANF], 1993). These strengths have been critical to allow the model to evolve to provide group and telephonic case manage- ment and automated standardized care instruments. Future endeavors will capitalize on the advances in information tech- nology to capture clinical and cost data in a timely manner for decision support (Cohen and Cesta, 2005).
Community-based statewide programs in New Jersey used case management methods to promote early identification, selection, evaluation, diagnosis, and treatment of children who are potentially physically compromised. Local case manage- ment units provided coordinated and comprehensive care. Col- laboration with existing local and regional agencies serving children supported this process. The nurse case manager (1) provided counseling and education to parents and children about identifying problems and increasing their knowledge, (2) developed individual plans incorporating multidisciplinary ser- vices (education, social issues, medical development, rehabilita- tion), (3) obtained appropriate community services, (4) acted as a family resource in crises and service concerns, (5) facilitated communication between child and family, and (6) monitored services for outcomes. Interprofessional teams include nurses and social workers (with master’s degrees) for larger caseloads. A recommended caseload was 300 to 350 children per case manager (Bower, 1992).
A national study of 2437 people who tested positive for human immunodeficiency virus (HIV) and who had case man- agers demonstrated that, regardless of the model, these clients were more likely to use life-prolonging HIV medications and meet the needs for income, health insurance, home care, and supportive emotional counseling than those without case management. Having contact with a case manager was not significantly related to use of outpatient care, hospital admis- sion, or emergency department visits. Case managers in this study included social workers, nurses, and acquired immu- nodeficiency syndrome (AIDS) service organization staff (Katz et al, 2001).
phase. Plans are based on a number of factors: social and cul- tural situation, leisure activities, educational and employment status, medical history, physical and psychological abilities, current status, assistance required for completing activities of daily living, and regulatory requirements.
McClinton DH: Protecting patients. Contin Care 17:6, 1998; Institute of Medicine (IOM): Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, 2001, National Academies Press.
HOW TO Ensure High-Quality Care The following actions can ensure high-quality care for clients and have implications for case managers in their practice: • Provide access to easily understood information for each client
based on his or her needs and health literacy level. • Remember that the client is the source of control and that
patient/family engagement is critical. • Provide access to appropriate specialists with coordination and
communication transparency. • Ensure continuity of care for those with chronic and disabling
conditions (transition care). • Provide access to emergency services when and where needed. • Disclose financial incentives that could influence medical deci-
sions and outcomes. • Prohibit “gag clauses” (which mean that providers cannot inform
clients of all possible treatment options). • Provide antidiscrimination protections. • Provide internal and external appeal processes to solve griev-
ances of clients. • Make decisions on the basis of evidence.
The following can ensure high-quality care for clients and have implications for case managers in their practice: • Provide access to easily understood information for each
client based on their needs and health literacy level • The client is the source of control and patient/family engage-
ment is critical. • Provide access to appropriate specialists with coordination
and communication transparency. • Ensure continuity of care for those with chronic and dis-
abling conditions (transition care). • Provide access to emergency services when and where
needed. • Disclose financial incentives that could influence medical
decisions and outcomes. • Prohibit “gag clauses” (which mean that providers cannot
inform clients of all possible treatment options). • Provide antidiscrimination protections. • Provide internal and external appeal processes to solve griev-
ances of clients. • Decision making is evidence based. • The plan includes projected costs and resources needed for
the frequency and duration of treatments, equipment, sup- plies, and future evaluations.
• The execution of a life care plan is typically managed by a case manager who will work with the life care planner, especially when re-evaluation of the plan is necessary (AANLCP, 2013).
488 PART 4 Issues and Approaches in Population-Centered Nursing
to assist them in living independently in the community and in maintaining their health by eliminating or reducing the need for hospital admissions or long-term care.
These models offer a solution to unnecessary health care expenses by reducing costs and accessing appropriate health care services. Imagine the impact on health status if these saved expenses were shifted to primary prevention and health promo- tion activities.
Contemporary Evidence Reducing the rate of readmission within 30 days of hospital discharge is a quality goal in health care. For psychiatric clients, the risk of rehospitalization is greatest and most costly during this time. Kolbasovsky (2009) replicated a model of intensive case management (ICM) in the United States that had been successful in Europe in reducing 30-day readmission rates (Burns et al, 2001, 2007) and found that ICM significantly reduced readmissions and the associated costs of 305 clients at a cost of $41.39 per member during the 30-day period. Had these persons been rehospitalized, the hospital psychiatric costs would have been $1528.14 per member. The nature of the case management activities included transitional and coordination of aftercare, monitoring of symptoms, medication and treat- ment adherence, education of client and families, motivational interviewing to detect barriers, linkages to community-based resources, treatment refill reminders, alcohol screening, and brief interventions.
In a randomized controlled trial of 450 clients post–cardiac bypass surgery, case management intervention by nurses using telephone-based collaborative care improved the mental and physical health of persons experiencing depression after cardiac bypass in an 8-month case management intervention. Case management activities included education about post–cardiac surgery depression, self-management skills, assessing and mon- itoring of treatment and medication adherence, interprofes- sional weekly case conferences, and routine communication with persons and primary care providers to ensure the provi- sion of coordinated, consistent care. The case manager used ongoing telephone support, encouragement of client prefer- ences, self-management workbooks, coaching, and electronic support for care guidelines and protocols. Outcomes included increased mental health scores, improved physical and func- tional status, and fewer readmissions among males with subse- quent cost savings (AHRQ, 2010a).
Using a managed care model of enrollment, the Care One program at the University of New Mexico Health Sciences Center provides intensive case management and care coordina- tion to medically complex, costly clients who lack health insur- ance. Among the top 1% of high-cost clients, all were offered enrollment in a case management service with an interprofes- sional team of providers who help persons in this population to navigate the system, access available financial assistance, and use appropriate community resources. Each person meets with the entire team to assess and prioritize needs, goals, and subsequent steps, and to schedule medical appointments. Activ- ities also include securing financial resources; counseling and assistance to complete paperwork; scheduling appointments,
Liberty Mutual Insurance Company had used case manage- ment principles for more than 30 years in workers’ compensation cases and expanded services for employees whose conditions were noted as chronic or catastrophic. Case managers coordi- nated all clients, providers, and services to reduce expenses caused by lack of coordination; failure to use beneficial alternatives; and duplication and fragmentation of services (Bower, 1992).
LINKING CONTENT TO PRACTICE
Important guidance in developing a community-based case management program can be found in the United States. Case management is a key com- ponent of federally financed and many state-financed health delivery options. The experiences of states over the past two decades provide testimony to the importance of case management for populations at risk. For older clients, state-derived case management provides objective advice and assistance with care needs. It also provides access to interprofessional providers and services. For payers (federal, state, clients), case management serves as a way to ensure that funds are allocated appropriately to those in greatest need. Case management serves a policy assurance and accountability function for communities. The PACE (Program of All-Inclusive Care for the Elderly) program addresses the needs of chronically ill seniors who wish to remain in their homes rather than be admitted to nursing homes and are enrolled in a managed care model of medical and support services, case management, medications, respite, hospital, and nursing home care when necessary. PACE prevents institutionalization in nursing homes, uses a strong social model of health care delivery, and case manages transitions of clients between delivery systems and providers. Studies (Wieland et al, 2013; Fretwell and Old, 2011) have demonstrated cost savings with PACE programs compared with nursing home costs. The PACE model has been permanently recognized as a provider type under both Medicare and Medicaid and has grown to 104 programs operating in 31 states (National PACE Association, 2014).
Within the states, the types of agencies designated to conduct case management are often district offices of state government, area agencies on aging, county social services departments, and private contractors. States maintain the oversight responsibili- ties for case management agencies to (1) ensure they are com- plying with program standards, contracts, reporting, and fiscal controls, (2) identify emerging problems and issues to be resolved by additional state policies, and (3) provide on-site technical assistance and consulting to improve performance. States’ payment methods for case management include daily/ monthly rates, hourly/quarterly rates, capped rates for services, and capped aggregate rates to cover both case management and provider costs (Health Resources and Services Administration [HRSA], 2004; U.S. Department of Health and Human Services [USDHHS], 2008).
The models of case management vary today as they did in the recent past. In 1999, Taylor described three models by their focus: client, system, and social service. Client-focused models are concerned with the relationship between case manager and client to support continuity of care and to access providers of care. System-focused models, in contrast, address the structure and processes of using the population-based tools of disease management and case management plans to offer care for client populations. The social service models provide services to clients
489CHAPTER 22 Case Management
reminders, and follow-ups; behavioral health counseling; medi- cation management; and access to community resources to support health. Case management resulted in 80% fewer hos- pital admissions, a 60% decline in emergency room visits, and consistently high client satisfaction scores (AHRQ, 2010b).
From Wright K, Hazelett S, Jarjoura D, Allen K: The AD-LIFE trial. Home Healthcare Nurse 25(5):308–314, 2007.
A successful pilot program led to the execution of a randomized controlled trial—After Discharge Care Management of Low Income Frail Elderly (AD- LIFE)—for community-based elderly. The care management model uses the integration of medical and social care to improve the outcomes of low-income and chronically and functionally impaired elderly after hospital discharge. AD-LIFE uses an interprofessional team, comprehensive geriatric assessment, and care management by a team nurse. Throughout the first year after hospital discharge, the nurse works with the area Agency on Aging social services program, performs a hospital and home assessment, uses a client goal-setting approach, creates a plan for development of self-care skills, and provides care planning for chronic illnesses and geriatric syndromes (e.g., incontinence, depression, nutrition, skin problems, and memory impairment). The interpro- fessional team can access specialists, and the primary care provider performs frequent evaluations and revises care plans as needed.
Ninety-two percent (92%) of the 118 clients had the need for at least one medical or social intervention. Half were taking 5 to 10 prescription drugs, 40% were living alone, 28% had congestive heart failure, 28% had diabetes, and many were unable to perform some ADLs or experienced geriatric syn- drome. About 70% of clients said the care management program improved their health, allowed them to more easily access health care services, and provided them with a greater understanding of their disease(s). Hospital admissions decreased and the care cost savings were $1000 per client per month. • As a nurse working in public health, aspects of this program could be built
on to design an interprofessional program for community-based clients with Alzheimer’s disease, people living with AIDS, chronically ill or dis- abled children, or clients with unstable psychiatric conditions.
Nurse Use Postdischarge care management that integrates medical, nursing, and socially and culturally proficient care can improve outcomes of the low-income elderly as well as other groups named above. It is important to identify the interpro- fessional team members who could be assembled to conduct the program with each client group, to identify measures of success for each of the pro- grams, and to relate the case management process to Healthy People 2020 objectives that could be addressed for each of these client groups.
EVIDENCE-BASED PRACTICE
most nurse and community health worker visits for their care (Gary et al, 2009). Culturally tailored interventions are essential to approaching health equity outcomes.
In a 2012 study with 83 clients in an urban setting, most of whom were uninsured, a community-based case management program with clients experiencing one or more chronic diseases yielded impressive results: acute outpatient encounters decreased by 62% and inpatient admissions by 53%. Primary care visits increased by 162% with an overall reduction in aggre- gate costs of 41%—from $16,208 preintervention to $9541 pos- tintervention (Glendenning-Napoli et al, 2012).
ESSENTIAL SKILLS FOR CASE MANAGERS Three skills are essential to the role performance of the case manager: advocacy, conflict management, and collaboration.
Advocacy Case managers report that they are first and foremost client advocates (Barefield, 2003; Stanton and Dunkin, 2009; CMSA, 2010). The definition of nursing includes advocacy: “Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations” (ANA, 2010, p. 6). For nurses, advocacy involves a number of activities, ranging from exploring self-awareness to lobbying for health policy. Advocacy is essential for practice with clients and their families, communities, organizations, and colleagues on an interprofessional team. The functions of advo- cacy require scientific knowledge, expert communication, facili- tating skills, and problem-solving and affirming techniques.
As the Guide to the Code of Ethics for Nurses (ANA, 2008) states, “The nurse, in all professional relationships, practices with compassion and respect…” (p. 4). This means the nurse has the obligation to move beyond his or her own personal feelings of agreement or disagreement to respond compassion- ately. However, this goal is a contemporary one; the perspective regarding the advocacy function has shifted through history. The nurse advocate has been described in earlier writings as one who acted on behalf of or interceded for the client (Nelson, 1988). An example of the nurse interacting on behalf of the client is the nurse who calls for a well-child appointment for a mother visiting the family planning clinic when the mother is capable of making an appointment on her own.
The advocate role evolved to that of mediator and is described as a response to the complex configuration of social change, reimbursement, and providers in the health care system (Tahan, 2005). Mediating is an activity in which a third party attempts to provide assistance to those who may be experiencing a con- flict in obtaining what they desire. The goal of the nurse advo- cate as mediator is to assist parties to understand each other on many levels so that agreement on an action is possible. In the example of a nurse as case manager for an HMO, mediating activities between an older adult client and the payer (the HMO) could accomplish the following results: the client may understand the options for community-based skilled nursing
The impact of using a nurse case manager (NCM) and com- munity health worker (CHW) team on diabetic control, emer- gency room (ER) visits, and hospitalizations among urban African Americans with type 2 diabetes in a randomized con- trolled clinical trial comparing intensive case management with minimal case management revealed the positive effects of the intensity of case management services on outcomes. Intensive services included mailings and telephone calls about preventive screenings, culturally tailored care provided by the NCM and CHW team, and evidence-based clinical algorithms with feed- back to the primary care providers. Those clients receiving intensive case management were 23% less likely to have ER visits, and this effect was strongest for clients who received the
490 PART 4 Issues and Approaches in Population-Centered Nursing
care, and the payer may understand the client’s desires for a less restrictive environment for care, such as the home. The case manager as mediator does not decide the plan of action but facilitates the decision-making processes between the client and the payee so that the desired care can be reimbursed within the options available.
In contemporary practice, nurse advocates place the client’s rights as the highest priority. The goal of promoter for the cli- ent’s autonomy and self-determination may result in an optimal degree of independence in decision making. For example, when a group of young pregnant women is the collective “client” (the aggregate), the nurse advocate’s role may be to inform the group of the benefits and consequences of breastfeeding their infants. However, if the new mothers decide on formula feeding, the nurse advocate should support the group and continue to provide parenting, infant, and well-child services. This example shows a different perspective of the nurse as advocate. It notes that the nurse’s role as advocate may demand a variety of func- tions that are influenced by the client’s physical, psychological, social, and environmental abilities. Advocacy can result in clients becoming their own “client expert” in problem solving, decision making, maximization of resources, partnership devel- opment with providers, and ultimately appropriate interven- tions (Burton et al, 2010).
The advocacy role aims to achieve client engagement—a process in which clients are invested in their health and care through programs that provide information and tools to empower them to take control and evaluate their care (ANA, 2013). The nurse adapts the advocacy function to the client’s dynamic capabilities as the client moves from one health state to another. Even clients who desire access to more substantial health promotion activities can benefit from a partnership with the nurse advocate. Case managers are called to mediate between client needs and payer requirements/economic constraints without becoming a barrier to quality care. Examples of advo- cacy in such cases might include promoting a client’s (as an aggregate) access to on-site physical fitness programs in the occupational setting, or supporting parents’ and students’ con- cerns about the high-fat content of vending machine food in the school system. With the cost of health care exceeding $2.7 trillion annually and consumers assuming a larger financial portion of the care they choose, the promoter role of advocacy for those clients capable of autonomy is expected to increase.
Process of Advocacy The goal of advocacy is to promote self-determination in a client. The client may be an individual, family, peer, group, or community. The classic process of advocacy has been histori- cally defined by Kohnke (1982), Mallik and Rafferty (2000), and Smith (2004) to include informing, supporting, and affirming. All three activities are more complex than they may initially seem, and they require self-reflection by the nurse as well as skill development. It is often easier for the nurse to inform, support, and affirm another person’s decision when it is consistent with the nurse’s values. When clients make decisions within their value systems that are different from the nurse’s values, the advocate may feel conflict about contributing to the process of
LINKING CONTENT TO PRACTICE
The clinical practice skill of advocacy as an inherent concept in the practice of case management. Of the 16 interventions by public health nurses described in the Wheel of Intervention model (see Chapter 9), both advocacy and case management are described in accordance with best practices and operational definitions of 2 of the 16 interventions. Advocacy can be applied at the com- munity, systems, individual, or family level. In fact, when a public health nurse advocates for clients at any of these levels, the source of conflict and collabo- ration will likely come from competing values, that is, those of the client and any of these other levels of population values. For example: • a client may want access to unlimited treatment, financial values may pose
a source of conflict as the system attempts to justify the comparative effectiveness or costs.
• Family members may pose conflicting values for the nature of care they wish a family member to receive, even as the client refuses care.
• Communities can divert budget allotments to needs that are in competition for other population services such as community policing, health care access, and environmental services.
The nurse as advocate must listen carefully to his or her client in order to truly represent the interest of the client and encourage “win-win” processes and outcomes for the client. Advocacy occurs in all three of the core functions of public health: assessment, policy development, and assurance.
Advocacy: Text Link to Public Health Nursing
informing, supporting, and affirming those decisions. Promot- ing self-determination in others demands that the nurse have a philosophy of free choice once the information necessary for decision making has been discussed.
Informing. Knowledge is essential, but it is not enough to make decisions that affect outcomes. Interpreting knowledge is affected by the client’s values and the meanings assigned to the knowledge. Interpreting facts is the result of both objective and subjective processing of information. Subjective processes greatly influence client decisions.
Informing clients about the nature of their choices, the content of those choices, and the consequences to the client is not a one-way activity. The information exchange process is composed of interactions that reflect three subprocesses: ampli- fying, clarifying, and verifying. Amplifying occurs between the nurse and the client to assess the needs and demands that will eventually frame the client’s decision. Information is exchanged from both viewpoints. Although the exchange may be initiated at the objective, factual level, it is likely to proceed to incorpo- rate the subjective perspectives of both parties.
The tone of the amplifying process can direct the remainder of the information exchange. It is important to relate with clients in a manner that reflects the advocate’s endorsement of the client’s self-determination. Setting aside the time necessary to listen to clients is critical. Clients will sense they are part of a mutual process if the nurse can engage them during the information exchange with a message that says, “I respect your needs and desires as I share my knowledge with you.” Nonverbal behaviors, including using direct eye contact, sitting at the client’s level, arriving and concluding at a prescribed time, and using verbal patterns that foster exchange (e.g., open- ended statements, questions, probes, reflections of feelings,
491CHAPTER 22 Case Management
develop. Information exchange is a critical process for advocacy and is applicable to all advocacy clients: individuals, families, groups, and communities (see the How To Box).
paraphrasing), convey the nurse’s desire to promote the client’s ability to self-determine. Recent research indicates that clients’ race and ethnicity may influence how providers and clients communicate with one another, thus contributing to disparities in health. Active communication among clients and providers has been linked to better treatment compliance and health out- comes (Schraeder and Shelton, 2011).
A client may not desire to exchange information because of lack of self-esteem, fear of the information, or inability to com- prehend the content of the communication. In such a case, the focus is to understand the client’s desire to be given no informa- tion and to express to the client the consequences of such inac- tion. The nurse may invite the client to ask for the information exchange at a later time, when the client is ready, and can peri- odically check with the client whether information exchange and amplifying are desired. In these cases, the nurse should document the implemented nursing actions to reflect the guidelines just discussed. This can reduce the basis for lawsuits and misunderstanding by other parties.
Clarifying is a process in which the nurse and client strive to understand meanings in a common way. Clarifying builds on the breadth and depth of the exchange developed during ampli- fying to determine whether the nurse and client understand each other. During this process, misunderstandings and confu- sions are examined. The goal of clarifying is to avoid confusion between the nurse and the client. To foster clarifying, nurses can use certain verbal prompts such as the following: • “What do you understand about…?” • “Please tell me more about how you…” • “I don’t think I am clear. Let me explain the situation in
another way.” • “As an example,…” • “What other information would be helpful so that we both
understand?” Verifying is the process used by the nurse advocate to estab-
lish accuracy and reality in the informing process. Low health literacy is a challenge for 90 million Americans who have dif- ficulty understanding and acting on health information. Peter- son and colleagues (2011) report that 40% of whites and 41% of those from Asia and the Pacific Islands living in the United States are proficient in reading English. In contrast, 13% of African American, 5% of Hispanic, and 18% of Native Ameri- can U.S. students are proficient in reading English. Reading/ literacy proficiency varies by ethnicity/race (Baer et al, 2009). In 2014, a Public Broadcasting Newshour publication cited the Department of Education as revealing that about 1 in 10 people in the United States has a proficient level of health literacy (Gorman, 2014).
If the nurse discovers that a client is misinformed, the nurse may return to the clarifying or amplifying stage and begin the process again. Verifying produces the chance for the advocate and client to examine “truth” from their points of view, which may include knowledge, intuition, previous experiences, and anticipated consequences.
Promoting a client’s self-determination may take the advo- cate and client through the information exchange process several times, as new dimensions, or obstacles, to an issue
HOW TO Provide for Information Exchange between Nurse and Client 1. Assess the client’s present understanding of the situation. Have
you considered your client’s literacy level? Health literacy level? Cultural and ethnic values? Age and any disabilities that would interfere with learning?
2. Provide correct information. 3. Communicate on the client’s literacy level, making the informa-
tion as understandable as possible. Use interpreters and transla- tors where needed.
4. Use a variety of media sources and teach-back methods to increase the client’s comprehension.
5. Discuss other factors that affect the decision, such as financial, legal, and ethical issues.
6. Discuss the possible consequences of a decision.
Supporting. The second major process, supporting, involves upholding a client’s right to make a choice and to act on it. People who are aware of clients’ decisions fall into three general groups: supporters, dissenters, and obstructers. Supporters approve and support clients’ actions. Dissenters do not approve and do not support clients. Obstructers cause difficulties when clients try to implement their decisions.
In 1998, Cary noted that the nurse advocate needs to imple- ment several actions to fulfill the supporting role. Important interventions are assuring clients that they have the right and responsibility to make decisions, and reassuring them that they do not have to change their decisions because of others’ objections.
Affirming. The third process in the advocacy role is affirming. It is based on an advocate’s belief that a client’s decision is con- sistent with the client’s values and goals. The advocate validates that the client’s behavior is purposeful and consistent with the choice that was made. The advocate expresses a dedication to the client’s mission, and a purposeful exchange of new information may occur so that the client’s choice remains possible. Recogniz- ing that a client’s needs may fluctuate with changing resources, the affirming activity must encourage a process of re-evaluation and rededication to promote client self-determination.
The importance of affirming activities cannot be empha- sized strongly enough. Many advocacy activities stop with assuring and reassuring, but affirming is often critical in pro- moting a client’s self-determination. Table 22-2 compares the nursing process with the advocacy process.
The advocate’s role in the decision-making process is not to tell the client that an option is correct or right. The advocate’s role is to provide the opportunity for information exchange, and to arm clients with tools that can empower them in making the best decision from their point of view. Enabling clients to make an informed decision is a powerful tool for building self- confidence. It gives clients the responsibility for selecting the options and experiencing the success and consequences of their decisions. Clients are empowered in their decision making when they recognize that although some events are beyond
492 PART 4 Issues and Approaches in Population-Centered Nursing
Systematic Problem Solving The nursing process—assessment, diagnosis, planning, imple- menting, and evaluating—is an example of a method of problem solving that can be used in the advocacy role. Advo- cates can be particularly helpful with clients in identifying values and generating alternatives.
Illuminating Values. People’s values affect their behavior, feelings, and goals. In the process of amplifying, clarifying, and validating, the advocate understands a client’s values. Through the process of self-revelation, an emerging value (such as envi- ronment, people, cost, or quality) may become more apparent to a client. This can have an effect in two ways. The client may be able to focus on actions on the basis of the value, or the value may confuse the decision process. The nurse can assist the client in prioritizing action and clarifying the value. Values can also change as new or relevant data are processed. The advocate’s role is to assist clients in discovering their values. This process can be particularly demanding in the information exchange and affirming process.
Generating Alternatives. Clients and advocates may feel limited in their options if they generate solutions before com- pletely analyzing the problems, needs, desires, and conse- quences. Several techniques can be used to generate alternatives, including brainstorming and a technique known as the problem- purpose-expansion method. In brainstorming, the nurse, client, professionals, or significant others generate as many alternatives as possible, without placing a value on them. Brain- storming creates a list that can then be examined for the critical elements the client seeks to preserve (e.g., environmental pref- erences, degree of control). The list can be analyzed according to the consequences and the effect of the alternatives on self and others.
The classic problem-purpose-expansion method, as described by Volkema (1983) and later expanded on by Heslin and Moldoveanu (2002) and Winston and Albright (2012), is a way to broaden limited thinking. It involves restating the problem and expanding the problem statement so that different solutions can be generated. If problem formulation yields to solution gen- eration too early, important dimensions of the problem may go undetected and opportunities are missed. For example, if the problem statement is to convince the insurance company to approve a longer length of service, the nurse and client have nar- rowed their options. However, if the problem statement is to improve the client’s convalescence and safety, several solutions and options are available, such as the following: • Obtaining skilled nursing facility placement • Obtaining home-health skilled services • Arranging physician home visits • Paying for custodial care • Paying for private skilled care • Obtaining informal caregiving
Impact of Advocacy Advocacy empowers clients to participate in problem-solving processes and decisions about health care. Clients try to under- stand changing opportunities in the health care system for access, use, and achieving continuity of care. Nurse advocates
their control, other events are predictable and can be affected by decisions they can make.
Nurses can promote client decision making by using the information exchange process, promoting the use of the nursing process, incorporating written techniques (e.g., contracts, lists), using reflecting and prioritizing techniques, and using role playing and sculpturing to “try on” and determine the “fit” of different options and consequences for the client. By engaging clients in the information-sharing process and assisting them to recognize the progression of activities they experience as they build their informed decision-making base, the nurse advocate is providing clients the opportunity to empower themselves with skills that can strengthen their autonomy and confidence in the future.
Advocacy is a complex process that maintains a delicate balance between doing for the client and promoting autonomy. The process is influenced by the client’s physical, emotional, and social capabilities. The goal of advocacy is to promote the maximal degree of client self-determination, given the client’s current and potential status; for most clients, this goal can be realized. When clients are comatose, unborn, or legally incom- petent, nurse advocates have unique functions. The advocate’s role is usually determined by the legal system; however, in some cases, nurses must decide what roles they will play. These are areas requiring intensive self-exploration, research, and collabo- ration with professionals, family members, and significant others. We are reminded that every encounter with a client is an opportunity to serve in the advocacy role (Mahlin, 2010).
Skill Development Skills needed by the nurse advocate are not unique to their profession. Nursing demands scientific, technical, relationship, and problem-solving knowledge and skills. Advocacy applies nursing skills of communication and competency to promote client self-determination.
Knowledge of nursing and other disciplines as well as of human behavior is essential for the advocacy role in establishing authority, promoting authenticity, and developing skills. The capacity to be assertive for personal rights and the rights of others is essential.
Nursing Process Advocacy Process
Assessment/ diagnosis
• Exchange information • Gather data • Illuminate values
Planning/outcome • Generate alternatives and consequences • Prioritize actions
Implementation • Make decisions • Support the client • Assure • Reassure
Evaluation • Affirm • Evaluate • Reformulate
TABLE 22-2 Comparison of Nursing Process and Advocacy Process
493CHAPTER 22 Case Management
systems level through budgetary decisions and staffing assign- ments. At the clinical level, demands relate to implementing treatment protocols. When nurses act as client advocates by clarifying a client’s desires or needs, they can conflict with systems procedures for allocation of limited resources within these systems. Case managers need to balance efficient use of resources.
Nurses who shoulder both advocacy and allocation respon- sibilities may benefit from a clear understanding of their per- sonal and professional values. A systematic procedure for mediating conflict between the two competing responsibilities is also helpful (Cary, 1998; Fink-Samnick and Muller, 2010).
Conflict Management Case managers help clients manage conflicting needs and scarce resources. Techniques for managing conflict include a range of active communication skills. These skills are directed toward learning all parties’ needs and desires, detecting their areas of agreement and disagreement, determining their abilities to col- laborate, and assisting in discovering alternatives and activities for reaching a goal. Mutual benefit with limited loss is a goal of conflict management.
Conflict and its management vary in intensity and energy in a number of ways. The effort needed to manage a conflict depends on various factors: the existing evidence to support facts and the objective and subjective perceptions of the parties involved.
Negotiating is a strategic process used to move conflicting parties toward an outcome. The outcome can vary from one in which one party gains benefit at the other’s expense (distributive outcomes) or in which mutual advantages override individual gains (integrative outcomes) (Thompson et al, 2010).
The process of negotiating can be characterized in three stages: prenegotiating (preparing and discussing), negotiating (discussing, proposing, bargaining), and aftermath (closing, renegotiating, willingness to negotiate again). Prenegotiating activities are designed to have parties agree to collaborate. Parties must see the possibility of agreeing and the costs of not agreeing (Lee and Lawrence, 2013). Preparations must be made as to time, place, and ground rules concerning participants, procedures, and confidentiality.
The negotiation stage consists of phases in which parties must develop trust, credibility, distance from the issue (to limit the feeling of “one best way”), and the ability to retain personal dignity. Bazarman (2005) and Lee and Lawrence (2013) agree that stages occur in negotiation: Phase 1: Establishing the issues and agenda. This is accom-
plished by identifying, clarifying, presenting, and prioritiz- ing the issues.
Phase 2: Advancing demands and uncovering interests. Negotia- tions center on presenting parties’ interests and differentiat- ing parties’ demands and positions on the conflict.
Phase 3: Bargaining and discovering new options. Debates include gathering facts, based on reasoning, that will gener- ate understanding and promote relearning. Bargaining reduces differences on issues by giving or removing rewards or desired objects. Creating new solutions or options through
promote client self-determination and management of behav- ior as it relates to health and the adherence to therapeutic regi- mens. Clients are part of larger systems: the family, the work environment, and the community. Each system interacts with the client to shape the available options through resources, needs, and desires. Each system also exhibits both confirming and conflicting goals and processes that need to be understood for client self-determination to be successful. For example, the practice of advocacy among minority groups may involve the ability to focus attention on the magnitude of problems caused by diseases affecting minority clients. Whether the client is an individual, family, group, or community, the advocacy function can promote the interest of self-determination, which influ- ences the progress of societies.
Advocacy is not without opposition. Clients and advocates may find barriers to services, vendors, providers, and resources. A community may experience a shortage in nursing home beds or providers, a childcare facility may experience staffing short- ages, a family may not have the money to keep a child at home, and a client may find that the school system cannot fund a full- time nurse for its clinic. The reality of scarce resources creates a difficult barrier for advocates. However, events such as these often stimulate a community’s self-determination and lead to innovative actions to correct gaps in service (see the Levels of Prevention box).
LEVELS OF PREVENTION
Levels of Prevention Strategy
Primary Use information exchange process to increase health literacy in order to use the health care system, adopt health promotion strategies that will maintain health, and engage in health education to create and maintain healthy lifestyles
Secondary Use case finding and dashboard data to identify existing health problems in your caseload and the population served by your agency. Timely, holistic assessments and interventions can slow disease trajectories and promote healing and health
Tertiary Monitor and adjust the use of prescription medications and adherence to treatment to reduce the risk of complications. Use models such as the CMSA Case Management Adherence Guidelines at http:// www.csma.org to prevent subsequent consequences of issues in medication compliance as part of the treatment plan. Institutionalize this model in your agency
Case Management
Allocation and Advocacy: Complements or Conundrum? Whereas advocacy holds a traditional role in the nursing profes- sion, allocation is a staple of market competition. Nurses perform allocation roles when they triage clients or perform the gatekeeping and rationing functions. Nurses often reflect that clinical judgments are influenced by their values and ethics as well as organizational demands (ANA, 2008). When working in organizations, nurses experience allocation demands at the
494 PART 4 Issues and Approaches in Population-Centered Nursing
collaboration, it is not sufficient to result in or maintain col- laboration. Although the collaboration model recognizes the contributions of joint decision making, one member of the team should be accountable to the system and to the client. This team member should be responsible for monitoring the entire process (see the following QSEN box.
brainstorming, reflective thinking, and problem-purpose- expansion techniques is important in achieving options that provide mutual benefits.
Phase 4: Working out an agreement. This may involve settling on some but not all points. Parties can agree to re-examine the issues later, and steps for implementing and follow-up must be clarified. The aftermath of negotiation is the period following an
agreement in which parties are experiencing the consequences of their decisions and will discern the degree to which they are willing to work together in the future (Thompson et al, 2010). The reality of their decisions may lead to re-evaluating their values. In a conflict situation, parties engage in behaviors that reflect the dimensions of assertiveness and cooperation. Asser- tiveness is the ability to present one’s own needs. Cooperation is the ability to understand and meet the needs of others. Each person uses a primary and secondary orientation to engage in conflict (Box 22-3).
Clearly, flexibility in conflict management behavior can facil- itate an outcome that meets the client’s goals. Helping parties navigate the process of attaining a goal requires effective per- sonal relations, knowledge of the situation and alternatives, and a commitment to the process.
Collaboration In case management, the activities of many disciplines (social workers, nurses, physicians, insurers, physical therapists, etc.) are needed for success. Clients, the family, significant others, payers, and community organizations contribute to achieving the goal. Collaboration is achieved through a developmental process. Collaboration is a dynamic, highly interactive, and interdependent process in which people work together, sharing resources and even a vision for a goal (Morales Arroyo, 2003). Androwich and Cary (1989) found that collaboration occurs in a sequence and is reciprocal and can be characterized by seven stages and activities (Figure 22-5).
The goal of communication in the collaborative develop- ment process is to amplify, clarify, and verify all team members’ points of view. Although communication is essential in
Modified from Volkema RJ, Bergmann TJ: Confl ict styles as indicators of behavioral patterns in interpersonal confl icts, J Social Psychol 135: 5-15, 2001; CPP: History and Validity of the Thomas-Kilmann Conflict Mode Instrument (TKI). Mountainview, CA, CPP, Inc. Available at http:// www.cpp.com/products/tki/tkiinfo.aspx. Retrieved June 14, 2010.
Accommodating: Individual neglects personal concerns to satisfy the con- cerns of another.
Avoiding: Individual pursues neither his or her concerns nor another’s concerns.
Collaborating: Individual attempts to work with others toward solutions that satisfy the goals of both parties.
Competing: Individual pursues personal concerns at another’s expense. Compromising: Individual attempts to find a mutually acceptable solution
that partially satisfies both parties.
BOX 22-3 Categories of Behaviors Used in Conflict Management
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES Targeted Competency: Teamwork and Collaboration—Function effec-
tively within nursing and interprofessional teams, fostering open commu- nication, mutual respect, and shared decision making to achieve quality client interventions and outcomes.
Important aspects of teamwork and collaboration include: Knowledge: Describe scopes of practice and roles of health care team
members Skills: Clarify roles and accountabilities under conditions of potential overlap
in team member functioning Attitudes: Value the perspectives and expertise of all health team members
Teamwork and Collaboration Question Observe a typical workday of a nurse in community health or public health nurse, noting the types of activities that are done in coordination and case management and the amount of time spent in these areas. Interview several staff members to determine whether they perceive that the amount of their time spent in case management is changing. To what degree are the staff members involved in care management activities? Ask about colleagues with whom case managers collaborate. Besides primary care physicians, which health care team members are often involved in managing clients’ care across time and across settings? What skills are needed by the case management nurse to best facilitate these interdisciplinary teams?
Case managers encounter conflict on a daily basis. Compet- ing needs, resources, organizational demands, and professional role boundaries present opportunities and pitfalls for conflict management and collaboration (Box 22-4). Providers report that in the collaborative role of serving as advocates for clients, they encounter competing expectations by other providers in the system—even other case managers (Sands, 2013).
Teamwork and collaboration clearly demand knowledge and skills about clients, health status, resources, treatments, and community providers. The ability to assess clients’ and families’ complex needs involves knowledge of intrapersonal, interper- sonal, medical, nursing, and social dimensions. Demonstrating team member and leadership skills in facilitating a goal-directed group process is essential. It is unlikely that any single profes- sional possesses the expertise required in all dimensions. It is likely, however, that the synergy produced by all can result in successful outcomes.
ISSUES IN CASE MANAGEMENT Legal Issues Case managers today face pressure to control costs, to use evidence-based guidelines for practice, and to reduce risks for
495CHAPTER 22 Case Management
FIG 22-5 Collaboration is a sequential yet reciprocal process. (From Androwich I, Cary AH: A Collaboration Model: A Synthesis of Literature and a Research Survey. Paper presented at the Association of Community Health Nurse Educators Spring Institute, Seattle, June 1989.)
Collaboration
Tentative exploration Mutual
acknowledgment
Trust buildingAwareness
Commitment
Consensus
Co lle
gia lity
Amplification
Negotiations
Staging of
Clarif i cation
Verifi cation
Com mun
icat ion
496 PART 4 Issues and Approaches in Population-Centered Nursing
i. Restricting access to otherwise necessary or appropriate care because of cost
j. Referring clients to treatment furnished by providers related to the case management agency without proper disclosure
k. Connecting case managers’ compensation to reduced use and access of services
l. Inappropriate delegation of care m. Inappropriate use of clinical practice guidelines
2. Negligent referrals a. Referral to a practitioner known to be incompetent b. Substituting inadequate treatment for an adequate but
more costly option c. Curtailing treatment inappropriately when treatment
was actually needed d. Referral to a facility or practitioner inappropriate for the
client’s needs e. Transfer to another facility that lacks care requirements f. Communication and transition handoff failures
3. Experimental treatment and technology a. Failure to apply the contractual definition of “experi-
mental” treatment found in the client’s insurance policy b. Failure to review sources of information referenced in
the applicable insurance policy (e.g., Food and Drug Administration, or published medical literature)
c. Failure to review the client’s complete medical record d. Failure to make a timely determination of benefits in
light of timeliness of treatment e. Failure to communicate coverage determined to be
needed, to the insured client or participant f. Improper economic considerations determining the
coverage g. Failure to understand and retrieve information from
HIT sources.
legal liability. They are vulnerable to legal risks because of inad- equate preparation, changing legislation and policy, health systems changes, the advent of new workers and the absence of title protection, insufficient support, and role expectations. Liability concerns of case managers exist when the following three conditions are met: (1) the provider had a duty to provide reasonable care, (2) a breach of contract occurred through an act or an omission to act, and (3) the act or omission caused injury or damage to the client. Case managers must strive to reduce risks, practice wisely within acceptable practice stan- dards, and limit legal defense costs through professional insur- ance coverage. Areas of risk are adapted from Hendricks and Cesar (2003), Cunningham (2007), Llewellyn and Leonard (2009), and Sambucini (2013): 1. Liability for managing care
a. Inappropriate design or implementation of the case management system
b. Failure to obtain all pertinent records on which case management actions are based
c. Failure to have cases evaluated by appropriately experi- enced and credentialed clinicians
d. Failure to confer directly with the treating provider (physician or nurse practitioner) at the onset and throughout the client’s care
e. Substituting a case manager’s clinical judgment for that of the medical provider
f. Requiring the client or his or her provider to accept case management recommendation instead of any other treatment
g. Harassment of clinicians, clients, and family in seeking information, and setting unreasonable deadlines for decisions or information
h. Claiming orally or in writing that the case management treatment plan is better than the provider’s plan
1. Awareness • Make a conscious entry into a group process; focus on goals of convening
together; generate a definition of collaborative process and what it means to team members.
2. Tentative exploration and mutual acknowledgment • Exploration: Disclose professional skills for the desired process; disclose
areas where contributions cannot be made; disclose values reflecting priorities; identify roles and disclose personal values, including time, energy, interest, and resources.
• Mutual acknowledgment: Clarify each member’s potential contributions; verify the group’s strengths and areas needing consultation; clarify members’ work style, organizational supports, and barriers to collaborative efforts.
3. Trust building • Determine the degree to which reliance on others can be achieved;
examine congruence between words and behaviors; set interdependent goals; develop tolerance for ambiguity.
4. Collegiality • Define the relationships of members with each other; define the respon-
sibilities and tasks of each; define entrance and exit conditions. 5. Consensus
• Determine the issues for which consensus is required; determine the processes used for clarifying and making decisions to reach consensus; determine the process for re-evaluating consensus outcomes.
6. Commitment • Realize the physical, emotional, and material actions directed toward the
goal; clarify procedures for re-evaluating commitments in light of goal demands and group standards for deviance.
7. Collaboration • Initiate a process of joint decision making reflecting the synergy that
results from combining knowledge and skills.
BOX 22-4 Stages of Collaboration
Modified from Cary A, Androwich I: A collaboration model: a synthesis of literature and a research survey, paper presented at the Association of Community Health Nurse Educators Spring Institute, Seattle, June 1989; Mueller WJ, Kell B: Coping with confl ict, Englewood Cliffs, NJ, 1972, Prentice Hall.
497CHAPTER 22 Case Management
4. Confidentiality/security a. Failure to deny access to sensitive information that is
awarded special protection by federal or state law b. Failure to protect access to computerized medical records c. Failure to adhere to regulatory provisions (e.g.,
Health Insurance Portability and Accountability Act provisions [http://hipaa.cms.gov]; Americans with Dis- abilities Act)
5. Fraud and abuse a. Making false statements of claims or causing incorrect
claims to be filed b. Falsifying the adherence to conditions of participation
of Medicare and Medicaid c. Submitting claims for excessive, unnecessary, or poor-
quality services d. Engaging in remuneration, bribes, kickbacks, or rebates
in exchange for referral e. Upcoding intensity of care or intervention requirements
Legal citations relevant to case management and managed care include negligent referrals, provider liability, payer liability, breach of contract, denial of care, and bad faith. As in any scope of nursing practice and with the potential growth in tort reform, it behooves the nurse to seek preventive education on contemporary practice and legal trends to lower exposure to legal liability.
Sambucini (2013) notes that court cases and federal and state tort reforms influence the legal considerations of case managers generally. When courts find that cost considerations affect medical care decisions, all parties to the decision will be liable for resulting damages. Guidelines to reduce risk exposure include the following: 1. Clear documentation of the extent of client participation in
decision making and reasons for decisions 2. Records demonstrating accurate and complete information
on interactions and outcomes 3. Use of reasonable care in selecting referral sources, which
may include verifying of licensure of providers 4. Written agreements when arrangements are made to modify
benefits other than those in the contract 5. Good communication with clients 6. Informing clients of their rights of appeal 7. Applying the ethical guidelines of case management (Valiant
and Jensen, 2012)
Ethical Issues Case managers as nursing professionals are guided in ethical practice by the Code of Ethics for Nursing (ANA, 2008; to be revised for publication in 2015) and Code of Professional Conduct for Case Managers (Commission for Case Management Certifi- cation [CCMC], 2005), by performance indicators for ethics in the Standards of Practice for Case Management (CMSA, 2010), and by the contract expressed in Nursing’s Social Policy State- ment (ANA, 2010).
By integrating these guidelines and philosophies, nursing practice is ideally suited to preserve the ethical principles of autonomy, beneficence, fidelity, justice, nonmaleficence, and veracity in case management processes. Numerous authors,
notably Hendricks and Cesar (2003), McCollom (2004), Llewellyn and Leonard (2009), Fink-Samnick and Muller (2010), and Apuna-Grummer and Howland (2013), describe how case managers may confront dilemmas in these areas: • Case management may hamper a client’s autonomy, or the
individual’s right to choose a provider, if a particular pro- vider is not approved by the case management system. If a new provider must be found who can be approved for cover- age, continuity of care may be disrupted.
• Beneficence, or doing good, can be impaired when excessive attention to containing costs supersedes the nurse’s duty to improve health or relieve suffering.
• Fidelity is defined as faithfulness to the obligation of duty (www.merriam-webster.com/dictionary), in this case to the client by keeping promises and remaining loyal within the nurse-client relationship (www.merriam-webster.com/ dictionary. Accessed July 7, 2014). Duty to clients to secure benefits on their behalf and to limit unnecessary expendi- tures can create dilemmas when the goals are not uniform.
• Justice as an ethical principle for case managers considers equal distribution of health care with reasonable quality. Tiers of quality and expertise among provider groups can be created when quality providers refuse to accept reimburse- ment allowances from the managed system, leaving less experienced or lower quality providers as the caregiver of choice for clients being managed.
• Nonmaleficence is defined as doing no harm. When case managers incorporate outcomes measures, evidence-based practice, and monitoring processes in their plans of care, this principle is addressed.
• Veracity, or truth telling, is absolutely necessary to the practice of advocacy and building a trusting relationship with clients. Clients particularly complain that in the changing health care system, payers do not seem to be able to provide comprehensive yet inexpensive options for care. Three of the most common legal dilemmas have been his-
torically classified as conflicts in advocacy, priorities, and duties (Hendricks and Cesar, 2003; Mahlin, 2010). For example, a case manager may advocate for many perspectives—clients, organi- zations, and society—that are not harmonious. When consider- ing priorities in values, the case manager will ultimately be considering personal, professional, organizational, and client values. Selecting which values to honor can result in violating the values of the other, and asking the question “Whose best interests can be served?” may create a dilemma. Finally, conflicts in duties can result when placing the best interest of a client first adversely affects the other party.
Standards of practice and care, codes of ethics, licensure laws, credentialing through certification, and organizational policies and procedures (e.g., ethics committees, risk manage- ment units) offer the case manager information and support in managing ethical conflicts and dilemmas in the case management system. Maintaining familiarity with ethical issues published in the case management literature can offer specific assistance for practicing case managers (Tables 22-3 and 22-4).
498 PART 4 Issues and Approaches in Population-Centered Nursing
Organization Website Credentials
American Nurses Credentialing Center http://www.nursecredentialing.org Nurses: RN-BC, for Registered Nurse-Board Certified for Case Management
Case Management Administrators http://www.ptcny.com CMA-C, for Case Management Administrator-Certified Certification of Disability Management Specialists
Commission http://www.cdms.org Interprofessionals: CDMS, for Certified Disability Management
Specialist Commission for Case Manager Certification http://www.ccmcertification.org Interprofessionals: CCM, for Certified Case Manager Certification Board for Certified Nurse Life Care
Planners http://www.ptcny.com CNLCP, for Certified Nurse Life Care Planner (specialty
certification for nurses who are life care planners) National Academy of Certified Care Managers http://www.naccm.net Interprofessionals: CLM, for Certified Long-term Care Manager Rehabilitation Nursing Certification Board http://www.rehabnurse.org/certification CRRN, for Certified Rehabilitation Registered Nurse
TABLE 22-3 Credentialing Resources for Case Managers (Individual Certification Options)
Resource Website Details
URAC www.urac.org Accredits disease management, case management, and health plan programs and other services. Supports efforts for clinical benchmarking, quality of care, chronic care evidence-based models
America’s Health Insurance Plans http://www.ahip.org Trade association representing health insurance industry American Nurses Credentialing Center http://www.nursecredentialing.org Offers review course materials for nurse case managers American Medical Association http://www.ama-assn.org Includes continuing medical education unit (CEU) programs Case Management Society of America http://www.cmsa.org Specialty organization for case managers Centers for Medicare and Medicaid Services http://www.cms.gov Oversees execution of rules and regulations for clients of state and
federally funded services Center Watch Clinical Trial Listing Service http://www.centerwatch.com Global source for clinical trials information Centers for Disease Control and Prevention http://www.cdc.gov Provides education, training, and research for disease, emergency
preparedness, environmental health, traveler health, workplace safety and health, population health, and healthy living
The Joint Commission (TJC) http://www.jointcommission.org Accredits health care–related delivery organizations and disease- specific care programs
Medscape http://www.medscape.org Features clinical updates and education for professionals National PACE Association http://www.npaonline.org Provides information on models and locations of PACE services for the
elderly National Transitions of Care Coalition
(NTOCC) http://www.ntocc.org Provides information on transitions of care models and outcomes
National Committee for Quality Assurance http://www.ncqa.org Publishes HEDIS performance indicators for provider systems and accredits managed care organizations. Provides certification of disease management, utilization management, and credentialing verification organizations. Also ACOs, case management and patient-centered medical homes (among other organizations)
National Library of Medicine http://www.nlm.nih.gov Global medical library NurseWeek http://www.nurse.com Provides information links to other sites and nursing professional
education course work Oncology http://www.oncolink.upenn.edu Oncology links Online Journal of Issues in Nursing http://www.nursingworld.org Publication on issues in nursing Commission on Accreditation of
Rehabilitation Facilities http://www.carf.org Accredits services globally that may be used by case management
clients such as adult day care, assisted living, behavioral health, disability rehab, addiction and substance abuse rehabilitation, employment and community services, and medical rehabilitation
TABLE 22-4 Websites for Case Management Resources
ACO, Accountable care organization; HEDIS, Healthcare Effectiveness Data and Information Set.
499CHAPTER 22 Case Management
K E Y P O I N T S • An important role of the nurse is that of client advocate. • The goal of advocacy is to promote the client’s self-
determination. • When performing in the advocacy role, conflicts may emerge
about the full disclosure of information, territoriality, accountability to multiple parties, legal challenges to clients’ decisions, and competition for scarce resources.
• The functions of advocacy and allocation can pose dilemmas in practice.
• Amplification, clarification, and verification are three com- munication skills necessary in the advocacy process.
• Additional skills important to fulfilling the role of client advocate include the helping relationship, assertiveness, and problem solving.
• Problem solving is a systematic approach that includes understanding the values of each party and generating alter- native solutions.
• Brainstorming and the problem-purpose-expansion method are two techniques to enhance the effectiveness of problem- solving skills.
• During conflict, negotiations can move conflicting parties toward an outcome.
• Prenegotiation, negotiation, and aftermath are three phases of managing a conflict.
• Each individual has a predominant orientation when engag- ing in conflict: competing, accommodating, avoiding, col- laborating, or compromising.
• Collaboration may result by moving through seven stages: awareness, tentative exploration and mutual acknowledg- ment, trust building, collegiality, consensus, commitment, and collaboration.
• Care management is a strategic program to maintain the health of a population enrolled in a delivery system.
• Continuity of care is a goal of nursing practice. It requires making linkages with services and information systems to improve the client’s health status.
• As the structure of the health care system moves toward delivering more services in the community, the achievement of continuity of care will present a greater challenge.
• Case management is typically an interprofessional process in which the client is the focus of the plan.
• Documentation and use of dashboards for case management activities and outcomes are essential to nursing practice.
• Case management is a systematic process of assessment, planning, service coordination, referral, monitoring, and evaluation that meets the multiple service needs of clients.
• A nurse’s scope of practice includes advocacy, allocation, and case management functions.
• Nurses functioning as advocates and case managers need to be aware of the ethical and legal issues confronting these components of their practice.
• Standardization of care for predictable outcomes can be achieved through critical paths, disease management proto- cols, dashboards, clinical guidelines, interprofessional action plans, and a caring-based practice in which processes of diagnosis and treatment are applied to the human experi- ences of health and illness.
• Nurses are guided by a philosophy of caring and advocacy. • Nurses have a high regard for client self-determination, inde-
pendence, and informed choice in decision making. • Recognizing that responses to illness and disability may limit
independence and self-determination, nurses focus on the rights of individuals, families, and communities to define their own health and evidence-based guidelines for practice.
• Telehealth application provides expansive alternatives within resource delivery options but must be customized for clients.
P R A C T I C E A P P L I C A T I O N During her regularly scheduled visit to a blood pressure clinic in a local apartment cluster, a Hispanic resident, Mrs. B., 45 years old, complained of feeling dizzy and forgetful. She could not remember which of her six medications she had taken during the last few days. Her blood pressure readings on reclin- ing, sitting, and standing revealed gross elevation. The nurse and Mrs. B. discussed the danger of her present status and the need to seek medical attention. Mrs. B. called her physician from her apartment and agreed to be transported to the emer- gency department.
In the emergency department, Mrs. B. manifested the pro- gressive signs and symptoms of a cerebrovascular accident (a CVA, or stroke). During hospitalization, she lost her capacity for expressive language and demonstrated hemiparesis and loss of bladder control. Her cognitive function became intermit- tently confused, and she was slow to recognize her physician and neighbors who came to visit. The utilization review/ discharge planning nurse at the hospital contacted the case manager from the health department to screen and assess for
the continuum of care needs as early as possible, because Mrs. B. lived alone and family members resided out of town.
It became apparent that family caregiving in the community could only be intermittent because family members lived too far away. Mrs. B. had residual functional and cognitive deficits that would demand longer-term care.
As the case manager contracted by the plan, place the fol- lowing actions in the correct sequence to construct a case man- agement plan: A. Discuss with the family their schedule of availability to offer
care in the client’s home. B. Discuss their cultural values in caring for family members. C. Call the client and introduce yourself, as a prelude to working
with her. D. Obtain information on the scope of services covered by the
benefit plan for your client. E. Arrange a skilled nursing facility site visit for the client and
family. Answers can be found on the Evolve site.
500 PART 4 Issues and Approaches in Population-Centered Nursing
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lation, noting the types of activities that are done in coordi- nation, transition care, case management, and documentation as well as the amount of time spent in these areas. Interview several staff members to determine whether they perceive that their time spent in case management is changing. To what degree are the staff members involved in care manage- ment activities? What are the top three legal and ethical issues they encounter in their practice? What do the nurses report as their greatest sources of satisfaction and dissatisfac- tion in their jobs?
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ers, policy makers, insurers)? C. What are the mixed values of society in the United States?
What are the mixed values of society in underdeveloped nations? How are the mixed values different or similar in these three situations (A-C)? How does your answer affect client outcomes?
Or read: Sands JR: Where was care coordination? CMSA Today 8:14-17, 201. A. Name three problems the author described as her aunt
transitioned between levels of care in the hospital. B. Name three problems the author experienced with the
manner in which case management was delivered. C. What changes would you make as the manager of the case
management office to the manner in which case manage- ment and coordination was delivered in the future? What criteria would you use to judge if the change was effective?
D. Which of the categories of legal risks exist based on the story the authors tells?
501CHAPTER 22 Case Management
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23 Public Health Nursing Practice and
the Disaster Management Cycle
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • Glossary • Answers to Practice Application
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Discuss how disasters, both human-made and natural,
affect people and their communities. 2. Differentiate disaster management cycle phases to include
prevention (mitigation and protection), preparedness, response, and recovery.
3. Examine the nurse’s role in the disaster management cycle. 4. Describe competencies for public health nursing practice
in disasters. 5. Explain how the community works together to prevent,
prepare for, respond to, and recover from disasters. 6. Identify organizations where nurses can volunteer to work
in disasters.
The authors wish to acknowledge the manuscript review and consultation of a review committee, which included Linda MacIntyre, PhD, RN, Chief Nurse, American Red Cross; Barbara J. Polivka, PhD, RN, Shirley B. Powers Endowed Chair & Professor, School of Nursing, University of Louisville; and Janice Springer, DNP, RN, Public Health Nurse Consultant and Division Disaster Health Services Advisor, American Red Cross.
Sharon A. R. Stanley, PhD, RN, FAAN Dr. Sharon Stanley was Chief Nurse of the American Red Cross, 2009 – 2013. She has worked in public health for over 30 years and her leadership positions in disaster include National Director of Disaster Health and Mental Health, American Red Cross; Chief of Disaster Planning, Ohio Department of Health; and Director, Ohio Center for Public Health Preparedness, The Ohio State University. Colonel Stanley retired from the U.S. Army Reserve in 2007 with 34 years of service, 12 of them on active duty to include Desert Storm and Operation Iraqi Freedom. She is the recipient of numerous awards, including the Order of Medical Military Merit, the Surgeon General’s “A” proficiency designator, the 2013 Florence Nightingale Medal of Honor, induction into the 2013 Ohio Veterans Hall of Fame, and the 2011 Association of State and Territorial Directors of Nursing (ASTDN) Recognition Award
Dr. Sharon Farra has practiced nursing for over 30 years and is experienced in emergency and disaster preparedness, response, and recovery. She is an Assistant Professor at Wright State University, where she is leading evaluation efforts for a national disaster health certificate program. A Regional Nurse Leader with the American Red Cross, Dr. Farra serves on the Clinton County Red Cross Board and volunteers with the Medical Reserve Corps. As a nurse educator she has designed, developed, and launched disaster courses for health care providers, to include nurses and allied health profes- sionals. Her research concentration is in disaster training, including innovative teaching methods integrating virtual reality simulation and interprofes- sional triage.
Dr. Susan Hassmiller is the Senior Advisor for Nursing at the Robert Wood Johnson Foundation in Princeton, New Jersey, and Director of the Future of Nursing: Campaign for Action. The Foundation provides support to improve the health and health care for all Americans. Dr. Hassmiller has taught public health nursing at the university level and has dedicated her career to the care and prevention of disease in vulnerable populations. She is a former member of the National Board of Governors for the American Red Cross, having served as the Chair of Chapter and Disaster Services. She is Chair of the Central New Jersey Chapter of the American Red Cross. She is a 2002 recipient of both the national American Red Cross Ann Magnussen Award and the regional American Red Cross Clara Barton Award, both recognizing her outstanding leadership in the field of nursing and disaster services. She is the 2009 recipient of the Florence Nightingale Medal of Honor, the highest award in nursing presented by the International Committee of Red Cross in Geneva, Switzerland. She oversees the annual Susan Hassmiller American Red Cross Award, which provides recognition to a Red Cross chapter that has made outstanding contributions in providing disaster health services involving nurses as leaders.
Sharon L. Farra, PhD, RN
Susan B. Hassmiller, PhD, RN, FAAN
504 PART 4 Issues and Approaches in Population-Centered Nursing
C H A P T E R O U T L I N E Defining Disasters Disaster Facts National Disaster Planning and Response: A Health-Focused
Overview Healthy People 2020 Objectives
The Disaster Management Cycle and Nursing Role Prevention (Mitigation and Protection) Preparedness Response Recovery
Future of Disaster Management
“Wherever disaster calls there I shall go. I ask not for whom, but only where I am needed.”
From Creed of the Red Cross Nurse, by Lona L. Trott, RN, 1953
Around the world, people are experiencing unprecedented disasters from natural causes, such as hurricanes and earth- quakes to human-made disasters such as oil spills and terrorism.
Disasters, whether human-made or natural, are inevitable, but there are ways to help communities prepare for, respond to, and recover from disaster. This chapter describes the disaster management cycle phases of prevention, preparedness, response, and recovery as well as the public health nurse’s role.
DEFINING DISASTERS A disaster is any natural or human-made incident that causes disruption, destruction, and/or devastation requiring external
K E Y T E R M S alternate care centers, p. 522 American Red Cross, p. 505 bioterrorism, p. 504 CBRNE threats (chemical, biological, radiological, nuclear,
and explosive), p. 508 Community Emergency Response Team, p. 511 community resilience, p. 507 crisis standards of care, p. 515 Disaster Medical Assistance Team, p. 511 Emergency Operations Center, p. 515 Emergency Support Function 8: Public Health and
Medical, p. 507 Functional Needs Support Services, p. 522 general population shelter, p. 522 Homeland Security Act of 2002, p. 506 Homeland Security Exercise and Evaluation Program, p. 514 Homeland Security Presidential Directive 21: Public Health
and Medical Preparedness, p. 507 human-made incident, p. 504 interprofessional, p. 508 Medical Reserve Corps, p. 511 mutual aid agreement, p. 515 National Disaster Medical System, p. 511
National Health Security Strategy, p. 507 National Incident Management System, p. 507 National Preparedness Guidelines, p. 506 National Response Framework, p. 506 One Health, p. 517 pandemic, p. 505 Pandemic and All-Hazards Preparedness Reauthorization
Act, p. 507 personal protective equipment, p. 510 points of dispensing, p. 508 Presidential Policy Directive 8: National
Preparedness, p. 506 psychological first aid, p. 507 public health surge, p. 505 public health triage, p. 507 rapid needs assessment, p. 508 risk communication, p. 521 Robert T. Stafford Disaster Relief and Emergency Assistance
Act, p. 515 Strategic National Stockpile, p. 508 triage, p. 520 utilitarian framework, p. 521 —See Glossary for definitions
assistance. Although natural incidents such as earthquakes or hurricanes trigger many disasters, predictable and preventable human-made factors can further affect the disaster. On March 11, 2011, northeastern Japan was rocked by a 9.0 magnitude earthquake that was quickly followed by a tsunami (see Figure 23-1). These dual natural disasters caused an estimated death toll of 20,000, but there was a third, human-made component to complete the incident triad: a nuclear reactor crisis. An inde- pendent parliamentary investigation later found the Fukushima nuclear disaster to be the result of a mix of several human-made factors (Inajima et al, 2012). Box 23-1 lists examples of natural and human-made disasters.
In the disaster response phase, the incident type and timing predict subsequent injuries and illnesses. If there is prior warning (e.g., in hurricanes or slow-rising floods), the impact brings fewer injuries and deaths. Disasters resulting with little or no advance notice such as earthquakes or bioterrorism could have more casualties because those affected have little time to make evacuation preparations or to obtain adequate
505CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
millions, as with floods, earthquakes, tornadoes, hurricanes, tsunamis, and bioterrorism. The American Red Cross reports that it responds to a disaster in the United States every 8 minutes, resulting in response to more than 70,000 incidents each year (American Red Cross, 2014).
The number of reported natural and human-made disasters continues to rise worldwide, yet the number of lives lost has declined over the past couple of decades. The increase in the number of lives saved in a disaster may be explained by better forecasting and early warning systems (International Federa- tion of Red Cross and Red Crescent Societies [IFRC], 2013).
Around the globe in 2012, the reported numbers of people (139 million) affected by disasters were the lowest of the decade after previous peaks in 2003, 2010, and 2011. Flooding, the largest number impacted in China, accounted for the majority of that influence, with droughts in Kenya, Sudan, and Ethiopia and elsewhere affecting 28 million people. Typhoon Bopha affected 6.3 million people in the Philippines and an earthquake in Guatemala affected 1.3 million people (IFRC, 2013).
In 2013 alone, there were more than 60 major disaster declarations in the United States with another 5 emergency declarations and more than 25 fire management assistance dec- larations (Federal Emergency Management Agency [FEMA], 2014a). An additional explanation on how a disaster declaration is made is presented later in this chapter, but the point is that disaster incidents are a regular occurrence. Hurricane names such as Katrina (2005) and Sandy (2012) and tornado pathways in Joplin, Missouri (2011) and Norman, Oklahoma (2013) are familiar to all. Yet, the latest report card for our nation’s emer- gency care environment in disaster preparedness grades our overall system with a C– for 2014, dropping from a C+ in 2009 (American College of Emergency Physicians [ACEP], 2014). The report states that this is due, in large part, to state variation. For example, although the average number of health profes- sionals registering in the volunteer system (the Emergency System for Advance Registration of Volunteer Health Profes- sionals [ESAR-VHP]) is 279.6 nurses per 1 million people overall, that number is 0 per 1 million in Mississippi and 1069 per 1 million in the District of Columbia (ACEP, 2014).
Disaster disproportionably strikes at-risk individuals, whether their day-to-day risk is physical, emotional, or eco- nomic. Disasters in less developed communities can also destroy decades of progress in a matter of hours, in a manner that rarely happens in more developed countries. The poor, elderly, ethnic minorities, people with disabilities, and women and children in developing communities are excessively affected and least able to rebound (World Health Organization, 2011). Unfor- tunately, by 2050, the percentages of population areas more vulnerable to disasters will increase. Eighty percent of the world’s population will live in developing countries, with 46% living in tornado and earthquake zones, near rivers, and on coastlines (United Nations Development Programme, 2012; Dilley et al, 2005).
The monetary cost of disaster recovery efforts also rose sharply. The cost in more developed countries is higher because of the extent of material possessions and complex infrastruc- tures, including technology. In the United States, increases in
treatment. Individuals can also be injured attempting to prepare for the disaster or while evacuating. Public health disasters can create needs across a widespread region. In a pandemic, press- ing and competing health needs occur within a close time frame, producing a public health surge. In the disaster recovery phase, the immediate threat shifts to adjusting to a new normal in the affected community or region.
DISASTER FACTS Disasters can affect one family at a time, as in a house fire, or they can kill thousands and result in economic losses in the
FIG 23-1 A week after the earthquake struck and tsunami surged through northeast Japan, a Japanese Red Cross volunteer surveys the damage to Ōtsuchi in Iwate Prefecture. (Courtesy of the American Red Cross Disaster Online News- room, Washington, DC. From: http://newsroom.redcross.org. Retrieved January 2015.)
Natural Hurricanes Tornadoes Hailstorms Cyclones Blizzards Drought Floods Mudslides Avalanches Earthquakes Volcanic eruptions Pandemics and epidemics Lightning-induced forest fires Tsunamis Thunderstorms and lightning Extreme heat and cold
Human-Made Conventional warfare Unconventional warfare (e.g.,
nuclear, chemical) Transportation accidents Structural collapse Explosions/bombing Fires Hazardous materials incident Pollution Civil unrest (e.g., riots) Terrorism (chemical, biological,
radiological, nuclear, explosives) Cyber attacks Airplane crash Radiological incident Nuclear power plant incident Critical infrastructure failure Water supply contamination
BOX 23-1 Types of Disasters
From U.S. Department of Health and Human Services: Healthy People 2020: A Roadmap to Improve all Americans Health. Washington, DC, 2010, USDHHS.
506 PART 4 Issues and Approaches in Population-Centered Nursing
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total
Africa 6,908 2,041 40 261 726 977 185 62 1,038 929 13,167 Americas 26,653 80,081 202,343 8,128 17,520 68,679 15,873 81,821 69,222 103,582 673,902 Asia 29,558 80,603 32,496 26,776 38,268 126,230 18,926 40,149 280,093 28,004 701,102 Europe 22,917 2,216 18,481 2,767 24,403 4,971 12,954 18,949 2,998 24,201 134,856 Oceania 740 671 258 1,465 1,592 2,683 1,846 17,562 20,982 855 48,654 Very high human
development 57,046 136,241 219,861 14,599 56,928 73,209 30,734 107,799 303,136 126,978 1,126,530
High human development
27,996 13,575 16,190 15,420 16,373 123,141 11,450 27,395 65,394 25,945 342,878
Medium human development
1,255 15,094 17,493 9,374 8,461 6,682 7,351 14,925 5,658 4,241 90,534
Low human development
479 704 73 4 747 509 249 8,423 145 406 11,739
Total: 86,776 165,613 253,617 39,396 82,509 203,540 49,784 158,542 374,333 157,570 1,571,681
TABLE 23-1 Total Amount of Disaster Estimated Damage by Continent, Level of Human Development,* and Year (2003-2012), in Millions of U.S. Dollars (2012 Prices)
From International Federation of Red Cross and Red Crescent Societies (IFRC): World Disasters Report 2012: Focus on Technology and the Future of Humanitarian Action. Geneva, Switzerland, 2013, IFRC, p. 233. Source: EM-DAT, The International Disaster Data Base. Centre for Research on the Epidemiology of Diseases, CRED. At the University of Louvain, Belgium. *See also UNDP. United Nations Development Programme. Human Development Reports. At www.hdr.undp.org for details and any later reports. Notes: Some totals in Table 23-1 may not correspond, due to rounding. Damage assessment is frequently unreliable. Even for existing data, methodologies are not standardized and the financial coverage can vary significantly. Depending on where the disaster occurred and who reported it, estimations may vary from zero to billions of U.S. dollars. The total amount of damage reported in 2012 was the fifth lowest of the decade. In the Americas and in Europe, the amount of damages was the second highest of the decade and the fifth highest in Africa. In Asia and Oceania, however, the amount of reported damages was, respectively, the third and fourth lowest of the decade. The Americas accounted for almost 66% of damage and Europe for 15%, higher than their respective 43 and 9% average for the decade. The contribution of very high human development countries to the total amount of damages climbed to 80%, an amount greater than their 72% average for the decade. Inversely, high human development countries accounted for only 16% of damage (decade average, 22%). The two costliest disasters in 2012 occurred in the United States. Hurricane Sandy cost U.S.$ 50 billion and a drought in the Southwest and Midwest regions cost U.S.$ 20 billion. Two earthquakes that hit Italy’s Ferrara region cost more than U.S.$ 15 billion.
population and development in areas vulnerable to natural disasters, especially coastal areas, have led to sharply increased insurance payouts (see Table 23-1).
NATIONAL DISASTER PLANNING AND RESPONSE: A HEALTH-FOCUSED OVERVIEW There is a concerted national effort to provide guidance to state and local planning regions to assist with the coordinated and successful responses and recovery efforts in all-hazard disasters and catastrophes. Many documents have been written at the national level, some of which are reviewed in this chapter.
The reader may ask: “Isn’t this all beyond what an individual nurse should have to know?”
As the single largest profession within the health care network, nurses must understand the national disaster manage- ment cycle. Without nursing integration at every phase, com- munities and clients lose a critical part of the prevention network, and the multidisciplinary response team loses a first- rate partner. Actually, it matters greatly how the nation dials 911, and it matters to individuals as well as communities,
regions, and the country as a whole. It also matters globally, beyond our own borders. Our national response is not just about the United States, but our international ability to assist other nations in their times of need.
The U.S. Department of Homeland Security (DHS) was created through the Homeland Security Act of 2002 (DHS, 2002), consolidating more than 20 separate agencies.
Presidential Policy Directive 8: National Preparedness (PPD-8) was signed and released by President Barack Obama on March 30, 2011. PPD-8 replaced Homeland Security Presi- dential Directive 8 from the Bush era, and guides how the nation, from the federal level to private citizens, can “prevent, protect against, mitigate the effects of, respond to, and recover from those threats that pose the greatest risk to the security of the Nation” (DHS, 2011). The National Preparedness Guide- lines (NPG) (DHS, 2007a) and the National Response Plan (NRP), which provide a national doctrine for preparedness that includes the National Response Framework (NRF), was pro- mulgated in January 2008. The second edition of the National Response Framework, updated in 2013, provides context for how the whole community works together and how response
507CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
efforts relate to other parts of national preparedness (DHS, 2013). Each of the five frameworks covers one mission area: Prevention, Protection, Mitigation, Response, or Recovery. In that framework there are also 15 emergency support functions. Emergency Support Function 8: Public Health and Medical provides coordinated federal assistance to supplement state, local, and tribal resources in response to public health and medical care needs (FEMA, 2013a).
Homeland Security Presidential Directive 5 (HSPD-5) created the National Incident Management System (NIMS), a unified, all-discipline, and all-hazards approach to domestic incident management (Naval Postgraduate School [NPS], 2014; FEMA, 2013c). The NIMS was established to provide a common language and structure enabling all those involved in disaster response to communicate with each other more effectively and efficiently.
Two national preparedness documents specifically guide disaster health preparedness, response, and recovery: Home- land Security Presidential Directive (HSPD) 21: Public Health and Medical Preparedness and the National Health Security Strategy (NHSS). HSPD-21 established a national strategy that enables a level of public health and medical preparedness suf- ficient to address a range of possible disasters. It did so through four critical components of public health and medical pre- paredness: (1) biosurveillance, (2) countermeasure distribu- tion, (3) mass casualty care, and (4) community resilience (NPS, 2014). The NHSS is updated every 4 years and focuses on the national goals for protecting people’s health in the case of disaster in any setting. National health security is achieved when “the Nation and its people are prepared for, protected from, respond effectively to, and able to recover from incidents with potentially negative health consequences” (U.S. Depart- ment of Health and Human Services [USDHHS], 2013a, p. 2). The NHSS was directed by the 2006 Pandemic and All-Hazards Preparedness Act (PAHPA), an act to improve the nation’s ability to detect, prepare for, and respond to a variety of public health emergencies. The PAHPA was re-enacted in 2013 and is now called the Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA). The PAHPRA funds public health and hospital preparedness programs, medical counter- measures under the BioShield Project, and enhances the author- ity of the Food and Drug Administration (FDA) (USDHHS, March 2014).
In discussing community resiliency and impact of health care reform on public health preparedness, Vinter and col- leagues (2010) state: “Comprehensive health reform presents a rare opportunity to further strengthen our nation. However, even with health reform, there are still major gaps in our public health preparedness. Addressing these underlying weaknesses in our health system will not be easy or cheap, but failure to address these concerns could prove extremely costly” (p. 340).
Our national system of homeland security includes public health preparedness and response as a core part of its national strategies. Some of the strategy documents introduced in this section are covered in greater detail throughout the chapter. Every aspect of disaster management involves the practice of public health nursing.
HEALTHY PEOPLE 2020
• PREP-1: Reduce the time necessary to issue official information to the public about a public health emergency.
• PREP-2: Reduce the time necessary to activate designated personnel in response to a public health emergency.
• PREP-3: Increase the proportion of Laboratory Response Network (LRN) laboratories that meet proficiency standards. • PREP-3.1: Increase the proportion of LRN biological laboratories that
meet proficiency standards for Category A and B threat agents (http:// www.bt.cdc.gov/agent/agentlist-category.asp).
• PREP-3.2: Increase the proportion of LRN chemical laboratories that meet proficiency standards for chemical threat agents.
• PREP-4: Reduce the time for state public health agencies to establish after-action reports and improvement plans following responses to public health emergencies and exercises.
Objectives Related to Preparedness
From U.S. Department of Health and Human Services (USDHHS): Healthy People 2020. Washington, DC, 2014 (updated 2015), USDHHS. Retrieved January 2015 from http://www.healthypeople .gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=34
HEALTHY PEOPLE 2020 OBJECTIVES Because disaster affects the health of people in many ways, disaster incidents have an effect on almost every Healthy People 2020 objective. For example, although Access to Health Services and Public Health Infrastructure comprise two important Healthy People 2020 topic areas with subsequent objectives, they become even more significant when individual and community needs escalate in disaster (USDHHS, 2010). Disasters also play a direct role in the objectives related to environmental health, food safety, immunization and infectious disease, and mental health and mental disorders. Public health professionals, such as those who work at the Centers for Disease Control and Pre- vention (CDC), study the effect that disasters have on popula- tion health and continuously develop new prevention strategies. Other organizations, such as the American Psychological Asso- ciation and the American Red Cross, work with communities in the preparedness, response, and recovery phases of a disaster and to revise and align the Healthy People 2020 objectives related to mental health.
THE DISASTER MANAGEMENT CYCLE AND NURSING ROLE Disaster management includes four stages: prevention (includ- ing mitigation and protection), preparedness, response, and recovery. Figure 23-2 shows the disaster emergency manage- ment cycle. Nurses have unique skills for all aspects of disaster including assessment, priority setting, collaboration, and addressing both preventive and acute care needs. In addition, public health nurses have a skill set that serves their community well in disaster, including health education and disease screen- ing, mass clinic expertise, an ability to provide essential public health services, community resource referral and liaison work, population advocacy, psychological first aid, public health
508 PART 4 Issues and Approaches in Population-Centered Nursing
measures implemented at the local government level achieve effectiveness, in an all-hazards approach to threats. Of course, prevention also includes human-made hazards and the ability to deter potential terrorists, detect terrorists before they strike, and take decisive action to eliminate the threat (DHS, 2007b). Prevention activities for terrorism may include heightened inspections; improved surveillance and security operations; public health and agricultural surveillance; and testing, immu- nizations, isolation, or neutralizing CBRNE threats (chemical, biological, radiological, nuclear, and explosive).
The nurse may be involved in many roles in the primary prevention of disaster. As community advocates, nurses promote environmental health by identifying environmental hazards and serving on the public health team for mitigation purposes. Public health nurses in particular are involved with organizing and participating in mass prophylaxis and vaccination cam- paigns to prevent, treat, or contain a disease. The nurse should be familiar with the region’s local cache of pharmaceuticals and how the Strategic National Stockpile (SNS) (described later in this chapter) will be distributed. Once federal and local authori- ties agree that the SNS is needed, medicine delivery to any state in the United States occurs within 12 hours (CDC, 2012c). State and local emergency planners then ensure points of dispensing (POD), to provide prophylaxis to the entire population within 48 hours.
In terms of human-made disaster prevention, the nurse should be aware of high-risk targets and current vulnerabilities and what can be done to eliminate or mitigate the vulnerability. Targets may include military and civilian government facilities, health care facilities, international airports and other transpor- tation systems, large cities, and high-profile landmarks. Terror- ists might also target large public gatherings, water and food supplies, banking and finance, information technology, postal and shipping services, utilities, and corporate centers.
Preparedness Role of the Public Health Nurse in Personal and Professional Preparedness Public health nurses play a key role in community preparedness, but they must accomplish the critical elements of personal and professional preparedness first.
Personal Preparedness. Disasters by their nature require nurses to respond quickly. Public health nurses without plans in place to address their own needs, to include family and pets, will be unable to fully participate in their disaster obligations at work or in volunteer efforts (Figure 23-3). In addition, the nurse assisting in disaster relief efforts must be as healthy as possible, both physically and mentally. Disaster workers who do not practice self-health are of little service to their family, clients, and community (see the How To box entitled Be Red Cross Ready). Disaster kits should be made for the home, workplace, and car. There are emergency supplies specific to nursing that should be prepared and stored in a sturdy, easy-to-carry con- tainer (see the accompanying How To box). Important docu- ments should always be in waterproof containers. Nurses should consider several contingencies for children and older adults with a plan to seek help from neighbors in the event of being
triage, and rapid needs assessment. Nurses have served world- wide in disaster care for more than a century. They continue to provide a significant resource to both the employee and the volunteer disaster management workforce, and their numbers are unmatched by any other profession. In addition, nurses work closely with the interprofessional health team, commu- nity leaders, and organizations, engaging with and advocating for clients as needed across the disaster management cycle.
The World Association for Disaster and Emergency Medi- cine (WADEM) includes a nursing section. The Nursing Section of WADEM represents nurses from all countries to strengthen and improve the practice and knowledge of disaster nursing. The Nursing Section purposes are as follows (WADEM, 2013): • Define nursing issues for public health care and disaster
health care. • Exchange scientific and professional information relevant to
the practice of disaster nursing. • Encourage collaborative efforts enhancing and expanding
the field of nursing disaster research. • Encourage collaboration with other nursing organizations. • Inform and advise WADEM of matters related to disaster
nursing. The International Council of Nurses (ICN) also hosts a
disaster-focused response network and published a framework of disaster nursing competencies in 2009 (ICN, 2013).
Prevention (Mitigation and Protection) All-hazards mitigation (prevention, protection) is an emer- gency management term for reducing risks to people and prop- erty from natural hazards before they occur. The ability to provide primary prevention through national missions of pre- vention, mitigation, or protection can include structural mea- sures, such as protecting buildings and infrastructure from the forces of wind and water, and nonstructural measures, such as land development restrictions. These primary prevention
FIG 23-2 Disaster management cycle. (From Ontario Agency for Health Protection and Promotion (Public Health Ontario). Public health emergency preparedness: an IMS-based work- shop. Base scenario. Toronto, ON: Queen’s Printer for Ontario; 2015 July. (p. 7))
Prevention
Recovery
Response
Preparedness
Mitigation
509CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
called to a disaster. Many public shelters do not allow pets inside and other arrangements must be made. At present, local emer- gency management agencies include pet management in the local disaster plans and so should the pet owner (FEMA, 2014c).
One way a nurse can feel assured about family member protection is by working with them to develop the skills and knowledge necessary for coping in disaster. For example, long- term benefits occur by involving children and adolescents in activities such as writing preparedness plans, exercising the plan, preparing disaster kits, becoming familiar with their school emergency procedures and family reunification sites, and learning about the range of potential hazards in their vicin- ity to include evacuation routes. This strategy also offers chil- dren and adolescents an opportunity to express their feelings.
Professional Preparedness. Every state needs a qualified workforce of public health nurses for solutions for today’s public health problems that include natural disasters and the threat of terrorism. Public health nurses, in turn, need “dedi- cated, resourceful, and visionary leaders” (ASTDN, 2008, p. 4). Chief public health nurse officers at the state level develop and maintain a strong public health nursing workforce and practice, especially when those nurses are scattered throughout state and local systems.
Disaster management in the community is about population health: The core public health functions of assessment, policy development, and assurance hold as true in disaster as in day-to- day operations. Operating in the chaos of disaster surge, however, demands a flexible and proficient practice base in each of public health’s 3 core functions and 10 essential services (see http://www.cdc.gov/nphpsp/essentialservices.html).
Just as the mission of public health and its core functions and essential services do not change in disaster, neither does the practice of public health nursing. The public health nurse must be prepared to advocate for the community in terms of a
FIG 23-3 Personal preparedness. Public health nurses need to develop their own disaster plan as a part of their community disaster activities. (Courtesy of the Wichita Falls Health District [Wichita Falls, TX]. From: http://tx-wichitafalls2.civicplus.com/ index.aspx?NID=1301. Retrieved January 2015.)
(Courtesy of the American Red Cross. Retrieved January 2015 from http://www.redcross.org/flash/brr/english-html/default.asp).
HOW TO Be Red Cross Ready 1. Get a Kit Consider the following when assembling or restocking your kit to ensure that you and your family are prepared for any disaster: • Store at least 3 days of food, water, and supplies in your family’s
easy-to-carry preparedness kit. Keep extra supplies on hand at home in case you cannot leave the affected area.
• Keep your kit where it is easily accessible. • Remember to check your kit every 6 months and replace expired
or outdated items. 2. Make a Plan When preparing for a disaster, always: • Talk with your family. • Plan. • Learn how and when to turn off utilities and how to use life-
saving tools such as fire extinguishers. • Tell everyone where emergency information and supplies are
stored. Provide copies of the family’s preparedness plan to each member of the family. Always ensure that information is up to date and practice evacuations, following the routes outlined in your plan. Don’t forget to identify alternative routes.
• Include pets in your evacuation plans. 3. Get Informed There are three key parts to becoming informed: • Get Info: Learn the ways you would get information during a
disaster or an emergency. • Know Your Region: Learn about the disasters that may occur in
your area. • Action Steps: Learn first aid from your local Red Cross chapter. Emergency Supplies That Nurses Should Have Ready • Identification badge and driver’s license • Proof of licensure and certification (e.g., RN, CPR/AED, First Aid) • Pocket-size reference books (e.g., nursing protocols and inter-
vention standards) • Blood pressure cuff (adult and child) and stethoscope • Gloves, mask, other personal protective equipment (PPE) for
general care • First aid kit with mouth-to-mouth cardiopulmonary resuscitation
(CPR) barrier • Radio with batteries and cell phone charger • Cash, credit card • Important papers and contact information in hard copy • Sun protection • Sturdy shoes with socks • Medical identification of allergies, blood type • Medications for self • Weather-appropriate clothing to include rain gear • Toiletries • Watch, cell phone, PDA with pre-entered emergency numbers • Flashlight, extra batteries • Record-keeping materials, including pencil/pen • Map of area
focus on population-based practice. The number of public health nurses available to get the job done is small when com- pared with those with generic or other specialty nurse prepara- tion. Also, disaster produces conditions that demand an aggregate-care approach, increasing the need for public health
510 PART 4 Issues and Approaches in Population-Centered Nursing
Professional preparedness also requires that nurses become aware of and understand emergency and disaster plans at their workplace and in their community. Nurses should review the disaster history of the community, understanding how past disasters have affected the community’s health care delivery system. It is important for nurses to understand and gain the competencies needed to respond in times of disasters before disaster strikes.
Box 23-3 displays core disaster competencies for those working in public health. Disaster competencies for public health nursing practice have been proposed in a set of 25 com- petencies categorized into preparedness, response, and recov- ery (Polivka et al, 2008). The preparedness competencies focus on personal preparedness and on comprehending disaster pre- paredness terms, concepts, and roles. The competencies also define the role of the public health nurse in a surge event. Response phase competencies include the ability to provide a rapid needs assessment, outbreak investigation and surveil- lance, public health triage, risk communication, and technical skills such as mass dispensing. Recovery competencies include after-action participation, disaster plan modifications, and
nursing involvement in community service during disaster and catastrophe.
The Public Health Nursing Intervention Wheel (Chapter 9) is a population-based practice model that encompasses 3 levels of practice (community, systems, and individual/family) and 16 public health interventions. Each intervention and practice level contributes to improving population health, providing a prac- tice foundation. This Wheel holds true to public health nursing interventions whether the nurse is working in day-to-day or in disaster operations.
Interprofessional disaster care teams need nurses with disas- ter and emergency management training and experience. Although the majority of disaster work is not high tech, the knowledge one needs for CBRNE disasters must be developed to include access to a ready cache of information related to nursing care. The following sites provide useful information: • CDC: Emergency Preparedness and Response: A to Z Index
(http://www.bt.cdc.gov/agent) • National Library of Medicine: Disaster Information Manage-
ment Research Center (http://disaster.nlm.nih.gov/) • Unbound Medicine: Relief Central (http://relief
.unboundmedicine.com/relief/ub/) • National Library of Medicine: WISER—Wireless Information
System for Emergency Responders (http://wiser.nlm.nih.gov/) (see Box 23-2 for further information) Depending on the job and possible volunteer assignments,
it is expected that nurses know how to use personal protective equipment (PPE), operate specialized equipment needed to perform specific activities, and safely perform duties in disaster environments.
From National Center for Disaster Medicine and Public Health (NCDMPH): Resources for Core Competencies in Disaster Health. Bethesda, MD, 2014, NCDMPH. From: http://ncdmph.usuhs.edu/ KnowledgeLearning/2013-CompetenciesResources.htm. Retrieved January 2015.
1.0: Demonstrate personal and family preparedness for disasters and public health emergencies.
2.0: Demonstrate knowledge of one’s expected role(s) in organizational and community response plans activated during a disaster or public health emergency.
3.0: Demonstrate situational awareness of actual/potential health hazards before, during, and after a disaster or public health emergency.
4.0: Communicate effectively with others in a disaster or public health emergency.
5.0: Demonstrate knowledge of personal safety measures that can be imple- mented in a disaster or public health emergency.
6.0: Demonstrate knowledge of surge capacity assets, consistent with one’s role in organizational, agency, and/or community response plans.
7.0: Demonstrate knowledge of principles and practices for the clinical management of all ages and populations affected by disasters and public health emergencies, in accordance with professional scope of practice.
8.0: Demonstrate knowledge of public health principles and practices for the management of all ages and populations affected by disasters and public health emergencies.
9.0: Demonstrate knowledge of ethical principles to protect the health and safety of all ages, populations, and communities affected by a disaster or public health emergency.
10.0: Demonstrate knowledge of legal principles to protect the health and safety of all ages, populations, and communities affected by a disaster or public health emergency.
11.0: Demonstrate knowledge of short- and long-term considerations for recovery of all ages, populations, and communities affected by a disas- ter or public health emergency.
BOX 23-3 Core Competencies for Disaster Medicine and Public Health
From National Library of Medicine: About WISER. Bethesda, MD, 2014, National Library of Medicine. From: http://wiser.nlm.nih.gov/ about.html. Retrieved January 2015.
WISER (Wireless Information System for Emergency Responders) is a system designed to assist emergency responders in hazardous material incidents. Developed by the National Library of Medicine, WISER provides a wide range of information on hazardous substances, including substance identification support, physical characteristics, human health information, and containment and suppression guidance. By inputting a substance’s physical properties and entering an individual’s symptoms, WISER can help narrow the range of substances that may be involved. It provides detailed information about haz- ardous substances, health effects, treatment, personal protective equipment, toxicity, the emergency resources available, and the surrounding environmen- tal conditions. In January 2014, WebWISER version 4.5 was released. This new release integrates Chemical Hazards Emergency Medical Manage- ment (CHEMM) content and updates the Emergency Response Guidebook (ERG) content to 2012. It also now includes hospital provider and preparedness profiles. WISER is available as a standalone application on Microsoft Windows PCs, Apple’s iOS devices (iPhone, iPad, and iPod touch), Google Android devices, BlackBerry devices (Internet connectivity required), Windows Mobile devices, and Palm OS PDAs.
BOX 23-2 Nurses and Technology Hazardous Material Information Delivered via Wireless
511CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
World Trade Center attacks of September 11, 2001, brought many qualified but unassociated responders to the site. “Many well-intentioned local physicians in shirt sleeves and light foot- wear proceeded to the area and attempted to find victims, risking further injuries to themselves and getting in the way of structured rescue protocols. … [They were] prohibited from participating in rescue operations within any area designated as a disaster by the Fire Department of New York” (Crippen, 2002). After the bombing of the Alfred P. Murrah building in Oklahoma City in 1995, a nurse who rushed into the building to rescue people became the only fatality who was not killed or injured in the initial blast and collapse (Oklahoma City National Memorial & Museum, 2010). See Box 23-6 for more on the importance of national preparedness.
coordinating efforts to address the psychosocial and public health impact. See Box 23-4 for education and training opportunities.
Nurses who seek increased participation or who seek a better understanding of disaster management can become involved in any number of community organizations. The National Disas- ter Medical System (NDMS) provides nurses the opportunity to work on specialized teams such as the Disaster Medical Assistance Team (DMAT). The Medical Reserve Corps (MRC) and the Community Emergency Response Team (CERT) provide opportunities for nurses to support emergency pre- paredness and response in their local jurisdictions. The Ameri- can Red Cross offers training in disaster health services and disaster mental health for both local response and national deployment opportunities. In the Red Cross, nurses and nursing students can join a local disaster action team (DAT); act as a liaison with local hospitals; plan health services support for shelter sites; participate on an interprofessional team for optimal service delivery; address the logistics of health and medical sup- plies; and teach disaster nursing in the community. A list of opportunities is shown in Box 23-5.
The importance of being adequately trained and properly associated with an official response organization to serve in a disaster cannot be overstated. In a disaster, many untrained and ill-equipped individuals rush in to help. Spontaneous volunteer overload, leading to role conflict, anger, frustration, and help- lessness, adds to the burden in an already tense situation. The
Public Health Workforce Development Centers • Centers for Disease Control and Prevention: http://www.bt.cdc.gov/
training/ • Heartland Centers for Public Health and Community Capacity Development:
http://www.heartlandcenters.slu.edu/ • National Public Health Training Centers Network, HRSA: http://
bhpr.hrsa.gov/grants/publichealth/trainingcenters/index.html • Northwest Center for Public Health Practice: http://www.nwcphp.org/
training
Government and Other Nurse-Specific Courses • American Red Cross Disaster Health and Sheltering Course for Nursing
Students: http://www.drc-group.com/library/exercise/osc/OSC-DHS- FactSheet.pdf
• Emergency Management Institute: http://training.fema.gov/ • Federal Emergency Management Agency (FEMA) Training: http://
www.fema.gov/prepared/train.shtm • National Nurse Emergency Preparedness Initiative: http://www.nnepi.org/
Public Health Organizations • American Public Health Association (APHA): http://www.apha.org • Association of Public Health Nurses (APHN): http://www.phnurse.org/ • Association of Schools of Public Health (ASPH): http://www.asph.org • National Association of County and City Health Offices (NACCHO): http://
www.naccho.org • Public Health Foundation (PHF): http://www.phf.org
BOX 23-4 Websites Providing Education and Training Opportunities
• American Red Cross (ARC): http://www.redcross.org • Buddhist Compassion Relief (Tzu Chi): http://www.tzuchi.org/ • Certified Emergency Response Team (CERT): https://www.citizencorps.gov/
cert/ • Citizen Corps: http://www.citizencorps.gov/ • Disaster Medical Assistance Team (DMAT): http://www.phe.gov/
Preparedness/responders/ndms/teams/Pages/dmat.aspx • Medical Reserve Corps (MRC): http://www.medicalreservecorps.gov/
HomePage • National Voluntary Organizations Active in Disaster (NVOAD): http://
www.nvoad.org • One Nurse at a Time: http://onenurseatatime.org/volunteer/ • The Salvation Army: http://www.salvationarmyusa.org/usn/www_
usn_2.nsf
BOX 23-5 Volunteer Opportunities in Disaster Work
From Trust for America’s Health: TFAH Initiatives—Bioterrorism and Public Health Preparedness. 2012. From: http://healthyamericans.org/ report/101/. Retrieved January 2015.
Health emergencies pose some of the greatest threats to our nation, because they can be difficult to prepare for, detect, and contain. Important progress has been made to improve emergency preparedness since September 11, 2001. However, while there has been significant progress toward improving public health preparedness over the past 10 years, particularly in core capabili- ties, there continue to be persistent gaps in the country’s ability to respond to health emergencies, ranging from bioterrorist threats to serious disease outbreaks to extreme weather events.
In the 10th annual Ready or Not? Protecting the Public from Diseases, Disasters, and Bioterrorism report, 35 states and Washington, DC, scored a 6 or lower on 10 key indicators of public health preparedness.
Along with its annual report on public health preparedness, TFAH also offers a series of recommendations to further strengthen America’s emergency preparedness.
What do you think about the recommendations through a public health nursing lens?
BOX 23-6 Trust for America’s Health (TFAH): Bioterrorism and Public Health Preparedness
512 PART 4 Issues and Approaches in Population-Centered Nursing
and response partners, providing opportunities to train, exer- cise, evaluate, and update disaster plans. Stronger predisaster partnerships, which include all stakeholders, produce a more coordinated response. Figure 23-4 shows FEMA regions across the nation.
Disaster planning involves simplicity and realism with back-up contingencies because (1) the disaster will never be an “exact fit” for the plan, and (2) all plans must be implementa- tion ready, no matter who is present to start them (DHS, 2007a). The following Quality and Safety Education for Nurses box describes safety guidelines for the nurse’s family.
Finally, the community must have an adequate warning system and an evacuation plan that includes measures to remove those individuals who hesitate to leave areas of danger. Some people refuse to leave their homes over fear that their posses- sions will be lost, destroyed, or looted. They also do not want to leave pets behind. Also, some people mistakenly believe that experience with a particular type of disaster is enough prepara- tion for the next one. This faulty belief was demonstrated in New York City during Hurricane Sandy in October 2012, fueled by a false sense of security after Hurricane Irene in August 2011. Sandy killed at least 125 people, including 60 in New York—48 of them in New York City (Huffington Post, 2012). The nurse’s visibility in the community can help develop the trust and cred- ibility needed to help in contingency planning for evacuation. In December 2014 nurses were rated the highest on honesty and ethics in a ranking of professions. Their ranking of 80% was compared to medical doctors at 65% and clergy at 4 percent (www.gallup.com/poll/1654/Honesty-Ethics-Professions.aspx).
Community Preparedness Presidential Policy Directive (PPD)-8 emphasizes that true pre- paredness is a whole community event. PPD-8 urges the strengthening of our nation’s security and resilience through an integrated set of guidance, programs, and processes to imple- ment the national preparedness goal, described earlier in this chapter (DHS, 2011).
This planning and implementation require a coordinated response that involves many stakeholders, including first and foremost the general public. Community preparedness also involves all levels of government, public health agencies, hospi- tals, first responders, emergency management, health care pro- viders within the community, schools and universities, the private sector, and business and nongovernmental organiza- tions (NGOs) such as the Red Cross. Mutual aid agreements and prior planning help to bridge perceived and actual barriers; establish relationships before the incident at the local, regional, state, and national levels; and ensure seamless service. Some- times barriers involve regulatory authority and jurisdictional boundaries; sometimes the barriers involve organizational control versus the common good.
Emergency management is responsible for developing and coordinating emergency response plans within their defined area, whether local, state, federal, or tribal. The Federal Emer- gency Management Agency (FEMA) coordinates comprehen- sive, all-hazard planning at the national level, assuring a menu of exercises and plan templates to address plausible incidents in any given community. Emergency management personnel at the state and local levels work closely with their communities
FIG 23-4 The 10 FEMA regions. (Courtesy of the Federal Emergency Management Agency [FEMA]: Regional Operations. Washington, DC, 2014, FEMA. From: http://www.fema.gov/ regional-operations. Retrieved January 2015.)
AK
HI Guam
X
IX
VIII
VI
VII III
II
I
V
IV
Seatle
Oakland Denver
Denton
Kansas City
Chicago
Philadelphia
New York
Boston
Washington, DC
Atlanta
PR VI
513CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Safety: Minimize risk of harm to clients and providers through both system effectiveness and individual performance. Selected knowledge, skills, and attitudes are cited below in order to develop a disaster safety plan:
Knowledge Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as workarounds and dangerous abbrevia- tions). Specific steps might be: 1. Learn how you can get information during the disaster or emergency.
a. Determine what types of disasters are most likely to happen. b. Learn about warning signals in your community. c. Ask about postdisaster pet care (shelters usually will not accept pets). d. Review the disaster plans at your workplace, school, and other places
where your family spends time. e. Determine how to help older adult or disabled family members or
neighbors. f. WHAT should you do?
Skills Demonstrate effective use of strategies to reduce risk of harm to self or others. 1. Create a disaster plan:
a. Talk with your family and create two places to meet, including outside your home and outside your neighborhood. Give each member of the family a copy of the plan.
b. Discuss the types of disasters that are most likely to happen, and review what to do in each case and make a plan.
c. Choose an out-of-state friend to be your family contact; this person will verify the location of each family member. After a disaster, it may be easier to call long distance than to make local calls.
d. Review evacuation plans, including care of pets. Have alternative routes for evacuation.
2. Complete this checklist: a. Post emergency phone numbers next to telephones. b. Teach everyone how and when to call 911.
c. Determine when and how to turn off water, gas, and electricity at the main switches.
d. Check adequacy of insurance coverage for yourself and your home. e. Locate and review the use of fire extinguishers. f. Install and maintain smoke detectors. g. Conduct a home hazard hunt and fix potential hazards. h. Stock emergency supplies and assemble a disaster supplies kit. i. Acquire first aid and cardiopulmonary resuscitation (CPR) certification. j. Locate all escape routes from your home. Find two ways out of each room. k. Find safe spots in your home for each type of disaster.
3. Practice and maintain your plan: a. Review the plan every 6 months. b. Conduct fire and emergency evacuation drills. c. Replace stored water every 3 months and stored food every 6 months. d. Test and recharge fire extinguishers according to manufacturer’s
instructions. e. Test your smoke detectors monthly and change the batteries at least once
a year. f. WHAT more should you do?
Attitudes Appreciate the cognitive and physical limits of human performance. 1. Monitor your personal reactions to the disaster and seek assistance if the
stress of the losses and the potential work to re-establish a new normal seem overwhelming. Monitor also the reactions of your colleagues and the clients you serve and provide or refer to others anyone who needs stress manage- ment intervention.
Safety Question To prepare more effectively for the event of a future disaster, list the steps that you would take to ensure the safety of your family, including any pets you may have.
the concept of community resilience into all preparedness oper- ations. The NHSS is designed to achieve two goals: (1) build community resilience and (2) strengthen and sustain health and emergency response systems (U.S. Department of Health and Human Services (USDHHS), 2013a). Some maintain, though, that the concept of community resilience is not fully defined at our national level and accountability measures to examine resil- ience pre- and postdisaster are lacking (Uscher-Pines et al, 2013). Community resilience is a policy issue in all levels of planning (federal, state, and local) because limited resources postdisaster demand whole community resilience in order to move back into normalcy. Healthier communities, by default, will have better bounce-back ability.
Community resilience is defined as the sustained ability of a community to withstand and recover from adversity (Chandra et al, 2011). Healthy individuals, families, and communities with access to health care and protective, preventive knowledge that can be used to launch timely action become some of our nation’s strongest assets in disaster incidents. A recent Rand publication
Nurses should be involved in identifying and educating com- munities about what effect the disaster might have on them, including helping at-risk populations to address preparedness planning. In addition to identifying high-risk individuals in neighborhoods, locations of congregate concern include schools, college campuses, residential centers, prisons, hospitals, and high-rise buildings. During Hurricane Sandy even the health care facilities did not have consistency in evacuation decisions and risk assessment (Powell et al, 2012). Nurses can greatly assist in community preparedness given their knowledge of the community’s diversity such as non–English-speaking groups, the immunocompromised, children, older adults with functional and access needs, and the physically and mentally challenged.
The National Health Security Strategy and Community Resilience The NHSS, mentioned earlier in this chapter, as part of the nation’s national planning has been instrumental in bringing
514 PART 4 Issues and Approaches in Population-Centered Nursing
The National Exercise Program (NEP) serves to test and validate core capabilities. Participation in exercises, simulations or other activities, including real world incidents, helps organi- zations validate their capabilities and identify shortfalls, pulling in their partners and stakeholders including citizen participa- tion (FEMA, 2014b). An annual Capstone Exercise, formerly titled the National Level Exercise (NLE), is conducted every 2 years as the final component of each NEP progressive exercise cycle. The Capstone Exercise for 2014 examined the nation’s collective ability to coordinate and conduct risk assessments and implement National Frameworks and associated plans to deliver core capabilities (FEMA, 2014b).
Most exercises conducted in hospitals, communities, col- leges, counties, or regions are much smaller in scope and scale than the Capstone Exercises. The Homeland Security Exercise and Evaluation Program (HSEEP) was developed to help states and local jurisdictions improve overall preparedness with all natural and human-made disasters. It provides a stan- dardized methodology and terminology for exercise design, development, conduct, evaluation, and improvement planning and assists communities to create exercises that will make a positive difference before a real incident (FEMA, 2013b). HSEEP is the national standard for all exercise development and implementation.
Whether conducted as drills, tabletops, functional, or full- scale scenarios, and whether the scope is local or national in nature, nurses and other health care providers must be included as a part of the exercise’s planning, response, and after-action activities. Nurses, as client and community advocates, are essen- tial players in the exercise and preparedness arena.
dedicated to advancing operational implementation of commu- nity resilience developed a list of resilience indicators after care- fully researching the existing literature and national disaster policy documents and conducting focus groups with communi- ties recently affected by disasters (Chandra et al, 2011): • Engagement at the community level, including a sense of
cohesiveness and neighborhood involvement or integration • Partnership among organizations, including integrated pre-
event planning, exercises, and agreements • Sustained local leadership supported by partnership with
state and federal government • Effective and culturally relevant education about risks • Optimal community health and access to quality health
services • Integration of preparedness and wellness • Rapid restoration of services and social networks • Individual-level preparedness and self-sufficiency • Targeted strategies that empower and engage vulnerable
populations • Financial resiliency of families and businesses, and efficient
leveraging of resources for recovery
Disaster and Mass Casualty Exercises Although practice will not ensure a perfect response to disas- ter, disaster and mass casualty drills and exercises are extremely valuable components of preparedness. After the exercise, the lessons learned through after-action reports are used to update disaster plans and subsequent operations. Exercise cat- egories include discussion-based simulations or “tabletops” and operations-based events such as drills, functional, and full-scale exercises (FEMA, 2013b). The latter operation types involve escalating scope and scale testing of the disaster pre- paredness and response network, using a specific plan. In addition, implementation of virtual reality (VR)-based train- ing for disaster preparedness and response, conducted either independently or combined with other training formats, is growing within the exercise community. For example, a virtual reality preparedness research project led through the Univer- sity of Minnesota Preparedness Emergency Response Research Center focuses on an immersive simulation workshop that is designed especially for health science students in public health, medicine, nursing, pharmacy, veterinary medicine, and den- tistry at the university. The researchers propose that engaging interprofessional health students in realistic simulated disaster response scenarios will improve system performance and quality disaster response through the acquisition of knowledge and team-based skills (University of Minnesota School of Public Health, 2014).
National Level Exercise 2009 (NLE09) was the first major exercise conducted by the U.S. government that focused exclu- sively on terrorism prevention and protection, as opposed to incident response and recovery. NLE09 was designated a Tier I National Level Exercise. These exercises started out as the Top Officials exercise series [TOPOFF]) but now incorporate the whole community, with an understanding that the practice must reach all levels of the public, private, and government sectors to be effective.
HOW TO Conduct a Disaster Exercise
Formidable Footprint: A National Community/Neighborhood Exercise Series A team of national, regional, state, and local agencies and organiza- tions has undertaken an effort to develop, conduct, and evaluate a recurring series of disaster exercises entitled “Formidable Footprint.”
This series of exercises serves as an opportunity for community and faith-based organizations along with governmental agencies to assess their capability to prepare for, respond to, and recover from a variety of natural disasters that affect communities and neighbor- hoods across the United States. There is no charge to participate in one or several of the neighborhood exercises, provided by the Disaster Resistant Communities (DRC) Group.
In addition, DRC provides the Disaster Health and Sheltering Course through nursing faculty and to their nursing students through the American Red Cross National Student Nurse Program.
Wherever and whenever you get to practice nursing in disaster response and recovery, you become a better-prepared health team member.
From Disaster Resistant Communities Group: Formidable Footprint—A National Community/Neighborhood Exercise Series, 2014. Retrieved January 2015 from http://www.drc-group.com/ project/footprint.html.
515CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
ESF #6: Mass Care, Emergency Assistance, Temporary Housing and Human Services
ESF #7: Logistics ESF #8: Public Health and Medical Services ESF #9: Search and Rescue ESF #10: Oil and Hazardous Materials ESF #11: Agriculture and Natural Resources ESF #12: Energy ESF #13: Public Safety and Security ESF #14: Long-Term Community Recovery ESF #15: External Affairs/Standard Operating Procedures.
Each ESF includes a coordinator function, and the primary and support agencies that work together to coordinate and deliver federal capabilities. Specifically, the ESFs provide the structure for coordinating federal interagency support to align with state, regional, and local capabilities. The NRFs also include support annexes, incident specific annexes, and partner guides.
ESF-8, Public Health and Medical Services, provides guid- ance for medical and mental health personnel, medical equip- ment and supplies, assessment of the status of the public health infrastructure, and monitoring for potential disease outbreaks (FEMA, 2013a). The ESF-8 primary coordinating agency is the U.S. Department of Health and Human Services; supporting agencies include the DHS, the American Red Cross, the Department of Defense, and the Department of Veterans Affairs. The National Disaster Medical System (NDMS) is part of ESF-8.
National Incident Management System The National Incident Management System (NIMS) is the national platform for disaster response and it includes univer- sal protocols and language. The NIMS identifies concepts and principles that answer how to manage emergencies from preparedness to recovery regardless of their cause, size, loca- tion, or complexity. “NIMS provides a consistent, nationwide approach and vocabulary for multiple agencies or jurisdictions to work together to build, sustain and deliver the core capabili- ties needed to achieve a secure and resilient nation” (FEMA, 2013c, p. 1).
No matter what type of nursing practice or which agency a nurse chooses, they will come into direct contact with NIMS, which includes the Incident Command System (ICS). Figure 23-5 displays basic ICS operations. The NIMS includes varying levels of education and training, with many organizations requiring a base level of familiarization to comply with federal funding requirements.
A well-developed training program promotes nationwide NIMS implementation, producing an adequate number of trained and qualified emergency management/response person- nel. The Emergency Management Institute (EMI) is the premier emergency management training institution, training more than 2 million students annually. The mission of EMI is to “directly supports the implementation of the National Incident Management System (NIMS), the National Response Frame- work (NRF), the National Disaster Recovery Framework (NDRF), and the National Preparedness Goal (NPG) by convey- ing necessary knowledge and skills to improve the nation’s capa-
Response The first level of disaster response occurs at the local level with the mobilization of a team of responders such as the fire depart- ment, law enforcement, public health, and emergency services. If the disaster exceeds local resources, the county or city emer- gency management agency (EMA) will coordinate activities through an Emergency Operations Center (EOC). The EOC provides central functions at a strategic level to oversee the emergency situation. In general, local responders within a county sign a regional or statewide mutual aid agreement to allow the sharing of needed personnel, equipment, services, and supplies.
The initial scope of disaster assessment is usually measured in dollars, health risk, injury, and/or lives lost. The more destruction and lives at risk, the greater the degree of atten- tion and resources provided at the local, regional, and state levels. When state resources and capabilities are overwhelmed, governors may, through provisions provided in the Robert T. Stafford Disaster Relief and Emergency Assistance Act (FEMA, 2013e), request federal assistance under a presidential disaster or emergency declaration. If the event is considered an incident of national significance (a potential or high- impact disaster), appropriate response personnel and resources are provided.
In a mass casualty incident, the goal is to maximize the number of lives saved and to do the greatest good for the great- est number of individuals. These circumstances could lead to changes in the usual standards of health and medical care in the affected locality or region. Rather than doing everything possible to save every life, crisis standards of care enable the health care operations necessary to allocate scarce resources in a different manner to save as many lives as possible (Insti- tute of Medicine [IOM], 2012). Crisis standards need to be explored and discussed with all community stakeholders in the preparedness phase. Community engagement is key to this process.
National Response Framework As previously discussed, the NRF was written to provide an approach to domestic incidents in a unified, well-coordinated manner, enabling all responding entities the ability to work together more effectively and efficiently. The online component of the NRF Resource Center (http://www.fema.gov/national -response-framework) contains supplemental materials includ- ing annexes, partner guides, and other supporting documents and learning resources. The framework involves the entire com- munity and is scalable, flexible, and adaptable to the given situ- ation. It is a living document that is revised every 18 months in response to evolving conditions, and real-world applications (DHS, 2013).
The NRF includes the 15 emergency support functions (ESFs) (FEMA, 2014d): ESF #1: Transportation ESF #2: Communications ESF #3: Public Works and Engineering ESF #4: Firefighting ESF #5: Information and Planning
516 PART 4 Issues and Approaches in Population-Centered Nursing
bility” (FEMA, 2012, paragraph 1). EMI is located at the National Emergency Training Center in Emmitsburg, Maryland, and offers a broad range of both onsite and online courses related to all phases of the disaster cycle. Some of the NIMS-related train- ing offered includes the following online courses (FEMA, 2013c): • IS-100.HCb: Introduction to the Incident Command System
for Healthcare/Hospitals • IS-200.HCa: Applying ICS to Healthcare Organizations • IS-700.a: National Incident Management System (NIMS),
An Introduction • IS-701.a: NIMS Multiagency Coordination System • IS-800.b: National Response Framework, An Introduction
Response to Biological Incidents Biological agents pose a high risk to public health because only small amounts of the agents are needed to affect thousands of people and some of the agents are easy to conceal, transport, and disseminate. The CDC is an excellent source of biological agent information, including the latest agent fact sheets for health (CDC, 2014a). Important information provided includes the methods of transmission and communicability period. Through the Pandemic and All-Hazards Preparedness Reautho- rization Act (PAHPRA), several biodefense programs exist to help public health professionals mount a proactive response to these events (USDHHS, 2013b): • BioWatch is an early warning system for biothreats that uses
an environmental sensor system to test the air for biological agents in several major metropolitan areas.
• BioSense is a data-sharing program to facilitate surveillance of unusual patterns or clusters of diseases in the United States. It shares data with local and state health departments and is a part of the BioWatch system.
• Project BioShield is a program to develop and produce new drugs and vaccines as countermeasures against potential bio- weapons and deadly pathogens.
• Cities Readiness Initiative is a program to aid cities in increas- ing their capacity to deliver medicines and medical supplies during a large-scale public health emergency such as a bio- terrorism attack or a nuclear accident.
• Strategic National Stockpile (SNS) is a CDC-managed program with the capacity to provide large quantities of medicine and medical supplies to protect the public in a public health emergency to include bioterrorism. The SNS is deployed through a combination of a state-level request and the public health system. Some of the most important lessons from live biological
incidents and exercises involve communication. In an effort to keep the public health community informed, the CDC devel- oped the Public Health Information Network (PHIN). The PHIN provides for the electronic exchange of information among governmental agencies. It focuses on six components that help ensure information access and sharing: early event detection, outbreak management, connecting laboratory systems, countermeasure and response administration, partner communications and alerting, and cross-functional compo- nents, and is critical to information exchange (CDC, 2014b).
FIG 23-5 Incident Command System (ICS). (Courtesy of U.S. Department of Health and Human Services, Washington, DC. From: http://www.phe.gov/Preparedness/planning/mscc/handbook/ chapter1/Pages/emergencymanagement.aspx. Retrieved January 2015.)
•
•
• •
•
• •
••
•
•
Establishes strategy (approach method- ology, etc.) and spe- cific tactics (actions) to accomplish the goals and objectives set by Command
Coordinates and executes strategy and tactics to achieve response objectives
Operations Logistics
Supports Command and Operations in their use of personnel, supplies, and equipment
Performs technical activities required to maintain the function of operational facilities and processes
Coordinates support activities for incident planning as well as contingency, long-range, and demobilization planning
Supports Command and Operations in processing incident information
Coordinates information activities across the response system
Planning
Supports Command and Operations with administrative issues as well as tracking and process- ing incident expenses
Includes such issues as licensure require- ments, regulatory compliance, and financial accounting
Admin/Finance
Defines the incident goals and operational period objectives
Includes an incident commander, safety officer, public information officer, senior liaison, and senior advisors
Command
517CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
economic estimates of more than $125 billion (National Oceanic and Atmospheric Administration [NOAA], 2007). The hurri- cane, floods, and more than 1800 confirmed deaths created traumatic stress that rose to unbearable levels in New Orleans, resulting in a tense and sometimes violent aftermath (Reagan, 2005). New Orleans was typically described as a war zone in the weeks following the disaster, as was the Gulfport-Biloxi coast- line in Mississippi, where 90% of the buildings were demol- ished. Hundreds of thousands of people lost access to their homes and their jobs as a result of Hurricane Katrina. Although the response and recovery efforts eventually superseded any natural recovery efforts in the history of the country, many residents of both Louisiana and Mississippi believed that the help was too little, too late. Despite the enormous efforts of people and the vast amounts of money spent to help the area recover, there is much work to be done and more funds will be needed to restore the area (Institute for Southern Studies [ISS], 2009).
Stress Reactions in Individuals. A traumatic event can cause moderate to severe stress reactions. Individuals react to the same disaster in different ways depending on their age, cultural background, health status, social support structure, and general ability to adapt to crisis. Symptoms that may require assistance are listed in Table 23-2.
People who are affected by a disaster often have an exacerba- tion of an existing chronic disease. For example, the emotional stress of the disaster may make it difficult for people with diabetes to control their blood glucose levels. Grief results in harmful effects on the immune system. It reduces the func- tion of cells that protect against viral infections and tumors. Hormones produced by the body’s flight-or-fight mechanism also play a role in mediating the effects of grief. Those with mental health issues may experience increased symptoms (CDC, 2012a).
Older adults’ reactions to disaster depend a great deal on their physical health, strength, mobility, independence, and income (Banks, 2013) (Figure 23-6). They can react deeply to the loss of personal possessions because of the high sentimental value attached to the items and their irreplaceable value. Their need for relocation depends on the extent of damage to their home or their compromised health. They may try and conceal the seriousness of their health conditions or losses if they fear loss of independence. Box 23-7 lists other populations at higher risk for serious disruption postdisaster, many of them the same populations at risk for adverse health effects predisaster as well.
The effect of disasters on young children (Figure 23-7) can be especially disruptive (National Institute of Mental Health [NIMH], 2013). Young children may respond with regressive behaviors such as thumb-sucking, bedwetting, crying, and clinging to parents. Older children tend to re-experience images of the traumatic event or have recurring thoughts or sensations, or they may intentionally avoid reminders, thoughts, and feel- ings related to disaster events. Children may have heightened sensitivity to sights, sounds, or smells and may experience exag- gerated responses or difficulty with usual activities. Children not immediately impacted by a disaster can also be affected by it. The constant bombardment of disaster stories on television
How Disasters Affect Communities One Health recognizes that the health of humans is connected to the health of animals and the environment, and the One Health concept integration in disaster preparedness and response requires interprofessional efforts at global, national, and local levels (CDC, 2013). The spread of infectious diseases and the relationships among humans, animals, and the environ- ment are at the core of One Health. For example, animals serve as early warning signs of potential human illness; an example is that birds often die of West Nile virus before humans get sick with West Nile virus fever.
The first goal of any disaster response is to re-establish sani- tary barriers as quickly as possible (Veenema, 2012). Water, food, waste removal, vector control, shelter, and safety are basic needs. Difficult weather conditions such as extreme heat or cold can hamper efforts, especially if electricity is affected. Continu- ous monitoring of the environment proactively addresses potential hazards. Disease prevention is an ongoing goal, espe- cially if there is an interruption in the public health infrastruc- ture. Infectious disease outbreaks can also occur in the recovery phase of disasters, and occasionally disaster workers introduce new organisms into the area.
People in a community will be affected physically and emo- tionally, depending on the type, cause, and location of the disas- ter; its magnitude and extent of damage; the duration; and the amount of prewarning provided. Immediate effects may include loss of life and morbidity, but other health effects such as those during and after disaster disease outbreaks may be delayed.
Although the immediate emotional response to a disaster by civilians may be unpredictable, the response is not always a negative one. For example, the terrorist attacks of September 11, 2001, created extreme anger and grief but also led to a marked increase in compassion and patriotism. Thousands of people helped, from donating blood and money to rescuing individuals from the buildings. Four days after the attack, buying an American flag was nearly impossible, as most stores had sold out (Associated Press, 2001). Within 1 month of the attack, an estimated $757 million in cash contributions and hundreds of truckloads of goods had been donated to help the families of victims and rescue workers (Yates, 2001). This was the worst human-made disaster in American history, killing more than 2500 civilians and 460 emergency responders. Yet, the terrorist attacks of September 11 will also be remembered for how they unified the country (Rand Corporation, 2004).
The psychological effects of September 11 were different from those of more contained, single-event disasters. The attack was unexpected and of great magnitude, with much uncertainty and fear about what might happen next. Not knowing when or if a subsequent attack will occur may sustain fear and anger.
Another U.S. disaster raised similar issues. At 7:10 a.m. EDT on August 29, 2005, Hurricane Katrina made landfall in south- ern Plaquemines Parish, Louisiana, as a category 3 hurricane. Starting as a natural disaster, its consequences were com- pounded by a human-made disaster caused by flooding from levee failure. Later joined by Hurricane Rita, Hurricane Katrina affected the Gulf Coast and the nation in ways that will be felt for generations to come. It is the costliest U.S. disaster ever, with
518 PART 4 Issues and Approaches in Population-Centered Nursing
can cause fear in children. Parental reaction to a disaster will greatly influence children (NIMH, 2013).
Public health nurses should help those in the affected com- munity talk about their feelings, including anger, sorrow, guilt, and perceived blame for the disaster or the outcomes of the disaster. Community members should be encouraged to engage in healthy eating, exercise, rest, daily routine maintenance, limited demanding responsibilities, and time with family and friends.
Stress Reactions in the Community. Communities reflect the individuals and families living in them, both during and after a disaster incident. Four community phases as seen in Figure 23-8 are commonly recognized: (1) heroic, (2) honey- moon, (3) disillusionment, and (4) reconstruction (Duane’s
From Substance Abuse and Mental Health Services Administration (SAMHSA): Coping with a Traumatic Event: Information for Health Professionals. 2005. From: http://media.samhsa.gov/MentalHealth/TraumaticEvent.aspx?from=carousel&position=1&date=3112011. Retrieved January 2015.
COGNITIVE EMOTIONAL PHYSICAL BEHAVIORAL
Poor concentration Confusion Disorientation Indecisiveness Shortened attention span Memory loss Unwanted memories Difficulty making decisions
Shock Numbness Feeling overwhelmed Depression Feeling lost Fear of harm to self and/or loved ones Feeling nothing Feeling abandoned Uncertainty of feelings Volatile emotions
Nausea Light-headedness Dizziness Gastrointestinal problems Rapid heart rate Tremors Headaches Grinding of teeth Fatigue Poor sleep Pain Hyperarousal Jumpiness
Suspicion Irritability Arguments with friends and loved ones Withdrawal Excessive silence Inappropriate humor Increased/decreased eating Change in sexual desire or functioning Increased smoking Increased substance use or abuse
TABLE 23-2 Common Responses to a Traumatic Event
FIG 23-6 Older adults and disaster. Red Cross nurse Jeanne Pollard chats with Ora White Church, 88, while making door-to- door visits with families in flood-damaged neighborhoods in Picayune, Mississippi, after Hurricane Isaac. (Courtesy of the American Red Cross Photo Library, photo by Talia Frenkel/ American Red Cross, Washington, DC. From: http://media .redcross.org/sites/. Retrieved January 2015.)
FIG 23-7 Children and disaster. In 2013, one week after Typhoon Haiyan made landfall, residents of Tanauan, the Philip- pines, struggle to cope amidst the devastation. Every house in the city of 50,000 was badly damaged or destroyed. The effects of a disaster on young children can be especially disruptive. (Courtesy of the American Red Cross Photo Library, photo by Patrick Fuller/International Federation of Red Cross and Red Crescent Societies, Geneva, Switzerland. From: http://media .redcross.org/sites/. Retrieved January 2015.)
BOX 23-7 Populations at Greatest Risk for Disruption after Disaster • Seniors • Vision and/or hearing impaired • Women • Children • Individuals with chronic disease • Individuals with chronic mental
illness • Non–English-speaking
• Low income • Homeless • Tourists; persons new to an area • Persons with disabilities • Single-parent families • Substance abusers • Undocumented residents
From National Institutes of Health, National Library of Medicine: Special Populations: Emergency and Disaster Preparedness. 2010. Available at http://sis.nlm.nih.gov/outreach/specialpopulationsanddisasters.html. Accessed January 25, 2011.
519CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
must make major changes and adjustments. Nurses in response must consider the psychosocial impact and the resulting emo- tional, cognitive, and spiritual implications. Public health nurses should identify groups/population segments particularly at risk for burnout and exhaustion, to include volunteers involved in response efforts. They may need breaks and reminders for nourishment. In addition, those in shock and those consumed by grief related to loss of loved ones will need compassionate care, with possible referrals to mental health counseling resources.
The last phase, reconstruction, is the longest. Recovery as a disaster cycle phase is addressed later in this chapter. Homes, schools, churches, and other community elements need to be rebuilt and reestablished. The goal is to return to a new state of normalcy. Community needs may still be extensive; the nurse continues to function as a member of the interprofessional team to provide and assure provision of the best possible coor- dinated care to the population.
Role of the Public Health Nurse in Disaster Response The role of the public health nurse during a disaster depends a great deal on the nurse’s experience, professional role in a com- munity disaster plan, and prior disaster knowledge to include personal readiness. Public health nurses bring leadership, policy, planning, and practice expertise to disaster preparedness and response (Association of Public Health Nurses [APHN], 2014). One thing is certain about disasters: continuing change. Public health nursing roles in disaster are generally consistent with the
Dartboard, 2010). The first two phases, the heroic and honey- moon phases, are most often associated with response efforts. The latter two phases, disillusionment and reconstruction, are most often linked with recovery.
During the heroic phase, there is an overwhelming need for people to do whatever they can to help others survive the disas- ter. First responders, including health and medical personal, will work hours on end with no thought of their own personal or health needs. They may fight needed sleep and refuse rest breaks in their drive to save others. Moreover, deployed responders from outside the disaster area may be unfamiliar with the terrain and inherent dangers. Those with supervisory responsi- bilities need to take necessary breaks and attend to their health needs. This means back-up plans must be made sooner than later. Exhausted, overworked responders present a danger to themselves and the community served.
In the honeymoon phase, survivors may be rejoicing that their lives and the lives of loved ones have been spared. Survi- vors will gather to share experiences and stories. The repeated telling to others creates bonds among the survivors. A sense of thankfulness over having survived the disaster is inherent in their stories.
The disillusionment phase occurs as time elapses and people notice that additional help and reinforcement are not coming as quickly as in the initial response. Fatigue and gloom can result and exhaustion starts to takes its toll on volunteers, rescu- ers, and medical personnel. The community begins to realize that a return to the previous normal is unlikely and that they
FIG 23-8 Phases of disaster: Collective reactions. (Courtesy of U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration [SAMHSA]: Training Manual for Mental Health and Human Services Workers in Major Disasters, ed 2. Wash- ington, DC, 2000, SAMHSA. From: http://store.samhsa.gov/product/Training-Manual-for-Mental -Health-and-Human-Service-Workers-in-Major-Disasters/SMA96-0538. Retrieved January 2015.)
Reconstruction A New Beginning
Honeymoon Community Cohesion
Disillusionment
Working Through Grief Coming to Terms
Setback
Anniversary Reactions
After AnniversaryUp to One Year
Trigger Events
Inventory
Impact
Pre-Disaster
Heroic
Threat Warning
Emotional Highs
Emotional Lows
520 PART 4 Issues and Approaches in Population-Centered Nursing
reports indicate the continuing status of the affected population and the effectiveness of ongoing relief efforts. Surveillance con- tinues into and through the recovery phase of a disaster, a vital part of establishing the new normal.
Nursing Role in Rapid Needs Assessment. The traditional model of community assessment presents the foundation for the rapid community assessment process. The acute needs of populations in disaster turn the community assessment into rapid appraisal of a sector or region’s population, social systems, and geophysical features. Elements of a rapid needs assess- ment include the following: determining the magnitude of the incident, defining the specific health needs of the affected pop- ulation, establishing priorities and objectives for action, identi- fying existing and potential public health problems, evaluating the capacity of the local response including resources and logis- tics, and determining the external resource needs for priority actions (Stanley et al, 2008). The Community Assessment for Public Health Emergency Response (CASPER) is a toolkit developed to assist public health practitioners and emergency management officials determine the health status and basic needs of the affected community. The CASPER guides in the collection of health and basic need information (CDC, 2012b). Noji (1997) points out that disaster assessment priorities relate to the type of disaster. Sudden-impact disasters such as torna- does and earthquakes involve ongoing hazards, injuries and deaths, shelter requirements, and clean water. Gradual-onset disasters such as famines produce concerns with mortality rates, nutritional status, immunization status, and environ- mental health.
Nursing Role in Disaster Communication. Nurses working as members of an assessment team need to return accurate information in the NIMS environment to facilitate situational awareness. A part of that communication is involved with the rapid and ongoing needs assessment just described. A lack of or inaccurate information regarding the scope of the disaster and its initial effects can contribute to mismatched resources and
scope of public health nursing practice, but that practice is often provided in chaotic surges. There is ongoing demand for flex- ibility in disaster, especially during the response phase of the disaster cycle (Stanley et al, 2008). See Table 23-3 to visualize the role of the public health nurses in response, using the nursing process.
Nursing Role in First Response. Although valued for their expertise in community assessment, case finding and referring, prevention, health education, and surveillance, there may be times when the nurse is the first to arrive on the scene. In this situation, it is important to remember that life-threatening problems take priority. Triage should begin immediately. Triage at the individual level is the process of separating casu- alties and allocating treatment on the basis of the individuals’ potentials for survival. Highest priority is given to those who have life-threatening injuries but, also, who have a high probability of survival once stabilized (Veenema, 2012). A type of triage called public health triage also exists, using a population-based approach for use in an incident undefined by a geographical location. Public health triage involves the sorting or identification of populations for priority interven- tions (Burkle, 2006).
Nursing Role in Epidemiology and Ongoing Surveillance. Public health remains the first line of defense in disease out- break. Epidemiology investigation components do not vary from normal operations in disaster, they simply become “field expedient” (Polivka et al, 2008). The need to collect surveillance data is heightened during a disaster. To detect adverse effects on the community, data are collected related to deaths, injuries, and illnesses. This information allows public health to deter- mine impacts of disaster and assess for potential problems related to response and recovery. Surveillance includes disease tracking, injury trends, and vigilance for the potential for disease outbreaks. These data allow decision-makers to plan and allocate resources. Ongoing assessments or surveillance reports are just as important as initial assessments. Surveillance
From Association of Public Health Nurses (APHN): The Role of the Public Health Nurse in Disaster Preparedness Response, and Recovery: A Position Paper. 2014. From: http://www.phnurse.org/index.php?option=com_content&view=article&id=120&Itemid=547. Retrieved January 2015.
Disaster Cycle Phase: RESPONSE Assessment Planning Implementation Evaluation
Response comprises “the capabilities necessary to save lives, protect property and the environment, and meet basic human needs after an incident has occurred.”
(Burkle, 2006, p. 1120)
Use public health, population- based triage to assess communicable disease outbreak impact and needed response (e.g., influenza)
Use population-based triage involving surveillance to divide the affected population into susceptible, exposed, infected, removed, and vaccinated for expedient and life-saving treatment
Collaborate with response partners to develop plans for triage algorithms that determine appropriate care and sustenance logistics for populations, based on their symptoms and comorbid conditions (e.g., chronic disease)
Identify and place public health nurses and other support personnel to provide care according to the developed algorithms
Assure that logistics are in place to support community care during the crisis period
Conduct ongoing rapid needs assessments during the response phase in order to meet population needs
Maintain ongoing response planning during the incident (e.g., the Incident Management System and its Planning “P”)
Participate in service planning and provide real-time adjustment on the basis of real-time public health response evaluation
Assure needed and necessary public health nursing care
TABLE 23-3 The Disaster Cycle Linked to the Nursing Process
521CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
to rapidly increase, and relief organizations such as the Ameri- can Red Cross are devoting separate response cells for the analy- sis of social media data in real time (American Red Cross, 2013). The following Evidence-based Practice box provides an example of communications in public health preparedness.
increased morbidity. After Hurricane Andrew in 1992, a well- meaning public continued to ship thousands of pounds of clothing to South Florida. Much of the clothing eventually was burned because there were inadequate on-site personnel to sort and distribute the clothing, and the piles eventually became a public health nuisance. This effort took resources away from real population-based needs.
Times of crisis or great uncertainty call for great skills in communication. The community needs accurate information transmitted in a timely manner. Health care personnel are the best sources for essential health information that is technical in nature. The NIMS approach uses public affairs spokespersons for formal communication. The Public Information Officer (PIO) is an individual with the authority and responsibility to communicate information to the public at large. Still, nurses are considered trustworthy sources of information and may be approached for an interview. The nurse should refer the media to the PIO representing the agency. If the public approaches the nurse for health information, however, it should be conveyed. Nurses provide health education and information to assist in disaster response and recovery.
Although there are official spokespersons in all major disas- ters, there may be an occasion for the nurse to serve as a health consultant on the risk communication team. Risk communica- tion includes providing critical information to the public. The information should be presented in a calm, brief, and concise manner. As a spokesperson in disaster, it is important to prepare key points in writing before speaking, verify all information is accurate, and never speculate or embellish.
Social media, mobile technology, and their combined use in disaster are quickly changing disaster communication for the community as well as responders (see the example of using social media in Box 23-8). The Federal Emergency Management Agency (2013d) National Preparedness Report states that during and immediately after Hurricane Sandy users sent more than 20 million Sandy-related Twitter posts despite the loss of cell phone service during the storm’s peak. This trend is expected
From Homeland Security Studies & Analysis Institute: The Resilient Social Network. 2014. From: http://homelandsecurity.org/node/1195. Retrieved January 2015.
A few hours after Superstorm Sandy made landfall in New Jersey, members of the Occupy Wall Street movement used social media to tap their estab- lished network for resources to combat the effects of the massive storm. Overnight, a corps of young, educated, tech-savvy individuals deployed to the region’s hardest-hit neighborhoods. The network that came to be known as “Occupy Sandy” emerged as one of the leading humanitarian collectives providing relief to survivors across New York City and New Jersey. At its peak, it mobilized an estimated 60,000 volunteers, most having no prior disaster relief experience. Yet unlike traditional disaster relief organizations, there were no appointed leaders, no regulations to follow, no predefined mission.
Learn more about how social networks are changing the world of disaster response.
BOX 23-8 The Resilient Social Network: @OccupySandy #SuperstormSandy
Savoia E, Lin L, Viswanath K: Communications in public health emergency preparedness: a systematic review of the literature. Biosecur Bioterror 11:170-184, 2013.
Savoia and colleagues (2013) performed a systematic review of the literature exploring communications in public health emergencies and preparedness (131 articles). One of the most consistent findings identified by the authors was an association between lower socioeconomic factors and public health emergency preparedness communication and outcomes. Specifically, individu- als living in poverty have lower levels of emergency preparedness and are less likely to receive communications regarding public health emergencies and preparedness.
The findings highlight the need for nurses to develop targeted communica- tion interventions toward identified population segments to help them better prepare and respond to emergencies. An example of one strategy is the Red Cross Mobile Applications (http://www.redcross.org/prepare/mobile-apps). These applications provide preparedness information, ongoing emergency communication and alerts, and give response information such as shelter locations and other features such as “I am safe” messaging. Nurses can assist in ensuring that at-risk populations with limited resources are assured the tools to be ready in the event of emergencies and disasters.
EVIDENCE-BASED PRACTICE
Nursing Role in Disaster Response Ethics. Hurricane Katrina’s impact was one of the largest catastrophic natural disasters in the United States. Thousands of health care person- nel were stranded in New Orleans hospitals. These workers were faced with limited resources and rapidly deteriorating condi- tions as they awaited evacuations (Powell-Young et al, 2013). In disasters, nurses may work with limited resources. In disaster surge the nurse may no longer be focused on the care of indi- vidual clients, but on the entire community. In extreme condi- tions, traditional ethics of doing the best for every patient may shift to a utilitarian framework where nursing’s goal becomes to do the “greatest good for the greatest number of individuals” (American Nurses Association [ANA], 2008, p. 10). In these circumstances, each patient may not receive all the care that would occur under normal conditions. Instead, the focus is on providing care that maximizes the benefit to the greatest number of people.
In addition to limited resources, nurses may be faced with situations that personally put them in harm’s way. The ANA Code of Ethics (2010a) states, “the nurse owes the same duties to self as to others.” Yet, abandonment of patients may be grounds for disciplinary action in many states. Extreme condi- tions may cause the nurse to make many difficult decisions, and using an ethical framework will make these decisions easier. As part of disaster preparedness, nurses need to consider their role in their agency’s disaster plan. Will they be needed in times of
522 PART 4 Issues and Approaches in Population-Centered Nursing
Alternate care centers may be used to shelter patients with medical needs designated as “Non-ambulatory care/Hospital overflow,” for example, care of nonambulatory patients with less intense medical needs. In addition, Federal Medical Sta- tions (FMSs) are another alternate care area for clients. These units also provide basic care for nonambulatory, hospital overflow, patients with minimal medical needs or to shelter patients with more advanced outpatient needs. Requested by state health or emergency management agencies, FMSs are designed to plug and play in “structures of opportunity” in the community, such as schools or convention centers (IOM, 2012). See the Linking Content to Practice box for ways to deal with a disaster.
Psychological Stress of Disaster Workers Disaster relief work can be rewarding because it provides an opportunity to have a profound and positive impact on the lives of those who may be experiencing their greatest time of need. However, the work can also be challenging and stressful. During an assignment, responders may be exposed to chaotic environments, long hours, rapidly changing infor- mation and directives, long wait times before getting to work, noisy environments, and living quarters that are less than ideal. According to the National Institute of Occupational Health and Safety (NIOSH, 2013), responders may not recog- nize the need for self-care, and to monitor their own emo- tional and physical health. As recovery efforts span time frames of weeks to months, there is increasing risk of adverse effects to responders.
No one who experiences a disaster either personally or in a professional capacity is untouched by it. Nurses who work with survivors of disasters may be at risk for stress reactions. Self- care is as important as the care that is provided to community members.
Symptoms that may signal a need for stress management assistance include the following: being reluctant or refusing to leave the scene until the work is finished; denying needed rest and recovery time; feelings of overriding stress and fatigue; engaging in unnecessary risk-taking activities; difficulty com- municating thoughts, remembering instructions, making deci- sions, or concentrating; engaging in unnecessary arguments; having a limited attention span; and refusing to follow orders (American Red Cross, 2012). Physical symptoms such as tremors, headaches, nausea, and colds or flulike symptoms can also occur.
The nurse should understand that everyone reacts differently after a disaster assignment. Most reactions are considered normal and are temporary, resolving in days to a few weeks. For some workers, disasters bring forth strong thoughts and emo- tions, both positive and negative. Other workers may experience mild reactions or hardly any reaction at all. There are some common strategies that will help individuals returning from the incident: rest and recovery time, focusing on accomplishments, using calming strategies such as relaxation techniques or working on hobbies, and concentrating on self-care to include healthy food and drink, exercise, and sleep (American Red Cross, 2012).
disasters? What plans have been made for their families if such a response is needed? Written policy should assure protections and make clear the expectations of the registered nurse, the employer, and the government response systems before the disaster occurs (ANA, 2010b).
Nursing Role in Sheltering. General population shelter management is often the responsibility of the local Red Cross chapter within their ESF-6 colead function. In catastrophic disaster, however, governmental authority may establish “mega shelters” housing thousands. ESF-6 provides for both short- and long-term care. This responsibility includes the plan for struc- ture, operations, management, and staffing of mass care sites.
Nurses, because of their comfort with delivering aggregate health promotion, disease prevention, and emotional support, make ideal shelter managers and team members. Nurses in shelter functions are involved in providing assessment and referral, health care needs (e.g., prescription glasses, medica- tions), first aid, and appropriate dietary adjustment; keeping client records; ensuring emergency communications; and pro- viding a safe environment (American Red Cross, 2013). The Red Cross provides training for shelter support and use of appropriate protocols and partners with other agencies such as the Medical Reserve Corps (MRC) and local public health agen- cies to accomplish this mission.
Common-sense approaches work best when dealing with the shelter community. Basic measures that can be taken by the shelter nurse include the following: listen to shelter residents tell and retell their disaster story and current situation; encour- age residents to share their feelings with one another if it seems appropriate to do so, especially those suffering from similar circumstances; help residents make decisions; delegate tasks (e.g., reading, crafts, and playing games with children) to teen- agers and others to help combat boredom; provide the basic necessities (e.g., food, clothing, rest); attempt to recover or gain needed items (e.g., prescription glasses or medication); provide basic compassion and dignity (e.g., privacy when appropriate and if possible); and refer to a mental health counselor or other sources of help as the situation warrants.
Emergency managers and shelter planners have the respon- sibility of planning to ensure that sheltering services and facili- ties are accessible to everyone. Children and adults with disabilities as well as those who have access and/or are func- tional should be integrated into general population shelters. According to FEMA (2010), the needs of the whole community should be considered in every aspect of emergency shelter plan- ning and response. To help assist these individuals, Functional Needs Support Services (FNSS) are implemented to aid indi- viduals in maintaining their independence with the general population shelter. Required FNSS include reasonable modifi- cation to policies, practices, and procedures to accommodate individuals with functional needs as well as access to durable medical equipment within the shelter environment (e.g., walkers, beds, ventilators), consumable medical supplies (e.g., ostomy supplies, dressings). All shelter residents should have access to personal assistance services and other goods and ser- vices as needed (FEMA, 2010), and arrangements to make this so must be made in advance.
523CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
Recovery Disaster recovery starts much sooner than most nurses may think. In recovery, the immediate response actions to address initial consequences subside, which could be within hours. Also, there will not be a clean break between response and recovery periods. Rather, the process is a transition. Recovery is about returning to the new normal, a community balance of infrastructure and social welfare that is near the level that it would have had if the event had not occurred (Leonard and Howitt, 2010).
The recovery phase is often the hardest part of a disaster. It involves ongoing work beyond preparedness and the response rush. Recovery is where prior community resilience has the ability to make a real difference. Although the initial disaster response phase provides an onslaught of relief aid and resources, the reality of loss and enormity of the task involved in getting back to normalcy is soon felt (see Figure 23-8). During the
From Centers for Disease Control and Prevention (CDC): Up and Running in 48 Hours: How Federal Medical Stations Help People after Natural Disasters Like Hurricane Sandy, 2012. Retrieved January 2015 from http://blogs.cdc.gov/cdcworksforyou24-7/2012/11/up-and-running-in -48-hours-how-federal-medical-stations-help-people-after-natural-disasters-like-hurricane-sandy/
LINKING CONTENT TO PRACTICE
Twenty-four hours. That is how long it took CDC’s Division of Strategic National Stockpile (DSNS) to unpack and set up a 40,000-square-foot federal medical station (FMS) in the Middlesex College gymnasium in Edison, New Jersey, capable of caring for up to 250 people displaced by Hurricane Sandy and in need of nonacute (nonemergency) medical care. Somewhere between a temporary shelter and temporary hospital, a FMS is a nonemergency medical center set up during a natural disaster to care for people with special health needs, including those with chronic health conditions (e.g., respiratory illnesses and diabetes), limited mobility, and common mental health issues. Although FMSs are typically up and running within 48 hours, their length of service is more open ended. FMSs remain operational for as long as they are needed by the state. The Middlesex College FMS opened on November 3 and discharged its last person 11 days later.
Are you ready to work in this type of environment?
About Federal Medical Stations
recovery phase for a large-scale incident, the federal govern- ment provides assistance with rebuilding property, restoring lifelines, and restoring economic institutions with the assis- tance of individuals, the private sector, and nongovernmental entities.
An incident that creates a need for a public health surge response is not a transitory event. Recovery involves a shift from short-term aid to long-term support for communities: sustain- ment of effort. Long-term support should include the disaster- affected population representation in the recovery effort, using local knowledge and skills to prioritize use of resources, person- nel, and surviving systems and infrastructure. Assisting relief organizations will integrate and build on the existing commu- nity resilience.
Role of the Public Health Nurse in Disaster Recovery The role of the public health nurse in the recovery phase of a disaster is as varied as in the preparedness and response phases,
524 PART 4 Issues and Approaches in Population-Centered Nursing
events that allow residents to interact (Chandra et al, 2011). Block associations and other local citizen-led efforts provide opportunities to develop social relationships in places that resi- dents will frequent postdisaster (e.g., schools or emergency distribution centers). Also, residents can connect with decision- makers (i.e., vertical relationship) or join a local volunteer group focused on disaster response and recovery (e.g., the Com- munity Emergency Response Team). A key to timely commu- nity recovery is in repairing or rebuilding social and community organizations, and this effort should be specifically referenced in response and recovery plans.
The Nursing Role in Psychosocial Support. Acute and chronic illnesses can become worse by the prolonged effects of disaster. The psychological stress of cleanup and/or moving can cause feelings of severe hopelessness, depression, and grief in the disillusionment phase (see Figure 23-8). Recent research, though, underscores the need for a tiered community approach where psychological disruption is viewed as normal in the immediate aftermath of the disaster, with a concurrent belief that community mental health wellness will return in time for most. In fact, leveraging primary prevention (i.e., community resilience education) and secondary prevention (e.g., use of early population-based mental health triage tools) can actually engage existing community resilience to promote population recovery (Stanley et al, 2012). Although the majority of indi- viduals will eventually recover from disasters, especially at risk are the members of high-needs populations who continue to live in chronic adversity.
Shehab and colleagues (2008) describe a community assess- ment of a Mississippi manufactured-home population con- ducted 2 years after Katrina. The researchers surveyed the displaced population for health care needs and access to care as well as identified barriers to and gaps in health care services. At the time of the study, there were about 17,800 trailers in 20 Mississippi counties. Manufactured home parks were included in the survey if they contained 10 or more trailers. There were 69 parks sampled, and homes were selected using random sam- pling methods. Data gathered included demographic data, dis- placement information, self-reported health status, types of health services needed and accessed during displacement, depression, suicidal ideation and attempts, and reproductive child health.
Key findings from the 610 respondents included the follow- ing: 80% of households had at least one adult with a chronic condition, and 58% of households had a child with a chronic condition. Sixty-two percent of respondents indicated their health was fair or poor since displacement. Fifty-seven percent of respondents were clinically depressed, 72% had depressive symptoms, 24% had suicidal ideation, and 5% had attempted suicide. Ninety-four percent noted that health care services were not available in their community, and 75% reported no access to counseling or support services since displacement (Shehab et al, 2008).
Referrals to mental health professionals should continue throughout the recovery phase and as long as the need exists. The role of the nurse in case finding and referral remains critical during this phase. In the end, it is the leveraging its resiliency
but the nurse’s connection to the community puts the nurse in an incredible position of knowledge and awareness on the inter- professional recovery team. Flexibility is key to a successful recovery operation. Nurses need awareness of the potential public health challenges specific to the disaster area and should monitor the physical and psychosocial environment. Disrup- tion of the public health infrastructure—water and food supply, sanitation system, vector control programs, and access to primary and mental health care—can lead to increased disease and community dysfunction for weeks and months after the incident.
Nursing Role in Ongoing Community Assessment. The reality of the recovery effort is that the rapid needs assessment continues into an ongoing community needs assessment. To determine effective interventions to ensure the best possible outcomes, it is essential to have ongoing accurate data about the population. Some conditions are manifest only after time elapses. A major advantage of the recovery community assess- ment efforts is that they can be more in-depth, with greater confidence in the results. Some examples of community data points in the recovery phase include the following: ongoing illness and injuries related to the disaster; diseases related to disruption of environmental or health services; health facility infrastructure in terms of adequate personnel, beds, medical and pharmaceutical supplies; and environmental health assess- ment to include water quantity and quality, sanitation, shelter, solid waste disposal, and vector populations.
A realistic perspective is most useful to the community recovery effort. It will take months or perhaps years to achieve the new sense of normalcy, which may be significantly different from the normal predisaster state. The health care system and its related resources will continue to be taxed, perhaps beyond its abilities for adequate response.
Nurses should also be aware that postdisaster cleanup creates opportunities for unintentional injury and hazards, including those occurring from falls, contact with live wires, accidents with cutting devices, heart attacks from overexertion and stress, and auto accidents resulting from road conditions and missing traffic controls (e.g., stoplights). Nurses should also educate the public of the hazards related to carbon monoxide poisoning stemming from using lanterns, gas ranges, or generators or from burning charcoal for a heat source in enclosed areas.
The Nursing Role in Community Resilience. The public health nurse understands that a resilient community is inter- connected; it has strong horizontal and vertical relationships among its residents. There is evidence that both the sense of community created by these relationships and the individual connections of those relationships help improve disaster pre- paredness and, by default, disaster recovery (Chandra et al, 2011). The recovery period demands that these relationships be reactivated as soon as possible. The public health nurse will have knowledge of the previously existing relationships, and must work with the population to find creative ways to reinstitute those ties.
After disaster, for example, it may be easier for individuals to get to know their neighbors through the promotion of hori- zontal social relationships, and local NGOs can host social
525CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
an all-hazards environment, regardless of their specialty prac- tice. As the largest national health care provider, nurses will remain leaders in disaster care.
Public health nurses are particularly critical members of the multidisciplinary disaster health team given their population- based nursing focus and specialty knowledge in epidemiology and community assessment skills. Although sophisticated tech- nology and surveillance will continue to advance in response to both human-made and natural disasters, the nature of disasters will retain the element of unpredictability. That unpredictabil- ity and the disaster medicine and public health surge require- ments make prevention and preparedness activities on the part of individuals and communities even more important. Disaster information changes rapidly because of the learning that occurs during and after each incident, producing progressive best prac- tices. Staying current in disaster training requires the public health nurse’s commitment in continuing to develop expertise related to community planning activities for disaster and every- day resilience.
Throughout this chapter, how nurses practice and provide care across the disaster cycle is aligned and applied using stan- dards of public health nursing, various sets of disaster compe- tencies for health professionals, and the Public Health Nursing Intervention Wheel. Other practice applications include discus- sion about the continuous processes of assessment, planning, implementation, evaluation, collaboration and cooperation in disaster. The role of the nurse in disaster practice and care aligns with standards of nursing practice as well as public health prac- tice. Specifically, in the disaster cycle the nurse must rapidly and continuously assess, and then plan, implement, and evaluate nursing practice while simultaneously providing interprofes- sional, population-based care.
that will help the community progress into its new normal. The public health nurse is the community and client advocate that ensures resilience is fostered in partnership with the population. The Levels of Prevention box provides examples of how nurses respond to preparation for and dealing with a disaster.
LEVELS OF PREVENTION
Primary Prevention Participate in community disaster exercises; assist in development of the disaster management plan for the agency/community; preidentify vulnerable populations.
Secondary Prevention Assess disaster survivors; conduct rapid needs assessment; use individual and population-based triage for care; provide psychological first aid.
Tertiary Prevention Ensure that community service linkages are available to individuals and fami- lies; conduct community outreach; participate in planning efforts for the com- munity’s “new normal.”
K E Y P O I N T S • The number of disasters, both human-made and natural,
continues to increase, as do the number of people affected by them.
• Professional preparedness involves personal planning as well as an understanding of the disaster plan at work and in the community.
P R A C T I C E A P P L I C A T I O N You are a nurse working in your middle school when a level 7.4 earthquake strikes with the epicenter 40 miles away. As a single parent, you have two children in grade school at a neighboring school complex, and older parents who live 10 miles out of town, toward the epicenter. The high school building is also connected to your complex.
You are not hurt and the middle school does not appear extensively damaged, but there is structural glass breakage and some visible cracks and damage. Neither cell phone nor landline phones are working. Emergency auxiliary electricity is acti- vated, but the computer system is down. A rapid damage assess- ment and visual survey within the immediate neighborhood reveals some structural damage, and 12 individuals with inju- ries have already approached your office for assistance. Two of
the clients’ injuries are serious but not life-threatening, with the remainder of the clients experiencing minor injuries and varying stress levels.
An hour passes and there is no word about damage outside of the immediate school area. School workers are very worried and concerned about their homes and family. Two staff members have already left on foot to check on their homes, which are within 3 miles of the school.
What are your priorities in this situation? List them in order and think through your position with another. Discuss the concepts of prevention and preparedness and how they relate to this disaster situation to include home, community, and workplace.
Answers can be found on the Evolve site.
FUTURE OF DISASTER MANAGEMENT Uber-disasters such as the terrorist events of September 11, 2001, Hurricane Katrina in 2005, the 2010 H1N1 pandemic and Haiti earthquake, and Japan’s 2012 earthquake, tsunami, and nuclear reactor meltdown continued to underscore the need for nursing involvement at every step of the disaster management cycle. To fully participate as a part of the interprofessional team across the disaster cycle, all nurses must continue to plan and train in
526 PART 4 Issues and Approaches in Population-Centered Nursing
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Select a vulnerable population within your community and
determine what needs the group would have in time of disas- ter. What community resources are currently available to help this group? Where is the gap in services?
2. Describe the role of the public health nurse across the disas- ter management cycle: prevention (mitigation and protec- tion), preparedness, response, and recovery. How do you practice nursing across these stages? How do you work with other members of the team?
3. Interview a nurse who has responded to a disaster. What role did the nurse play? Were his or her interventions provided at the individual, population level or both? Can you describe two specific examples?
4. Conduct an interview with a leader from the Emergency Management Agency, American Red Cross, Medical Reserve
Corps, or other agency involved with disaster management. What is your community’s plan for response to a disaster? What agencies are involved?
5. Discuss the advantages and disadvantages of serving on a disaster team in your own community. Are you a good can- didate to serve on a disaster team? What about your personal preparedness? Is there a work conflict? How (or does) this differ from day-to-day nursing practice?
6. Contact your local public health department to determine its role in a local disaster. Describe a specific nurse’s role in disaster management. How does that nurse navigate interpro- fessional practice?
7. Determine what the disaster plan is where you work. Get specific details and share them with others who are impor- tant to you.
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K E Y P O I N T S — cont’d • Healthy People 2020 objectives are linked in many ways to
the disaster management cycle, because a disaster incident affects the health of a community in many areas.
• For effectiveness in disaster prevention, preparedness, response, and recovery, nurses must get involved in their community’s disaster plan: as a community member, through their workplace, or with a partnering community organization.
• Nurses must be adequately trained and properly associated with an official response organization to best serve those affected by a disaster.
• Becoming knowledgeable about available community resources before a disaster incident will ensure a better coor- dinated response and recovery.
• Flexibility is a key attribute in providing nursing care during disaster.
• The Public Health Nursing Intervention Wheel is appropri- ate for daily operations as well as during disaster chaos.
• With any disaster it is always best to use the resources, per- sonnel, and infrastructure of the community itself to promote self-reliance and resilience.
• Our nation’s planning efforts for disaster continue to develop, test, and evaluate the goal of a unified, well-coordinated public and private national response.
• The public health nursing role in the disaster management cycle includes helping clients maintain a safe environment and advocating for environmental safety measures in the community; risk communication and client education; com-
munity assessment to include rapid needs assessment; public health triage; and surveillance and field epidemiology.
• Triage in a disaster setting involves both individual and population-based approaches, and everything possible for one individual is provided while determining how to promote the greatest good for the greatest number of those affected.
• People in a community react differently to a disaster depend- ing on the type, cause, and location of the disaster; its mag- nitude and extent of damage; its duration; and the amount of warning that was provided.
• Individual variables that cause people to react differently include their age, cultural background, health status, social support structure, and general adaptability to crisis.
• The affected community experiences four stages of stress during disaster: heroic, honeymoon, disillusionment, and reconstruction.
• The recovery phase begins almost immediately after a disas- ter occurs.
• Community organizations and social networks can foster community resiliency across the disaster cycle.
• The nurse assisting in disaster relief efforts must maintain self-health, both physically and mentally, to be of service to his or her family and clients.
• Ongoing community assessment is just as important as initial rapid needs assessment. Surveillance reports indicate the continuing status of the affected population and the effectiveness of ongoing relief efforts.
527CHAPTER 23 Public Health Nursing Practice and the Disaster Management Cycle
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Stanley S, Bulecza S, Gopalani S: Psychological impact of disasters on communities. In Couig MP, Kelley PW, editors: Annual Review of Nursing Research: Disasters and Humanitarian Assistance. New York, 2012, Springer Publishing.
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24 Public Health Surveillance
and Outbreak Investigation
Marcia Stanhope, PhD, RN, FAAN Dr. Marcia Stanhope is currently an Associate of the Tufts and Associates Search Firm, Chicago, Ill. She is also a consultant for the nursing program at Berea College, Kentucky. She has practiced community and home health nursing, has served as an administrator and consultant in home health, and has been involved in the development of two nurse-managed centers. At one time in her career, she held a public policy fel- lowship and worked in the office of a U.S. Senator. She has taught community health, public health, epide- miology, policy, primary care nursing, and administration courses. Dr. Stanhope formerly directed the Division of Community Health Nursing and Administration and served as Associate Dean of the College of Nursing at the University of Kentucky. She has been responsible for both undergraduate and graduate courses in population-centered nursing. She has also taught at the University of Virginia and the University of Alabama, Birmingham. During her career at the University of Kentucky she appointed to the Good Samaritan Founda- tion Chair and Professorship in Community Health Nursing, and was honored with the University Provost’s Public Scholar award. Her presentations and publications have been in the areas of home health, community health and community-focused nursing practice, as well as primary care nursing.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Define public health surveillance. 2. Analyze types of surveillance systems. 3. Identify steps in planning, analyzing, interviewing, and
evaluating surveillance.
4. Recognize sources of data used when investigating a disease/condition outbreak.
5. Relate the role of the nurse in surveillance and outbreak investigation to the national core competencies for public health nurses.
K E Y T E R M S algorithms, p. 532 biological terrorism, p. 531 BioNet, p. 537 case definition, p. 533 chemical terrorism, p. 531 clusters of illness, p. 530 common source, p. 538 disease surveillance, p. 530 endemic, p. 538 Enhanced Surveillance Project, p. 537 epidemic, p. 538
event, p. 531 holoendemic, p. 538 hyperendemic, p. 538 infectivity, p. 538 intermittent or continuous source, p. 538 Laboratory Response Network, p. 537 mixed outbreak, p. 538 National Notifiable Disease Surveillance System, p. 536 outbreak, p. 538 outbreak detection, p. 538 outcome data, p. 531
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks—Of special note, see the link for these sites:
• National Notifiable Disease Surveillance System • Enhanced Surveillance Project
• Quiz • Case Studies
• Glossary • Answers to Practice Application • Appendix D.3: Prevention and Control of Pandemic
Influenza: Individuals and Families
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Disease surveillance has been a part of public health protection since the 1200s, during the investigations of the bubonic plague in Europe. During the 1600s John Graunt developed the fun- damental principles of public health including surveillance and outbreak investigation, and in the 1700s Rhode Island passed the first public health laws to provide for the protection of health and care of the population of the state. In the eighteenth century, William Farr introduced the modern version of sur- veillance and, along with the United States, Italy, and Great Britain, began required reporting systems for infectious dis- eases. In 1901, the United States began the requirement for reporting cases of cholera, smallpox, and tuberculosis. By 1925 the United States began national reporting of morbidity causes. By 1935 the first national health survey had been conducted, and in 1949 the National Office of Vital Statistics published weekly mortality and morbidity statistics in the journal Public Health Reports. This activity was later transferred to the Centers for Disease Control and Prevention, who began publishing the Morbidity and Mortality Weekly Report in 1961. Laws, regula- tions, reporting mechanisms, and data collections are all essen- tial to surveillance and disease outbreak investigations (Thacker et al, 2012).
The Constitution of the United States provides for “police powers” necessary to preserve health safety as well as in other events (see Chapter 8). These powers include public health surveillance. State and local “police powers” also provide for surveillance activities. Health departments usually have legal
C H A P T E R O U T L I N E Disease Surveillance
Definitions and Importance Uses of Public Health Surveillance Purposes of Surveillance Collaboration among Partners Nurse Competencies Data Sources for Surveillance
Notifiable Diseases National Notifiable Diseases State Notifiable Diseases
Case Definitions Criteria Case Definition Examples
Types of Surveillance Systems Passive System Active System Sentinel System Special Systems
The Investigation Investigation Objectives Patterns of Occurrence When to Investigate Steps in an Investigation Displaying of Data
K E Y T E R M S — cont’d pandemic, p. 538 pathogenicity, p. 538 point source, p. 538 process data, p. 531 propagated outbreak, p. 538 public health protection, p. 530 PulseNet, p. 537
person under investigation, p. 536 sentinel, p. 534 sporadic, p. 538 syndromic surveillance systems, p. 537 virulence, p. 538 —See Glossary for definitions
authority to investigate unusual clusters of illness as well (Gostin, 2010).
Florence Nightingale first demonstrated the nurse’s role in responding to disasters. Public health nurses bring specific skills to events that require emergency responses. They are prepared to focus on the population that is affected in order to develop policies and comprehensive plans for conducting and evaluat- ing disaster response drills, exercises, and trainings. Public health nurses are first responders in emergency situations in the community, they can lead and manage in the field and in the incident command center, and they are able to collaborate with others to sustain the emergency infrastructure (Association of Public Health Nurses [APHN], 2013). It is important for nurses to be prepared to lead and be a team member if an unusual occurrence or event strikes a community (see Chapters 3 and 46 about the public health response to the Ebola virus outbreak in the United States in 2014).
DISEASE SURVEILLANCE Definitions and Importance Disease surveillance is the ongoing systematic collection, anal- ysis, interpretation and dissemination of specific health data for use in public health (Lee et al, 2010; Webster’s New World Medical Dictionary, 2014). Surveillance provides a means for nurses to monitor disease trends in order to reduce morbidity and mortality and to improve health (Veenema, 2013).
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Chemical terrorism is the intentional release of hazardous chemicals into the environment for the purpose of harming or killing (CDC, 2013a). In the event of a bioterrorist attack, imagine how difficult it would be to control the spread of bio- logical agents such as botulism or anthrax or chemical agents such as sarin or ricin if no data were available about these agents, their resulting diseases or symptoms, and their usual incidence (new cases) patterns (new cases) in the community. The United States spent approximately $60 billion by 2012 to assist states in preparing for bioterrorist incidents. Roughly one half of that money has funded detection systems; dramati- cally expanded research on bioweapon agents; and the develop- ment, procurement, and stockpiling of vaccines and other medical countermeasures against these agents.
Uses of Public Health Surveillance Public health surveillance can be used to facilitate the following (CDC, 2010a): • Estimate the magnitude of a problem (disease or event) • Determine geographic distribution of an illness or
symptoms • Portray the natural history of a disease • Detect epidemics; define a problem • Generate hypotheses; stimulate research • Evaluate control measures • Monitor changes in infectious agents • Detect changes in health practices • Facilitate planning (Koo 2010)
Purposes of Surveillance The overall purposes of surveillance are as follows: • Assess public health status • Define public health priorities • Evaluate programs • Stimulate research
Surveillance helps public health departments identify trends and unusual disease patterns, set priorities for using scarce resources, and develop and evaluate programs for commonly occurring and universally occurring diseases or events. Surveil- lance activities can be related to the core functions of public health: assessment, policy development, and assurance. Disease surveillance helps establish baseline (endemic) rates of disease occurrence and patterns of spread. Surveillance makes it pos- sible to initiate a rapid response to an outbreak of a disease or event that can cause a health problem. For example, surveillance made it possible to respond quickly to the anthrax outbreak that occurred shortly after the September 11, 2001, attack on the World Trade Centers. Surveillance also made it possible to respond early to the H1N1 outbreak that initially began in Mexico in 2009 (CDC, 2012).
Surveillance data are analyzed, and interpretations of these data analyses are used to develop policies that better protect the public from problems such as emerging infections, bioterrorist biological and chemical threats, and injuries from problems such as motor vehicle accidents. In 2006 a great deal of empha- sis was placed on developing disaster management policies in health care organizations, industries, and homes so that the U.S.
Surveillance is a critical role function for nurses practicing in the community. A comprehensive understanding and knowl- edge of the surveillance systems and how they work will help nurses improve the quality and the usefulness of the data collected for making decisions about needed community ser- vices, community actions, and public health programming (Chapter 23 provides additional information). The surveillance features indicate it: • Is organized and planned • Is the principal means by which a population’s health status
is assessed • Involves ongoing collection of specific data • Involves analyzing data on a regular basis • Requires sharing the results with others • Requires broad and repeated contact with the public about
personal health issues • Motivates public health action as a result of data analyses to:
• Reduce morbidity • Reduce mortality • Improve health Surveillance is important because it generates knowledge
of a disease or event outbreak patterns (including timing, geographic distribution, and susceptible populations). The knowledge can be used to intervene to reduce risk or prevent an occurrence at the most appropriate points in time and in the most effective ways. Surveillance is built on understanding of epidemiologic principles of agent, host, and environmental relationships and on the natural history of disease or condi- tions (see Chapter 12). Surveillance systems make it possible to engage in effective continuous quality improvement activi- ties within organizations and to improve quality of care (Veenema, 2013).
Surveillance focuses on the collection of process and outcome data. Process data focus on what is done (i.e., services provided or protocols for health care delivery). Outcome data focus on changes in health status. The activities generated by analyses of these data aim to improve public health response systems. An example of process data is collection of data about the propor- tion of the eligible population vaccinated against influenza in any one year. Outcome data in this case are the incidence rates (new cases) of influenza among the same population in the same year.
Although surveillance was initially devoted to monitoring and reducing the spread of infectious diseases, it is now used to monitor and reduce chronic diseases and injuries, and environ- mental and occupational exposures (Centers for Disease Control and Prevention [CDC], 2014e; Veenema, 2013) as well as per- sonal health behaviors. Surveillance systems help nurses and other professionals monitor emerging infections and bioterror- ist outbreaks (Pryor and Milligan, 2013). Bioterrorism is one example of an event creating a critical public health concern that involves environmental exposures that must be monitored. This event also requires serious planning in order to be able to respond quickly and effectively. Biological terrorism is defined as “the deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death in people, animals, or plants” (http://www.bt.cdc.gov/bioterrorism) (CDC, 2014a).
532 PART 4 Issues and Approaches in Population-Centered Nursing
• Whom to contact • How and to whom information is to be disseminated • Who is responsible for appropriate action
Nurses are often in the forefront of responses to be made in the surveillance process whether working in a small rural agency or a large urban agency; within the health department, school, or urgent care center; or on the telephone performing triage services during a disaster. It is the nurse who sees the event first (APHN, 2013).
population could be prepared in the event of an emergency. Surveillance within individual organizations, such as infection control systems in hospitals, can be used to establish policies related to clinical practice that are designed to improve quality of care processes and outcomes. An example is documented by Ergaz and colleagues (2010), where a policy of weekly fecal cultures for vancomycin-resistant enterococci (VRE) was insti- tuted after the investigation of an outbreak of VRE in the neo- natal intensive care unit.
Surveillance makes it possible to have ongoing monitoring in place to ensure that disease and event patterns improve rather than deteriorate. They can also make it possible to study whether the clinical protocols and public health policies that are in place can be enhanced, based on current science, so that disease rates actually decline (World Health Organization [WHO], 2014a). For example, the ongoing monitoring of obesity in children in a community may show that new clinical and effec- tive protocols need to be developed to be used in school-based clinics to reduce the prevalence of obesity among the school populations.
Surveillance data are very helpful in determining whether a program is effective. Such data make it possible to determine whether public health interventions are effective in reducing the spread of disease or the incidence of injuries. By determining the change in the number of cases at the beginning of a program (baseline) with the number of cases after program implementa- tion, it is possible to estimate the effectiveness of a program. One could then compare the effectiveness of different approaches to reducing the problem or to improving health. Johns and col- leagues (2010) investigated whether prior seasonal influenza vaccination was effective against the pandemic strain of H1N1 (pH1N1) virus among military personnel. Their findings indi- cated that with the seasonal influenza vaccines of 2004 to 2009, moderate protection against H1N1 was associated with the vac- cines of these years. The protection seemed to have a greater association with severe disease rather than a mild case regard- less of age of the ill person.
Collaboration among Partners A quality surveillance system requires collaboration among a number of agencies and individuals: federal agencies, state and local public health agencies, hospitals, health care providers, medical examiners, veterinarians, agriculture, pharmaceutical agencies, emergency management, and law enforcement agen- cies, as well as 911 systems, ambulance services, urgent care and emergency departments, poison control centers, nurse hotlines, schools, and industry. Such collaboration promotes the devel- opment of a comprehensive plan and a directory of emergency responses and contacts for effective communication and infor- mation sharing. It is sometimes essential to include collabora- tion with international agencies as well. The type of information to be shared includes the following: • How to use algorithms to identify which events should be
investigated (i.e., this means using a precise step-by-step plan outlining a procedure that in a finite number of steps helps to identify the appropriate event)
• How to investigate
From Sherman RL, Henry KA, Tannenbaum SL, et al: Applying spatial analysis tools in public health: an example using SaTScan to detect geographic targets for colorectal cancer screening interventions. Prev Chronic Dis 11:130264, 2014. DOI: http://dx.doi.org/10.5888/ pcd11.130264.
An analysis was conducted to identify uses of spatial analysis in cancer screening interventions. Researchers used a spatial analysis tool called cluster detection to identify geographic areas with populations at high risk for colorectal cancer. Specifically, the investigators used the free cluster detec- tion software application SaTScan to map the at-risk population. The research- ers sought to identify which spatial analysis method was most successful in identifying at-risk populations. Various methods were used to detect areas in Florida where the population was at high risk. Although no single method emerged as being able to detect all significant clusters, all methods did detect one area as high risk. This area could be seen as a priority area to implement a screening intervention to improve early identification of disease and early treatment.
Nurse Use Cluster detection is a surveillance tool that public health nurses can use to determine geographic priority areas for health promotion and disease preven- tion interventions. Being able to focus on a specific area would enable the nurse to use public health resources in an efficient manner and provide out- reach to the populations at highest risk for disease.
EVIDENCE-BASED PRACTICE
Nurse Competencies The national core competencies for public health nurses were developed from the Core Competencies for Public Health Pro- fessionals (Council on Linkages between Academia and Public Health Practice, 2014) and by the Quad Council of Public Health Nursing Organizations (2011). These competencies are divided into eight practice domains: analytical assessment skills, policy development/program planning, communication, cul- tural competency, community dimensions of practice, basic public health sciences, financial planning/management, and leadership and systems thinking.
To be a participant in surveillance and investigation activi- ties, the staff nurse must have the following knowledge related to the core competencies: 1. Analytical assessment skills
• Defining the problem • Determining a cause • Identifying relevant data and information sources • Partnering with others to give meaning to the data
collected • Identifying risks
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records (Pryor and Milligan, 2013). The following are select sources of mortality and morbidity data: 1. Mortality data are often the only source of health-related
data available for small geographic areas. Examples include the following: • Vital statistics reports (e.g., death certificates, medical
examiner reports, birth certificates) • Mortality data can be obtained from the National Vital
Statistics System. These data are available and one of the few sources of health-related data that are available for a long time period for small geographic areas (CDC, 2014g)
2. Morbidity data include the following: • Notifiable disease reports • Laboratory reports • Hospital discharge reports • Billing data • Outpatient health care data • Specialized disease registries • Injury surveillance systems • Environmental surveys • Sentinel surveillance systems A good example of a process in place to collect morbidity
data is the National Program of Cancer Registries (CDC, 2014f ). This program provides for monitoring of the types of cancers found in a state and the locations of the cancer risks and health problems in the state.
Each of the data sources has the potential for underreporting or incomplete reporting. However, if there is consistency in the use of surveillance methods, the data collected will show trends in events or disease patterns that may indicate a change needed in a program or a needed prevention intervention to reduce morbidity or mortality. Underreporting or incomplete report- ing may occur for the following reasons: social stigma attached to a disease (such as human immunodeficiency virus [HIV]/ acquired immunodeficiency syndrome [AIDS]); ignorance of required reporting system; lack of knowledge about the case definition, procedural changes in reporting, or changes in a database; limited diagnostic abilities; or low priority given to reporting (CDC, 2010a).
Mortality data assist in identifying differences in health status among groups, populations, occupations, and communi- ties, and in monitoring preventable deaths; they also help in examining cause-and-effect factors in diseases (CDC, 2014g). Vital statistics can be used to plan programs and to monitor
2. Communication • Providing effective oral and written reports • Soliciting input from others and effectively presenting
accurate demographic, statistical, and scientific informa- tion to other professionals and the community at large
3. Community dimensions of practice • Establishing and maintaining links during the investigation • Collaborating with partners • Developing, implementing, and evaluating an assessment
to define the problem 4. Basic public health science skills
• Identifying individual and organizational responsibilities • Identifying and retrieving current relevant scientific
evidence 5. Leadership and systems thinking
• Identifying internal and external issues that have an effect on the investigation
• Promoting team and organizational efforts • Contributing to developing, implementing, and monitor-
ing of the investigation While the staff nurse participates in these activities, the nurse
clinical specialist should be proficient in applying these compe- tencies. In addition, the nurse applies the nursing process in preparedness as illustrated in Table 24-1.
The Minnesota Model of Public Health Interventions: Appli- cations for Public Health Nursing Practice (2001, pp. 15-16; also see Chapters 9 and 23) suggests that surveillance is one of the interventions related to public health nursing practice. The model gives seven basic steps of surveillance for nurses to follow: 1. Consider whether surveillance as an intervention is appro-
priate for the situation. 2. Organize the knowledge of the problem, its natural course
of history, and its aftermath. 3. Establish clear criteria for what constitutes a case. 4. Collect sufficient data from multiple valid sources. 5. Analyze data. 6. Interpret data and disseminate to decision-makers. 7. Evaluate the impact of the surveillance system.
Data Sources for Surveillance Clinicians, health care agencies, and laboratories report cases to state health departments. Data also come from death certificates and administrative data such as discharge reports and billing
DEFINITION OF:
Preparedness Assessment Planning Implementation Evaluation
Assure capacity to respond effectively to disasters and emergencies
Assess the populations at risk for special needs during a disaster
Develop plans to care for special needs populations during a disaster
Conduct training, drills, and exercises related to care of special needs persons
Evaluate plans for serving populations with special needs
TABLE 24-1 Phases of Nursing Process Linked to Preparedness
Excerpted from Association of Public Health Nurses (APHN): The Role of Public Health Nurses in Emergency Preparedness and Response: Position Paper [Table 1: The Phases of Disaster Linked to the Nursing Process], 2013. Retrieved January 2015 from https://www.resourcenter .net/images/ACHNE/Files/APHNRoleofPHNinDisasterPRR_30May13.pdf
534 PART 4 Issues and Approaches in Population-Centered Nursing
programs to meet Healthy People 2020 goals (see the Healthy People 2020 box for objectives related to surveillance).
The National Notifiable Disease Laboratory (NNDSS) as well as local public health laboratories, hospital discharge data, and billing data provide mechanisms for classifying diseases and events and calculating rates of diseases within and across groups, populations, and communities (CDC, 2013).
The sentinel surveillance system provides for the monitor- ing of key health events when information is not otherwise available for vulnerable populations in order to calculate or estimate disease morbidity. Registrations monitor chronic disease in a systematic manner, linking information from a variety of sources (health department, clinics, hospitals) to identify disease control and prevention strategies. Surveys then provide data from individuals about prevalence of health condi- tions and health risks. Such surveys allow for monitoring changes over time and assessing the individual’s knowledge, attitudes, and beliefs (see QSEN box). This information can be used for health education and other planned interventions (Gostin, 2010).
NOTIFIABLE DISEASES Before 1990 state and local health departments used many dif- ferent criteria for identifying cases of reportable diseases. Using different criteria made the data less useful than it could have been because it could not be compared across health depart- ments or states. For this reason some diseases may have been under-reported and others may have been over-reported. In 1990 the CDC and the Council of State and Territorial Epide- miologists assembled the first list of standard case definitions. This list was revised in 1997, and more information may be
HEALTHY PEOPLE 2020
• EH-5: Reduce waterborne disease outbreaks arising from water intended for drinking among persons served by community water systems.
• FS-1: Reduce outbreaks of infections caused by key foodborne bacteria. • FS-2: Reduce infections associated with foodborne outbreaks due to patho-
gens commonly transmitted through food. • GH-1: Reduce the number of cases of malaria reported in the United
States. • IID-16: (Developmental) Increase the scientific knowledge on vaccine
safety and adverse events. • PHI-2: Increase the proportion of tribal, state, and local public health
agencies that incorporate core competencies for public health profession- als into the job.
• PHI-7: Increase the proportion of population-based Healthy People 2020 objectives for which national data are available for all population groups identified for the objective.
Surveillance Objectives
From USDHHS Healthy People 2020: A Roadmap to improve all Americans’ health. Wash, DC, 2010 US Govt Printing Office
found at the CDC Division of Public Health Surveillance and Informatics website (CDC, 1997). This site contains informa- tion about the National Notifiable Disease Surveillance System (CDC-NNDSS, 2013), and the standard case definitions are updated on a case-by-case basis or otherwise remain the same. For example, the definition of anthrax was updated in 2010. New case definitions are added as new diseases are identified.
National Notifiable Diseases Box 24-1 shows the national notifiable infectious diseases. Reporting of disease data by health care providers, laboratories, and public health workers to state and local health departments is essential if trends are to be accurately monitored. “The data provide the basis for detecting disease outbreaks, for identifying person characteristics, and for calculating incidence, geographic distribution, and temporal trends. They are used to initiate prevention programs, evaluate established prevention and control practices, suggest new intervention strategies, identify areas for research, document the need for disease control funds, and help answer questions from the community” (CDC, 2014b). The CDC and the Council of State and Territo- rial Epidemiologists have a policy that requires state health departments to report selected diseases to the CDC-NNDSS. The data for nationally notifiable diseases from 50 states, the U.S. territories, New York City, and the District of Columbia are published weekly in the Morbidity and Mortality Weekly Report (MMWR). Data collection about these diseases is ongoing and revision of statistics is ongoing. Annual updated final reports are published in the CDC Summary of Notifiable Diseases— United States (CDC, 2014b).
State Notifiable Diseases Requirements for reporting diseases are mandated by law or regulation. Although each state differs in the list of reportable diseases, the usefulness of the data depends on “uniformity,
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Safety Minimizes risk for harm to clients and providers through both system effective- ness and individual performance. • Knowledge: Discuss potential and actual impact of national client safety
resources, initiatives, and regulations. • Skill: Use national resources for own development and to focus attention
on safety in the community. • Attitude: Value relationships between national safety campaigns and
implementation in locales, times and settings.
Safety Question The Quad Council competency for communication skills indicates that the public health nurse uses a variety of methods to disseminate public health information to populations within a community and provides a presentation of targeted health information to multiple audiences at a local level: groups, professionals, and agency peers.
How would the nurse use the national sentinel surveillance system to identify health conditions and risks in the community? What types of data sources in this system would the nurse collect? After careful analysis of the data sources, what would the nurse include in a presentation to multiple audiences?
535CHAPTER 24 Public Health Surveillance and Outbreak Investigation
• Anthrax • Arboviral diseases, neuroinvasive and non-neuroinvasive • Babesiosis • Botulism • Chancroid • Chlamydia trachomatis infection • Cholera • Coccidioidomycosis • Congenital syphilis • Cryptosporidiosis • Cyclosporiasis • Dengue virus infections • Diphtheria • Ehrlichiosis and anaplasmosis • Giardiasis • Gonorrhea • Haemophilus influenzae, invasive disease • Hansen’s disease • Hantavirus pulmonary syndrome • Hemolytic uremic syndrome, postdiarrheal • Hepatitis A, acute • Hepatitis B, acute • Hepatitis B, chronic • Hepatitis B, perinatal infection • Hepatitis C, acute • Hepatitis C, past or present • HIV infection (AIDS has been reclassified as HIV stage III) • Influenza-associated pediatric mortality • Invasive pneumococcal disease • Legionellosis • Leptospirosis • Listeriosis • Lyme disease • Malaria • Measles
• Meningococcal disease • Mumps • Novel influenza A virus infections • Pertussis • Plague • Poliomyelitis, paralytic • Poliovirus infection, nonparalytic • Psittacosis • Q fever • Rabies, animal • Rabies, human • Rubella • Rubella, congenital syndrome • Salmonellosis • Severe acute respiratory syndrome–associated coronavirus disease • Shiga toxin–producing Escherichia coli • Shigellosis • Smallpox • Spotted fever rickettsiosis • Streptococcal toxic-shock syndrome • Syphilis • Tetanus • Toxic shock syndrome (other than streptococcal) • Trichinellosis • Tuberculosis • Tularemia • Typhoid fever • Vancomycin-intermediate Staphylococcus aureus and vancomycin-resistant
Staphylococcus aureus • Varicella • Varicella deaths • Vibriosis • Viral hemorrhagic fever • Yellow fever
BOX 24-1 Infectious Diseases Designated as Notifiable at the National Level during 2014*
From Centers for Disease Control and Prevention (CDC): Summary of notifiable diseases in the United States, 2014. Retrieved January 2015 from www.CDC.gov
simplicity, and timeliness.” Because state requirements differ, not all nationally notifiable diseases are legally mandated for reporting in a state. For legally reportable diseases, states compile disease incidence data (new cases) and transmit the data electronically (weekly) to the CDC through the National Electronic Telecommunications System for Surveillance (CDC- NETSS, 2013) (www.cdc.gov/surveillance).
Ongoing analysis of this extensive database has led to better diagnosis and treatment methods, national vaccine schedule recommendations, changes in vaccine formulation, and the rec- ognition of new or resurgent diseases (CDC-NETSS, 2013d). Selected data are also reported in documents such as Epidemio- logic Notes and Reports located weekly in the CDC MMWR report (www.CDC.gov). Adverse health data for the calendar year are documented on the reportable disease form, entitled EPID, to the local health department or the state department for public health. Local health department surveillance person- nel investigate case reports and proceed with recommended
public health measures, requesting assistance from the state’s department assigned to monitor the reports when needed. Reports are forwarded by mail or fax or, in urgent circum- stances, by telephone 24 hours a day, 7 days a week. When reports are received, they are scrutinized carefully and, when appropriate, additional steps are initiated to assist local health departments in planning interventions.
To determine which of the national notifiable diseases are reportable in your state, go to your state health department website.
CASE DEFINITIONS Criteria Criteria for defining cases of different diseases are essential for having a uniform, standardized method of reporting and moni- toring diseases. A case definition provides understanding of the data that are being collected and reduces the likelihood that
536 PART 4 Issues and Approaches in Population-Centered Nursing
respiratory syndrome coronavirus (MERS-CoV) infections. The case definition of a person under investigation (PUI) includes “fever and pneumonia or acute respiratory distress syndrome and either (1) a history of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset, or (2) close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula, or (3) a member of a cluster of persons with severe acute respiratory illness of unknown etiol- ogy in which MERS-CoV is being evaluated” (CDC, 2014c). This case definition relies on clinical presentation of the patient, clinical judgment of the provider, and the geographic location (epidemiologic place) of the person to confirm possible expo- sure to the disease.
TYPES OF SURVEILLANCE SYSTEMS Informatics is essential to the mission of protecting the public’s health. Surveillance systems are designed to assist public health professionals in the early detection of disease/event outbreaks in order to intervene and reduce the potential for morbidity or mortality, or to improve the public’s health status (CDC, 2012; Koo, 2010). Surveillance systems in use today are defined as passive, active, sentinel, and special.
Passive System In the passive system, case reports are sent to local health departments by health care providers (e.g., physicians, public health nurses), or laboratory reports of disease occurrence are sent to the local health department. The case reports are sum- marized and forwarded to the state health department, national government, or organizations responsible for monitoring the problem, such as the CDC or an international organization such as the World Health Organization (WHO).
The National Notifiable Disease Surveillance System (NNDSS) is a voluntary system monitored by the CDC and includes a total of 68 infectious diseases or conditions with case definitions that are considered important to the public’s health. In the list of 68 reportable conditions, 10 critical biological agents have potential use in a terrorist attack (CDC, 2014b). Each state determines for itself which of the diseases and conditions are of importance to the state’s health and legally requires the reporting of those diseases to the state health department by health care providers, health care agencies, and laboratories. The passive system may not provide an accurate picture of the problem because of delayed reporting by provid- ers and laboratories and incomplete reporting across providers and laboratories. This system, however, has the ability to provide disease-specific demographic, geographic, and seasonal trends over time for reported events. An example is a cancer registry system in which cases are required to be reported to the state on the basis of the type of cancer, the demographics of the client, and the geographic location. Because the system has limits, a disease outbreak may be occurring before all reports are received by the state health department (Veenema, 2013; CDC-NNDSS, 2013c).
different criteria will be used for reporting similar cases of a disease. Case definitions may include clinical symptoms, labo- ratory values, and epidemiologic criteria (e.g., exposure to a known or suspected case). Each disease has its own unique set of criteria based on what is known scientifically about that particular disease. Cases may be classified as suspected, probable, or confirmed, depending on the strength of the evidence sup- porting the case criteria.
Although some diseases require laboratory confirmation, even though clinical symptoms may be present, other diseases do not have laboratory tests to confirm the diagnosis. Other cases are diagnosed on the basis of epidemiologic data alone, such as exposure to contaminated food. If a case definition has been established by the CDC or another official source, it should be used for reporting purposes. The case definition should not be used as the only criterion for clinical diagnosis, quality assur- ance, standards for reimbursement, or taking public health action. Action to control a disease should be taken as soon as a problem is identified, although there may not be enough infor- mation to meet the case definition. For example, following the September 11, 2001, terrorist attacks and subsequent crises, when white powder substances were found in the offices of Congress and select post offices, the offices were shut down and evacuated for safety until the final determination of the pres- ence or absence of anthrax (Wright et al, 2010).
Case Definition Examples Many examples of case definitions exist in the literature and in government documents. The case definition for a confirmed case of anthrax was given by the CDC (2010b) as “(1) a clini- cally compatible case of cutaneous, inhalational, or gastrointes- tinal illness that is laboratory confirmed by isolation of B. anthracis from an affected tissue or site, or (2) other laboratory evidence of B. anthracis infection based on at least two sup- portive laboratory tests.” A suspected case was defined as “an illness suggestive of one of the known anthrax clinical forms. No definitive, presumptive, or suggestive laboratory evidence of B. anthracis, or epidemiologic evidence relating it to anthrax” (http://www.cdc.gov).
Kuo and colleagues (2009) reported on the first Shigella sonnei outbreak in Austria in July 2008. They provided case definitions for confirmed cases as follows: a cluster of 22 laboratory-confirmed cases of infection with S. sonnei, which was restricted to public health district X in the province of Salzburg. All cases had attended a youth group trip to a small village in the province of Tyrol from July 7 to July 9. An out- break case among the trip participants was a person who (1) attended the trip, and (2) fell ill with diarrhea in the period between July 8 and July 12. Among the 61 trip participants, 42 fit the outbreak case definition, including 31 culture-confirmed cases. A household outbreak case was a person who (1) did not participate in the trip, (2) fell ill with diarrhea not before July 10, and (3) had household contact with an outbreak case between 1 and 3 days before the onset of illness.
Although at this time there are limited data on the clinical presentation, the CDC (2014c) encourages health care provid- ers to be familiar with the case definitions for Middle East
537CHAPTER 24 Public Health Surveillance and Outbreak Investigation
Laboratories, and federal food regulatory agencies to “finger- print” foodborne bacteria. This system is designed to provide data for early recognition and investigation of foodborne out- breaks in all 50 states. Similarly, BioNet is a system developed by the PulseNet Partners and the Laboratory Response Network (LRN) to detect and determine links between disease agents during terrorist attacks. As a result of bioterrorism, newer systems called syndromic surveillance systems are being devel- oped to monitor illness syndromes or events. For example, data showing increased medication purchases, physician or emer- gency department visits, or culture orders as well as increased school or work absenteeism may indicate that an epidemic is developing hours or days before disease clusters are recognized or specific diagnoses are made and reported to public health agencies (Goodman et al, 2012). This approach requires the use of automated data systems to report continued (real time) or daily (near real time) disease outbreaks (Tokars et al, 2010) (Box 24-2).
Another example of a special system designed to help assess unusual patterns of diseases or conditions is the CDC’s Enhanced Surveillance Project (CDC, 2013c). The ESP moni- tors emergency department data to detect unusual patterns (or aberrations) so that quick epidemiologic case confirmation and follow-up can be initiated. More information on this system can be found at the WebLinks website. Although useful, these systems are designed to be used for disease case detection, case management, and outbreak management; they require good timing. False alarms occur. The systems provide national data to detect, diagnose, and handle disease and the effects of bio- logical and chemical agents resulting from bioterrorism. The systems are intended to be used with more traditional systems. In epidemics or terrorist attacks, there is a network of links for foodborne (PulseNet), chemical (LRN), and biological genetic patterns of disease (BioNet). New systems are being developed and tested to predict epidemics, as in bioterrorism, before they have occurred (CDC, 2013c; Veenema, 2013). The new syn- dromic systems may also predict naturally occurring epidemics
Active System In the active system, the public health nurse, as an employee of the health department, may begin a search for cases through contacts with local health providers and health care agencies. In this system, the nurse names the disease/event and gathers data about existing cases to try to determine the magnitude of the problem (how widespread it is).
A recent example would be a search for existing cases of severe acute respiratory syndrome (SARS) within a geographic area or a foodborne outbreak of gastroenteritis, or H1N1 at the local school. An ongoing tracking system within an occupa- tional setting to monitor work-related injuries/illnesses and symptoms is a process that includes occupational health and infection control personnel in interviewing workers, collecting laboratory data and demographics of workers, and seeking potential agents of exposure (Utterback and Schnorr, 2010). The active system is costly and requires numerous personnel. Because the nurse is actively looking for a case, this system offers a more complete picture of the number of existing cases. Because of limits, the active system is often used on a limited basis for investigation after a disease outbreak has been recog- nized (Gordis, 2008; Veenema, 2013).
Sentinel System In the sentinel system, trends in commonly occurring diseases or key health indicators are monitored (Healthy People 2020 [U.S. Department of Health and Human Services (USDHHS), 2010]; WHO, 2014a). A disease/event may be the sentinel, or a population may be the sentinel. In this system a sample of health providers or agencies is asked to report the problem. Some of the questions that may be asked include the following: What really happened? What are the consequences? What was different in this event? What was the outcome? Could the occur- rence have been prevented? Did providers follow procedures? Did providers know what to do? Has this happened before? If so, how was it fixed? Who reported the event? What might prevent it from happening again? (WHO, 2014b).
For example, certain providers/agencies in a community may be asked to report the number of cases of influenza seen during a given time period in order to make projections about the severity of the “flu season.” Another example would be monitoring the population of children in the local elementary school to determine the rate of obesity among school-age chil- dren. Although much may be learned about diseases and condi- tions using the sentinel system, because the system data are based on a sample of a problem or a specific population, they cannot be used to monitor specific clients, or to initiate preven- tion and control interventions for individuals. The system is useful because it helps monitor trends in commonly occurring diseases/events.
Special Systems Special systems are developed for collecting particular types of data and may be a combination of active, passive, and/or sen- tinel systems. An example of a special system is the PulseNet system developed by the CDC, the Association of Public Health
Integrating of training and response preparedness can be supported by the following networks: • Health Alert Network • Emergency Preparedness Information Exchange (EPIX) • Emerging Infections program • Epidemiology and Laboratory Capacity program • Assessment initiatives • Hazardous substances • Emergency events surveillance • Influenza surveillance • Local metropolitan medical response systems
BOX 24-2 Bioterrorism and Response Networks
From Koo D: Overview of Public Health Surveillance, 2010, Epidemiology Program Office, Centers for Disease Control and Prevention. Available at http://www.cdc.govncphidisssnndssphs overview.htm. Accessed September 27, 2010.
538 PART 4 Issues and Approaches in Population-Centered Nursing
influenza outbreak). Outbreak detection, or identifying an increase in frequency of disease above the usual occurrence of the disease, is the function of the investigator (Tokars et al, 2010).
Patterns of Occurrence Patterns of occurrence can be identified when investigating a disease or event. These patterns are used to define the boundar- ies of a problem to help investigate possible causes or sources of the problem. A common source outbreak refers to a group exposed to a common noxious influence such as the release of noxious gases (e.g., ricin in the Japanese subway system several years ago and in a water system in the United States) (Sobel and Watson, 2009). A point source outbreak involves all persons exposed becoming ill at the same time, during one incubation period. A mixed outbreak (which was described by Kuo and colleagues [2009] while investigating a foodborne gastroenteri- tis caused by a Shigella sonnei virus) is a common source fol- lowed by secondary exposures related to person-to-person contact, as in the spreading of influenza. Intermittent or con- tinuous source cases may be exposed over a period of days or weeks, as in the recent food poisonings at restaurants through- out the United States as a result of the purchase of contaminated sprouts. A propagated outbreak does not have a common source and spreads gradually from person to person over more than one incubation period, such as the spread of tuberculosis from one person to another.
Causal Factors from Epidemiologic Triangle Factors that must be considered as causes of outbreak are cat- egorized as agents, hosts, and environmental factors (see Chapter 12). The belief is that these factors may interact to cause the outbreak and therefore the potential interactions must be examined. The following presents definitions used to classify agents in an attack: • Infectivity: Refers to the capacity of an agent to enter a
susceptible host and produce infection or disease • Pathogenicity: Measures the proportion of infected people
who develop the disease • Virulence: Refers to the proportion of people with clinical
disease who become severely ill or die Box 24-3 lists the types of agent factors that may be present.
The host factors associated with cases may be age, sex, race, socioeconomic status, genetics, and lifestyle choices (e.g., ciga- rette smoking, sexual practices, contraception, eating habits). The environmental factors that may be related to a case are physical (e.g., weather, temperature, humidity, physical sur- roundings) or biological (such as insects that transmit the agent). Some of the socioeconomic factors that might affect development of a disease/event are behavior (e.g., terrorist behaviors), personality, cultural characteristics of group, crowd- ing, sanitation, and availability of health services.
When to Investigate An unusual increase in disease incidence should be investigated. The amount of effort that goes into an investigation depends on the severity or magnitude of the problem, the numbers in
(see Box 24-2 for a list of special systems available to assess data in the case of a terrorist event).
Although all of the systems are important, the public health nurse is most likely to use the active or passive systems. An example of when one might use a passive system is the use of the state reportable disease system to complete a community assessment or MAPP (Mobilizing for Action through Planning and Partnerships; see Chapters 18 and 25). The active system is used when several school children become ill after eating lunch in the cafeteria or at the local hot dog stand, to investigate the possibility of food poisoning, or following up on contacts of a newly diagnosed tuberculosis or sexually transmitted disease (STD) client at the local homeless shelter (CDC, 2012). The most recent use of the active system occurred in 2012, when a Liberian citizen in Dallas, Texas, was found to be infected with Ebola virus (see Chapter 46).
THE INVESTIGATION Investigation Objectives Any unusual increase in disease incidence (new cases) or an unusual event in the community should be investigated. The system used for investigation depends on the intensity of the event, the severity of the disease, the number of people/ communities affected, the potential for harm to the community or the spread of disease, and the effectiveness of available inter- ventions (CDC, 2013b). The objectives of an investigation are as follows: • To control and prevent disease or death • To identify factors that contribute to the disease outbreak/
event occurrence • To implement measures to prevent occurrences
Defining the Magnitude of a Problem/Event The following definitions provide a way to describe the level of occurrence of a disease/event for purposes of communicating the magnitude of the problem. A disease/event that is found to be present (occurring) in a population is defined as endemic if there is a persistent (usual) presence with low to moderate disease/event cases. The endemic levels of a disease/event in a population provide the baseline for establishing a public health problem. For example, foodborne botulism is endemic to Alaska. One would need to know the baseline to determine the existence of a change or increase in the number of cases from the baseline. If a problem is considered hyperendemic, there is a persistently (usually) high number of cases. An example is the high cholera incidence rate among Asians/Pacific Islanders. Sporadic problems are those with an irregular pattern, with occasional cases found at irregular intervals. Holoendemic implies a highly prevalent problem found in a population and commonly acquired early in life. The prevalence of this problem decreases as age increases (Mosby’s Medical Dictionary, 2013). Epidemic means that the occurrence of a disease within an area is clearly in excess of expected levels (endemic) for a given time period. This is often called the outbreak. Pandemic refers to the epidemic spread of the problem over several countries or continents (such as the SARS and most recently the H1N1
539CHAPTER 24 Public Health Surveillance and Outbreak Investigation
1. Biological • Bacteria (e.g., tuberculosis, salmonellosis, streptococcal infections) • Viruses (e.g., hepatitis A, herpes) • Fungi (e.g., tinea capitis, blastomycosis) • Parasites (protozoa causing malaria, giardiasis; helminths [roundworms,
pinworms]; arthropods [mosquitoes, ticks, flies, mites]) 2. Physical
• Heat • Trauma
3. Chemicals • Pollutants • Medications/drugs
4. Nutrients • Absence • Excess
5. Psychological • Stress • Isolation • Social support
BOX 24-3 Types of Agent Factors
the population who are affected, the potential for spreading the disease, and the availability and effectiveness of intervention measures to resolve the problems. Most of the outbreaks of diseases (or increased incidence rates) occur naturally and/or are predictable when compared with the consistent patterns of previous outbreaks of a disease, such as influenza, tuberculosis, or common infectious diseases. When a disease/event outbreak occurs as a result of purposeful introduction of an agent into the population, the predictable patterns may not exist. Clues are provided to be used when trying to determine the existence of bioterrorism. These clues are simplified and appear in the How To box entitled “Recognize the Epidemiologic Clues” (Khan and Pesik, 2011).
Steps in an Investigation First confirm whether a real disease/condition outbreak exists or if there has been a false alarm. Review the information avail- able about the situation. Determine the nature, location, and severity of the problem. Verify the diagnosis and develop a case definition to estimate the magnitude of the problem; this may change as new information is made available. Compare current incidence (number of new cases) with usual or baseline inci- dence. Use local data if available and compare them with the literature, or call the state health department. Assess the need for outside consultation. Report the situation to state public health authorities if required. Check the state reportable disease list. Early and continually changing control measures should be used on the basis of the magnitude and nature of the condition (infectious disease, chronic disease, injuries, personal behaviors, environmental exposure). Control measures may include elimi- nating a contaminated product, modifying procedures, treating carriers, or immunizing those who might contract the infec- tious disease. A request should be made that laboratory speci- mens be saved until the investigation is completed (if applicable to the case definition).
HOW TO Recognize the Epidemiologic Clues That May Signal a Covert Bioterrorism Attack • Large number of ill persons with similar disease or syndrome • Large number of unexplained disease, syndrome, or deaths • Unusual illness in a population • Higher morbidity and mortality than expected with a common
disease or syndrome • Failure of a common disease to respond to usual therapy • Single case of disease caused by an uncommon agent • Multiple unusual or unexplained disease entities coexisting in the
same person without other explanation • Disease with an unusual geographic or seasonal distribution • Multiple atypical presentations of disease agents • Similar genetic type among agents isolated from temporally or
spatially distinct sources • Unusual, atypical, genetically engineered, or antiquated strain of
agent • Endemic disease with unexplained increase in incidence • Simultaneous clusters of similar illness in noncontiguous areas,
domestic or foreign • Atypical aerosol, food, or water transmission • Ill people presenting at about the same time • Death or illness among animals that precedes or accompanies
illness or death in humans • No illness in people not exposed to common ventilation systems,
but illness among those people in proximity to the systems
Centers for Disease Control and Prevention (CDC): Steps to Investigation, 2014h. Retrieved January 2015 from www.CDC.gov
HOW TO Conduct an Investigation • Identify investigation team and resources. • Confirm the existence of an outbreak. • Verify the diagnosis/define a case. • Estimate the number of cases. • Orient the data collected to person, place, and time. • Develop and evaluate a hypothesis. • Institute control measures and communicate findings. • Maintain surveillance (CDC, 2014h).
As the investigation continues, seek additional cases and collect critical data and specimens. Encourage immediate reporting of new cases from laboratory reports (e.g., radiology in cases of pneumonia) and physicians/other health care pro- viders, including public health nurses, health care agencies, and others in the community as appropriate. In addition, search for other cases that may have occurred in the past or are now occur- ring by reviewing laboratory reports, medical records, and client charts and questioning physicians, other health providers and agencies, and others in the community. Use a specific data collection form such as a questionnaire or a data abstract summary form. Characterize the cases by person, place, and time. Evaluate the client characteristics (i.e., age, sex, underlying disease, geographic location) and possible exposure sites. The place where the outbreak occurs provides clues to the popula- tion at risk. Did the problem occur in a community, school, or homes? Drawing tables or spot maps helps to visualize the clusters of the disease condition in specific areas of the
540 PART 4 Issues and Approaches in Population-Centered Nursing
opportunity of an outbreak to review and correct practices related to the current situation that may contribute to an out- break in the future.
Communicate findings to those who should be notified. Communication of findings may take two forms: an oral brief- ing for local authorities or a written report. Describe the problem, the data collected, the case definition with verification of the diagnosis, data sources, the hypothesis, and testing of the hypothesis. Present only the facts of the situation, the data analysis, and the conclusions.
Displaying of Data Reporting of data in an investigation needs to be valid: Does the event reported reflect the true event as it occurs? It must also be reliable: Is the same event reported consistently by dif- ferent observers? A number of tools can be used to display data according to time, place, or person. The spatial map shows where the event is occurring and allows prevention resources to be targeted. Figure 24-1 provides a map of the location of reported cases of hepatitis A in the United States. From looking at this map, priority prevention target areas appear to be
community. The exact time period of the outbreak/occurrence is important (be sure to go back to the first case or first indica- tion of outbreak/occurrence activity). Given the diagnosis, describe what appears to be the period of exposure. Record the date of onset of morbidity/mortality cases and draw an epi- demic curve. Determine whether the outbreak/condition origi- nates from a common source or is propagated. Table 24-2 suggests factors to monitor and explains the reasons for their use. It provides clues to the use of time, place, and person.
As the investigation continues, develop a tentative hypoth- esis (the best guess about what is happening). Do a quick evalu- ation of the outbreak by assessing previous findings. Record, tabulate, and review data collected from the previously described activities to summarize common agent, environment, host factors, and exposures. On the basis of this analysis (and litera- ture review if necessary), develop a hypothesis (best guess) on (1) the likely cause, (2) the source(s), and (3) the mode of transmission of the disease. The hypothesis should explain the majority of cases. Frequently, there will be concurrent cases not explained by the hypothesis that may be related to endemic or sporadic cases, a different disease or condition (similar symp- tomatology), or a different source or mode of transmission.
Test your hypothesis with other public health team members (e.g., epidemiologists). Many investigations do not reach this stage because of lack of available personnel, lack of severity of the problem, and lack of resources available. Situations that should be studied include disease/events associated with a com- mercial product, disease/events associated with considerable morbidity and/or mortality, and disease/events associated with environmental exposures (e.g., terrorist attack). Analyze data collected to determine sources of transmission and risk factors associated with disease/condition. Determine how this problem differs in incidence or exposure for other population groups. Refine the hypothesis (best guess) and carry out additional studies if necessary.
Evaluate the effects of control measures. Cases may cease to occur or return to endemic (normal) level. If the control inter- ventions do not produce change, return to the beginning and start the investigation over or reevaluate cases. Use the
Factors Reason
Disease located in one geographic area Might indicate a point source of a disease agent that can be discovered and controlled Severe symptoms/diagnoses such as encephalitis or death Indicates disease process that needs rapid investigation because of severity Rapid rise to very high numbers of illness two to three times
normal baseline with steep epidemic curve Potential for continuing rapid rise in numbers; requires immediate investigation to
institute control measures Outbreak detected and confirmed by multiple data sources Unlikely to be attributable to error; possibly widespread Outbreak occurring at an unusual time or place (e.g.,
respiratory/influenza-like symptoms in summer) Might indicate targeted population or early signs in a susceptible population (e.g., very
young or very old) Outbreak confined to one age or gender group Might indicate targeted population or early signs Number of cases continuing to rise over time Indicates sustained outbreak that might continue to grow
TABLE 24-2 Potential Epidemiologic Factors That Call for Increased Investigation or Monitoring
From Andersson T, Bjelkmar P, Hulth A, et al: Syndromic surveillance for outbreak detection and investigation. Online J of Public Health Inform 5:e78, 2013.
FIG 24-1 Hepatitis A cases reported in the United States and U.S. territories in 1 year.
DC
NYC
AS
CNMI
GU
PR
VI
0-2.4 2.5-4.9 5.0-9.9 10.0-19.9 �20
NA
541CHAPTER 24 Public Health Surveillance and Outbreak Investigation
Year 1 Year 2 Year 3 Year 4
January 12 20 21 16 February 14 19 26 19 March 7 21 8 27 April 12 10 11 13 May 5 0 11 0 June 4 11 1 6 July 5 5 9 8 August 5 9 12 7 September 6 7 13 8 October 15 8 10 70 November ? 8 11 0 December 0 11 20 0 Total 75 129 153 174
TABLE 24-3 Example of Ways to Display Data* Number of Clients with Hepatitis A, by Month, for 4 Years
Modified from Centers for Disease Control and Prevention (CDC): Notifiable diseases and mortality tables. MMWR 63(28):ND-382-ND-395, July 18, 2014d. Retrieved January 2015 from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6328md. htm?s_cid=mm6328md_w
*This table shows the number of persons who match a case definition of a select infectious disease over a 4-year period. Note that for Year 4, there were overall more cases, especially in March and October, with a serious outbreak in October.
Georgia, the District of Columbia, California, New Mexico, Kansas, and Florida. Table 24-3 shows the number of cases of an infectious disease compared by month and year over 4 years. In this table, cases have increased by year with a serious out- break in October of Year 4. When cases are reported by person, they are usually reported by a person’s characteristics. Data displays are a step in analysis that shows graphically what is happening. It reduces the assumptions made about the event and provides a means for describing the event using quantita- tive data. Data help in stating your hypothesis or your best guess about what is happening (refer to the CDC website for addi- tional information on outbreak investigations).
LEVELS OF PREVENTION
Primary Prevention Develop an approach for mass immunizations of citizens to prevent the occur- rence of H1N1 in the community.
Secondary Prevention Investigate an outbreak of flulike illness in a local school.
Tertiary Prevention Provide health care and treatment for those infected by H1N1.
Surveillance Activities
LINKING CONTENT TO PRACTICE
Remember that disease and event surveillance systems exist to help improve the health of the public through the systematic and ongoing collection, distri- bution, and use of health-related data. A nurse can contribute to such systems and best use the data collected through such systems to help manage endemic health problems and those that are emerging, such as evolving infec- tious diseases and bioterrorist (human-made) health problems. Functions of surveillance and investigation are detecting cases, estimating the impact of disease or injury, showing the national history of a health condition, determin- ing the distribution and spread of illness, generating hypotheses, evaluating prevention and control measures, and facilitating planning (CDC, 2012). Response to bioterrorism or large-scale infectious disease outbreak may require the use of emergency public health measures such as quarantine, iso- lation, closing public places, seizing property, mandatory vaccination, travel restrictions, and disposal of the deceased. In 2008 in preparation for a pro- jected H1N1 flu epidemic, information was distributed about the use of several of these interventions, including isolation and closure of public places (see Appendix D-3).
Suggestions for protecting health care providers from exposure include use of standard precautions when coming in contact with broken skin or body fluids, use of disposable nonsterile gowns and gloves followed by adequate hand washing after removal, and use of a face shield (CDC, 2012).
The Robert Wood Johnson Foundation (RWJF) funded a project initiative focusing on the development of competencies and resources to enhance the ability of nursing professionals to deliver high-quality and safe nursing care. The Quality Safety Education for Nurses (QSEN) collaboration identified and defined six quality and safety competencies for nursing. In addition, the
project allowed for the development of proposed targets for the knowledge, skills, and attitudes of students for each of the six competencies that were identified by the Institute of Medicine as client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. The overall goal for the QSEN project is to meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems within which they work. This chapter focuses on the importance of using informatics to identify, monitor, and intervene in unusual occurrences and events to protect the public and to keep communities safe (see Chapter 26 for further discussion). Informatics in the QSEN project is defined as the use of information and technology to communicate, manage knowledge, mitigate error, and support decision making. The knowledge requirement for the public health nurse and student is to explain why infor- mation and technology skills are essential for safety. The skill to be devel- oped is the seeking of education about how information is managed in the setting before providing an intervention. This chapter applies this by looking at trends of occurrences and events before investigating the situation and deciding on an intervention. It is also important to be able to use the data- bases and the tools of investigation to ensure safe processes of care. The attitude of engaging in continuous learning and the development of new technology skills is essential. In the case of an influenza pandemic and to assist clients in being safe during such an outbreak, the How To box entitled “Plan for Pandemic Flu, Using a Planning Checklist for Individuals and Fami- lies” provides steps for assisting individuals and families in preparation for such an occurrence.
From Centers for Disease Control and Prevention: National Electronic Telecommunications System for Surveillance, 2011. Available at http://www.cdc.gov/surveillance. Accessed June 1, 2011.
542 PART 4 Issues and Approaches in Population-Centered Nursing
Excerpted and adapted from the U.S. Department of Health and Human Services: Plan for pandemic flu using a planning checklist for individuals and families, 2006. Available at www.flu.gov. Accessed October 28, 2010.
HOW TO Plan for Pandemic Flu, Using a Planning Checklist for Individuals and Families Nurses are responsible for assisting clients by providing them the means for safety. One of the roles of the nurse, to assure safety, is to assist clients in being prepared for an occurrence or an event in emergency and urgent situations that could compromise their health status or health outcomes. Following is a checklist to assist individual and family clients to prepare for a pandemic. Although this presents a process in preparation for pandemic flu, this process may be used in other communicable disease outbreaks that may reach pandemic proportions.
Use this as a guide to educate clients if an epidemic or pandemic is forecast:
Prepare for an influenza pandemic as soon as it is forecast. Prepare clients with the knowledge of both the magnitude of what can happen during a pandemic outbreak and what actions can be taken to help lessen the impact of an influenza pandemic on the client(s). This checklist helps to gather the information and resources needed in case of a flu pandemic. 1. To plan for a pandemic: the client(s) will want to:
• Store a 2-week supply of water and food. • During a pandemic, if clients cannot get to a store, or if stores
are out of supplies, it will be important to have extra supplies on hand.
• This can be useful in other types of emergencies, such as power outages and disasters.
• Periodically check regular prescription drugs to ensure a con- tinuous supply at home.
• Have nonprescription drugs and other health supplies on hand, including pain relievers, stomach remedies, cough and cold medicines, fluids with electrolytes, and vitamins.
2. To limit the spread of germs and prevent infection: • Teach children to wash hands frequently with soap and water,
and suggest that family members model the current behavior. • Teach children to cover coughs and sneezes with tissues, and
be sure to model that behavior in families.
• Teach children to stay away from others as much as possible if they are sick.
• Encourage family members to stay home from work and school if sick.
3. Items to have on hand for an extended stay at home: • Examples of food and nonperishables
• Ready-to-eat canned meats, fish, fruits, vegetables, beans, and soups
• Protein or fruit bars • Dry cereal or granola • Peanut butter or nuts • Dried fruit • Crackers • Canned juices • Bottled water • Canned or jarred baby food and formula • Pet food
• Examples of medical, health, and emergency supplies • Prescribed medical supplies such as glucose and blood
pressure–monitoring equipment • Soap and water, or alcohol-based (60% to 95%) hand wash • Medicines for fever, such as acetaminophen or ibuprofen • Thermometer • Antidiarrheal medication • Vitamins • Fluids with electrolytes • Cleansing agent/soap • Flashlight • Batteries • Portable radio • Manual can opener • Garbage bags • Tissues, toilet paper, disposable diapers
P R A C T I C E A P P L I C A T I O N As a clinical project, the health department asked the public health nursing class at the university to develop a community service message to air on local radio about the potential of a
pandemic flu H1N1 outbreak in 2014. What does the message need to contain to help the community prepare?
Answers can be found on the Evolve site.
K E Y P O I N T S • Disease surveillance has been a part of public health protec-
tion since the 1200s, during the investigations of the bubonic plague in Europe.
• By 1925 the United States began national reporting of mor- bidity causes.
• Surveillance provides a means for nurses to monitor disease trends in order to reduce morbidity and mortality and to improve health.
• Surveillance is a critical role function for nurses practicing in the community.
• Surveillance is important because it generates knowledge of a disease or event outbreak patterns.
• Surveillance focuses on the collection of process and outcome data.
• Although surveillance was initially devoted to monitoring and reducing the spread of infectious diseases, it is now used to monitor and reduce chronic diseases and injuries, and environmental and occupational exposures.
543CHAPTER 24 Public Health Surveillance and Outbreak Investigation
K E Y P O I N T S — cont’d • Surveillance activities can be related to the core functions of
public health of assessment, policy development, and assurance.
• A quality surveillance system requires collaboration among a number of agencies and individuals.
• The Minnesota Model of Public Health Interventions: Appli- cations for Public Health Nursing Practice (2001) suggests that surveillance is one of the interventions related to public health nursing practice.
• Clinicians, health care agencies, and laboratories report cases to state health departments. Data also come from death cer- tificates and administrative data such as discharge reports and billing records.
• Each of the data sources has the potential for under-reporting or incomplete reporting. However, if there is consistency in the use of surveillance methods, the data collected will show trends in events or disease patterns that may indicate a change needed in a program or a needed prevention inter- vention to reduce morbidity or mortality.
• The National Notifiable Disease Laboratory, hospital dis- charge data, and billing data provide mechanisms for clas- sifying diseases and events and calculating rates of diseases within and across groups, populations, and communities.
• The sentinel surveillance system provides for the monitoring of key health events when information is not otherwise avail- able or in vulnerable populations to calculate or estimate disease morbidity.
• In 1990 the CDC and the Council of State and Territorial Epidemiologists assembled the first list of standard case definitions.
• Reporting of disease data by health care providers, laborato- ries, and public health workers to state and local health departments is essential if trends are to be accurately monitored.
• Requirements for reporting diseases are mandated by law or regulation.
• Criteria for defining cases of different diseases are essential for having a uniform, standardized method of reporting and monitoring diseases. A case definition provides understand- ing of the data that are being collected and reduces the likeli- hood that different criteria will be used for reporting similar cases of a disease.
• Surveillance systems in use today are defined as passive, active, sentinel, and special.
• Any unusual increase in disease incidence (new cases) or an unusual event in the community should be investigated.
• Patterns of occurrence can be identified when investigating a disease or event. These patterns are used to define the boundaries of a problem to help investigate possible causes or sources of the problem.
• Factors that must be considered as causes of outbreak are categorized as agents, hosts, and environmental factors.
• An unusual increase in disease incidence should be investigated.
• Functions of surveillance and investigation are detecting cases, estimating the impact of disease or injury, showing the national history of a health condition, determining the dis- tribution and spread of illness, generating hypotheses, evalu- ating prevention and control measures, and facilitating planning.
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APHNRoleofPHNinDisasterPRR _30May13.pdf.
Centers for Disease Control and Prevention (CDC): Case definitions for infectious conditions under public health surveillance. MMWR Morb Mortal Wkly Rep 46(RR– 10):2, 1997.
Centers for Disease Control and Prevention (CDC): Public Health Preparedness: Strengthening the Nation’s Emergency Response State by State, 2010a. Retrieved January 2015 from http://
www.cdc.gov/phpr/pubs-links/2010/ index.htm.
Centers for Disease Control and Prevention (CDC): Anthrax (Bacillus anthracis): 2010 Case Definition, 2010b. Retrieved January 2015 from http://wwwn.cdc.gov/nndss/ script/casedef.aspx?CondYrID=609 &DatePub=1/1/2010%20 12:00:00%20AM.
Centers for Disease Control and Prevention (CDC): CDC’s vision for public health surveillance in the 21st century. MMWR Morb Mortal
Wkly Rep 61(Suppl; July 27, 2012), 2012. Retrieved January 2015 from http://www.cdc.gov/mmwr/pdf/ other/su6103.pdf.
Centers for Disease Control and Prevention (CDC): Chemical Emergencies Overview, 2013a. Retrieved January 2015 from http:// www.bt.cdc.gov/chemical/.
Centers for Disease Control and Prevention (CDC): Multistate and Nationwide Foodborne Outbreak Investigations: A Step-by-Step Guide, 2013b. Retrieved January
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Call the local health department and attend an emergency
response team planning meeting. How many agencies are involved? Determine the roles of each agency. Does the nurse have a role on the team? Explain.
2. Go to the Health Hazard Evaluation program website (see WebLinks). What is the purpose of this program? How
would information from the website be used in a disease investigation?
3. Explain the purpose of applying the sentinel system to improve population health outcomes.
544 PART 4 Issues and Approaches in Population-Centered Nursing
2015 from http://www.cdc.gov/ foodsafety/outbreaks/investigating- outbreaks/investigations/index.html.
Centers for Disease Control and Prevention (CDC): Summary of notifiable diseases in the United States, 2014. Retrieved January 2015 from www.cdc.gov.
Centers for Disease Control and Prevention (CDC): Bioterrorism Overview, 2014a. Retrieved January 2015 from http:// www.bt.cdc.gov/bioterrorism.
Centers for Disease Control and Prevention (CDC): 2014 Nationally Notifiable Infectious Diseases, 2014b. Retrieved January 2015 from http:// wwwn.cdc.gov/NNDSS/script/ ConditionList.aspx?Type=0&Yr= 2014.
Centers for Disease Control and Prevention (CDC): Middle East Respiratory Syndrome (MERS)- Case Definitions, 2014c. Retrieved January 2015 from http:// www.cdc.gov/coronavirus/mers/ case-def.html.
Centers for Disease Control and Prevention (CDC): Notifiable diseases and mortality tables. MMWR 63(28):ND-382-ND-395, 2014d. Retrieved January 2015 from http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm6328md. htm?s_cid=mm6328md_w.
Centers for Disease Control and Prevention (CDC): Monitoring Chronic Diseases, 2014e. Retrieved January 2015 from www.cdc.gov.
Centers for Disease Control and Prevention (CDC): National Program of Cancer Registries, 2014f. Retrieved January 2015 from www.cdc.gov.
Centers for Disease Control and Prevention (CDC): National Vital Statistics System, 2014g. Retrieved January 2015 from www.cdc.gov.
Centers for Disease Control and Prevention (CDC): Steps to Investigation, 2014h. Retrieved January 2015 from www.cdc.gov.
Centers for Disease Control and Prevention–National Electronic Telecommunications System for
Surveillance (CDC-NETSS): NETSS, 2013d. Retrieved January 2015 from http://wwwn.cdc.gov/nndss/ script/netss.aspx.
Centers for Disease Control and Prevention–National Notifiable Disease Surveillance System (CDC-NNDSS): NNDSS/NBS, 2013c. Retrieved January 2015 from http://wwwn.cdc.gov/nndss/ script/nedss.aspx.
Council on Linkages between Academia and Public Health Practice: Core Competencies for Public Health Professionals, 2014. Retrieved January 2015 from http:// www.phf.org/resourcestools/ Documents/Core_Competencies_ for_Public_Health_ Professionals_2014June.pdf.
Ergaz Z, Arad I, Bar-Oz B, et al: Elimination of vancomycin-resistant enterococci from a neonatal intensive care unit following an outbreak. J Hosp Infect 74:370– 376, 2010.
Goodman RA, Posid JM, Popvic T: Investigations of selected historically important syndromic outbreaks: impact and lesson learned for public health preparedness and response. Am J Public Health 102:1079–1090, 2012.
Gordis L: Epidemiology, ed 4. New York, 2008, Saunders.
Gostin LO: Public Health Law and Ethics: A Reader, ed 2. Los Angeles, CA, 2010, University of California Press.
Johns MC, Eick AA, Blazes DL, et al: Seasonal influenza vaccine and protection against pandemic (H1N1) 2009-associated illness among US military personnel. PLoS ONE 5:e10722, 2010.
Khan AS, Pesik N: Forensic public health: epidemiological and microbiological investigations for biosecurity. In Bodowle B, Schutzer SE, Breeze RG, et al, editors: Microbial Forensics, ed 2. Burlington, MA, 2011, Academic Press.
Koo D: Overview of Public Health Surveillance, 2010, Epidemiology
Program Office, Centers for Disease Control and Prevention. Retrieved January 2015 from www.cdc.gov/ncphi/disss/nndss/ phs/overview.htm.
Kuo HW, Kasper S, Jelovcan S, et al: A food-borne outbreak of Shigella sonnei gastroenteritis, Austria, 2008. Wien Klin Wochenschr 121:157–163, 2009.
Lee LM, Michael L, Teutsch SM, et al: Principles and Practice of Public Health Surveillance, ed 3. New York, 2010, Oxford University Press.
Public Health Nursing Section: Public Health Interventions–Applications for Public Health Nursing Practice. St. Paul, 2001, Minnesota Department of Health, pp 15–16.
Mosby’s Medical Dictionary, ed 9. St. Louis, MO, 2013, Elsevier Mosby.
Pryor ER, Milligan GW: Surveillance systems for detection of biological events. In Veenema TG, editor: Disaster Nursing and Emergency Preparedness for Chemical, Biological, and Radiological Terrorism and Other Hazards, ed 3. New York, 2013, Springer, pp 330–353.
Quad Council of Public Health Nursing Organizations: Quad Council Competencies for Public Health Nurses, Summer 2011. Retrieved January 2015 from http:// www.resourcenter.net/images/ ACHNE/Files/QuadCouncil CompetenciesForPublicHealth Nurses_Summer2011.pdf.
Sherman RL, Henry KA, Tannenbaum SL, et al: Applying spatial analysis tools in public health: an example using SaTScan to detect geographic targets for colorectal cancer screening interventions. Prev Chronic Dis 11:130264, 2014. DOI: http://dx.doi.org/10.5888/ pcd11.130264.
Sobel J, Watson JC: Intentional terrorist contamination of food and water. In Lutwick SM, Lutwick LI, editors: Beyond Anthrax: The Weaponization of Infectious Diseases, ed 2. New York, 2009, Springer.
Thacker SB, Qualters JR, Lee LM, et al: Public health surveillance in the United States: evolution and challenges. MMWR Surveill Summ 61(Suppl):3–9, 2012.
Tokars JI, English R, McMurray P, et al: Summary of data reported to CDC’s national automated biosurveillance system, 2008. BMC Med Inform Decis Mak 10:30, 2010. Retrieved January 2015 from http://www.biomedcentral.com.
Utterback DF, Schnorr TM: Use of Workers’ Compensation Data for Occupational Injury & Illness Prevention, May 2010, U.S. Department of Health and Human Services and U.S. Department of Labor, Bureau of Labor Statistics. Retrieved January 2015 from http:// www.cdc.gov/niosh/docs/2010-152/ pdfs/2010-152.pdf.
U.S. Department of Health and Human Services (USDHHS): Healthy People 2020: A Roadmap to Improve All Americans’ Health, Washington, DC, 2010, U.S. Government Printing Office. Retrieved January 2015 from http:// www.healthypeople.gov.
Veenema TG: Disaster Nursing and Emergency Preparedness for Chemical, Biological, and Radiological Terrorism and Other Hazards, ed 3. New York, 2013, Springer.
Webster’s New World Medical Dictionary, ed 5. New York, 2014, Webster’s New World.
World Health Organization (WHO): Sentinel Surveillance, 2014a. Retrieved January 2015 from http:// www.who.int/immunization/ monitoring_surveillance/burden/vpd/ surveillance_type/sentinel/en/.
World Health Organization (WHOB): Trade, Foreign Policy, Diplomacy, and Health, 2014b. Retrieved January 2015 from www.who.int.
Wright PG, Quinn CP, Shadomy S, et al: Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm Rep 59(RR–6):1–30, 2010.
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25
Program Management
Marcia Stanhope, PhD, RN, FAAN Dr. Marcia Stanhope is currently an Associate of the Tuft and Associates Search Firm, Chicago, Ill. She is also a consultant for the nursing program at Berea College, Kentucky. She has practiced community and home health nursing, has served as an administrator and consultant in home health, and has been involved in the development of two nurse-managed centers. At one time in her career, she held a public policy fellowship and worked in the office of a U.S. Senator. She has taught community health, public health, epidemiology, policy, primary care nursing, and administration courses. Dr. Stanhope formerly directed the Division of Community Health Nursing and Administration and served as Associate Dean of the College of Nursing at the University of Kentucky. She has been responsible for both undergraduate and graduate courses in population-centered nursing. She has also taught at the University of Virginia and the University of Alabama, Birmingham. During her career at the University of Kentucky she appointed to the Good Samaritan Foundation Chair and Professorship in Community Health Nursing, and was honored with the University Provost’s Public Scholar award. Her presentations and publications have been in the areas of home health, community health and community-focused nursing practice, as well as primary care nursing.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Compare and contrast the program management process
and the nursing process. 2. Analyze the application of the program planning process
to nursing.
3. Critique a program planning method to use in nursing practice.
4. Analyze the components of program evaluation methods, techniques, and sources.
5. Compare different types of cost studies applied to program management.
K E Y T E R M S case registers, p. 564 community assessment, p. 549 community health planning, p. 546 cost studies, p. 557 evaluation, p. 547 evidence-based practice, p. 553 formative evaluation, p. 546 grant writing, p. 565 health program planning, p. 551 outcome, p. 564 planning, p. 547 planning process, p. 557 population needs assessment, p. 550
process, p. 564 program, p. 546 program effectiveness, p. 547 program evaluation, p. 547 program management, p. 546 projects, p. 546 quality assurance, p. 557 strategic planning, p. 549 structure, p. 564 summative evaluation, p. 546 tracers, p. 564 — See Glossary for definitions
A D D I T I O N A L R E S O U R C E S Evolve website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • WebLinks—Of special note see the links for these sites:
• Turning Point Program • Centers for Disease Control and Prevention • National Association of County & City Health Officials
• Quiz • Case Studies • Glossary • Answers to Practice Application • Appendix
• Appendix B: Program Planning and Design
546 PART 4 Issues and Approaches in Population-Centered Nursing
Program management consists of assessing, planning, imple- menting, and evaluating a program. This chapter focuses primarily on planning and evaluation. Although presented in separate discussions, these factors are related and interdepen- dent processes that work together to bring about a successful program. This chapter does not address implementing programs because other chapters in this text focus on implementation.
The program management process is parallel to the nursing process. One process is applied to a program that addresses the needs of a specific population, whereas the other process is applied to individuals or families. The process of program man- agement, like the nursing process, consists of a rational decision- making system designed to help nurses know when to make a decision to develop a program (through the needs assessment and defining the problem), where they want to be at the end of the program (goal setting), how to decide what encompasses a successful program (planning), how to develop a plan to go forward so they will know where they want to be (implement- ing), how to know that they are getting there (formative evalu- ation), and what to measure to know that the program has successful outcomes (summative evaluation).
Today there is a greater need for the nurse to be accountable for nursing actions and client outcomes. Prospective payment systems, pay for performance, health care reform, and inte- grated care delivery models have changed the focus of nursing. Planning for nursing services is necessary today if the nurse is to survive in the health care delivery field. Nurses are expected to demonstrate leadership in addressing community-based health problems.
This chapter examines how nurses can act, instead of react, by planning programs that can be evaluated for their effective- ness. The discussion focuses on the historical development of health planning and evaluation, a general program planning and evaluation method, the benefits of planning and evalua- tion, the elements of planning and evaluation, how cost studies are applied to program evaluation, and how programs may be
C H A P T E R O U T L I N E Definitions and Goals Historical Overview of Health Care Planning and
Evaluation Benefits of Program Planning Assessment of Need
Community Assessment Population Needs Assessment
Planning Process Basic Program Planning Model Using a Population-Level
Example Objectives Development for Program Planning and
Evaluation Program Evaluation
Benefits of Program Evaluation Planning for the Evaluation Process
Evaluation Process Sources of Program Evaluation Aspects of Evaluation
Advanced Planning Methods and Evaluation Models Program Planning Method Multi-Attribute Utility Technique Planning Approach to Community Health (PATCH) Assessment Protocol for Excellence in Public Health
(APEXPH) Mobilizing for Action through Planning and Partnership
(MAPP) Evaluation Models and Techniques Case Register
Program Funding
funded. Some sections of this chapter can be used by under- graduate students, whereas other sections are more appropri- ately used by graduate students.
DEFINITIONS AND GOALS Community health planning is population focused, and it positions the well-being of the public above private interests (American Planning Association, 2013). A program is an orga- nized approach to meet the assessed needs of individuals, fami- lies, groups, populations, or communities by reducing the effect of or eliminating one or more health problems. Community health programs are planned to meet the needs of designated populations or subpopulations in a community. Many pro- grams exist as specific efforts within the umbrella of large, complex organizations such as state health departments, uni- versities, health systems, and private organizations such as insurance companies. Unlike these complex organizations, smaller programs are endeavors that focus on more specific services and communities or groups. Specific examples in population-focused nursing are home health, immunization and infectious disease programs, health-risk screening for industrial workers, and family planning programs. These are usually conducted under the direction of the total plan of a local health department, a managed care agency, or, in some instances, an insurance company. Examples of more complex broadly based group and community programs are the community school health, occupational health and safety, environmental health, and community programs directed at preventing spe- cific illnesses through special-interest groups (e.g., American Heart Association, American Cancer Society, March of Dimes). Disaster preparedness is a type of program that may be con- ducted through collaborative efforts of several community organizations or agencies.
Programs are ongoing organized activities that become part of the continuing health services of a community or organiza- tion, whereas projects are smaller, organized activities with a
547CHAPTER 25 Program Management
of reducing the growth of health care costs by ensuring that only needed services and facilities would be added to the health care system. Under this legislation, health care providers were required to obtain a certificate of need (CON) in order to add services or facilities. However, very little authority existed to carry out some of the more critical tasks of improving the health of clients, increasing access and quality of services, restraining costs, and preventing the duplication of unnecessary services. Power over the private health care sector continued to be absent.
As “the new federalism” became the catch phrase of the 1980s and emphasis was placed on shifting costs, reducing costs, and providing more competition within the health care system, President Ronald Reagan proposed eliminating the federal gov- ernment’s role in health planning. In 1981, with cutbacks in federal spending, states began the takeover or dismantling of their own health planning systems. The national health plan- ning system came to a halt. The federal, state, and consumer partnership for health care was ended.
In 1993, with President Bill Clinton’s emphasis on health care reform, the decision was made that the government would continue to not be involved in health planning. It would use its power to set limits on health insurance costs and limit overall health care spending. In this way, it would influence health planning decisions made by the private health care agencies and providers (Sparer, 2011). Although national health care reform did not occur, many states engaged in reforming their systems.
Today, in the early years of the twenty-first century, the process of health planning is not coordinated but is for the most part in the control of different interests in the health care indus- try. The health care system has been mainly shaped by decisions of hospitals, physicians, pharmaceutical companies, equipment companies, insurance companies, and managed care organiza- tions, which determine where, how, and for whom health care will be delivered. Although the federal health planning legisla- tion is no longer in effect, some states continue to have health system agencies (HSAs), even though these organizations have much less authority than when they were established in the 1970s. In some states, the HSA must approve the planned expanding of agencies or services, and a CON must be issued by the state before these plans may proceed. The primary purpose of such health planning is to improve the health of local communities by increasing available and accessible ser- vices, preventing the duplication of services, and controlling health care costs.
The political party in power often influences the outcome of the national and state health planning efforts. To impact the direction of health care reform, nurses must be involved in all aspects of health planning for the community in which they live. An example of this is the passage of the Affordable Care Act, led by President Obama and the Democratic party in March 2010, which addresses planning at national, state, and local levels (PL 111-148). The American Nurses Association (March 2010) reports numerous activities nurses participated in related to the health care reform effort (see http://www .nursingworld.com/healthcarereform).
limited time frame. A health fair and a blood pressure screening day at the mall are examples of projects that nurses may implement.
Planning is defined as the selecting and carrying out of a series of activities designed to achieve desired improvements (Issel, 2013). The goal of planning is to ensure that health care services are acceptable, equal, efficient, and effective. Planning provides a blueprint for coordination of resources to achieve these goals. Evaluation is determining whether a service is needed and can be used, whether it is conducted as planned, and whether the service actually helps people in need (Royse, 2010). Evaluation is a process of accountability. Evaluation for the purpose of assessing whether objectives are met or planned activities are completed is referred to as formative or process evaluation. This type of evaluation begins with an assessment of the need for a program and involves ongoing monitoring of the activities conducted by the program. Evaluation to assess program outcomes or as a follow-up of the results of the program activities is called summative or impact evaluation.
Program evaluation is an ongoing process from the begin- ning of the planning phase until the program ends. It is used to make judgments about improving, managing, and continuing programs. The major goals of program evaluation are to determine the relevance, adequacy, progress, efficiency, effec- tiveness, impact, and sustainability of program activities (USDHHS, 2011).
HISTORICAL OVERVIEW OF HEALTH CARE PLANNING AND EVALUATION As the health care delivery system has grown during the last century, emphasis on health planning and evaluation has increased. Factors that have intensified interest in planning and evaluation are advances in health care technology and con- sumer education, escalating health care costs, increased con- sumer expectations, third-party payers, focus on health care as a business, personnel shortages, unionizing of health care workers, professional conflicts, focus on preventive care, recog- nition of increasing health disparities, and the threats from terrorism, natural disasters, and emerging infectious diseases. From the 1920s to the 1940s, specific actions were initiated that related to health planning. Table 25-1 outlines the development of health planning.
The post–World War II era brought an interest in evaluating program effectiveness. As government and third-party payers began to finance health care services and money became more plentiful, public demand for health services grew. As a result, numbers and kinds of health care agencies increased; laws were passed to increase the scope of and control over health care, and the health care delivery system began to be held accountable for its actions. During this time, legislation was passed to require health care providers and consumers to work together in groups to address issues in health care.
Through the 1970s, laws were passed to provide more com- prehensive structure and more power over federal program funds. In 1974 Congress enacted the National Health Planning and Resources Development Act. This legislation had the goal
548 PART 4 Issues and Approaches in Population-Centered Nursing
Year Initiator Action-Purpose
Late 1800s Lumber, railroad, mining, and other industry Contract with providers for health care to maintain health of workers.
1920 Committees on administrative practice and evaluation of American Public Health Association
Called for public health officers to engage in better program planning. Reduced haphazard methods used to develop public health programs.
1920s Committee on costs of medical care Studied social and economic aspects of health services. Cited the need for comprehensive health care planning because of rising costs and unequal health care services to target populations.
1921 Congress Sheppard Towner Act on Maternity and Infancy provided first continuing program of federal grants-in-aid for state health departments to provide direct care. States established maternal-child divisions with the funding.
1930s Federal government, Congress Blue Cross Insurance founded for provision of prepayment for hospital services in response to Great Depression and increased cost of health care.
1935 Federal government, Congress Social Security Act passed. This was an early movement to provide resources for the elderly and impoverished.
1944 American Hospital Association Established committee on postwar planning.
1946 Federal government, Congress Passed the Hospital Survey and Construction Act (Hill-Burton Act) to legislate health planning, which resulted in increase in number of hospitals.
1963 Federal government, Congress Community Mental Health Centers Act (PL 88-464) passed to provide mental health programs in the states; defined the role of consumers in making decisions and of professionals as advisors in the planning process.
1965 U.S. Department of Health and Human Services
Office of Health Planning opened; no direct authority for health planning given.
1965 Federal government, Congress Passed regional medical program legislation (PL 89-239); upgraded quality of tertiary health care services for the leading causes of death. Coined the term Partnership for Health.
1966 Federal government, Congress Passed the Comprehensive Health Planning (CHP) and Public Health Services amendments (Public Law 89-749). Developed a national health planning system.
Late 1960s to early 1970s
Individual state legislation Certificate of Need established as a check against duplication of services. Limited new construction, plant modernization, and major technology.
1973 President Nixon Government encouragement for health maintenance organizations (HMOs) for prepaid health insurance with emphasis on preventive health efforts.
1974 Federal government, Congress Passed National Health Planning and Resources Development Act (Public Law 93-641), which provided specific directions for developing the structure, process, and functions of a national health planning system.
1980 U.S. Department of Health and Human Services
Began Healthy People initiative. Support for national level assessment, data collection, analysis, goal setting, and evaluation for the U.S. population.
1982 Congress Tax Equity and Fiscal Responsibility Act (TEFRA) imposed financial cuts to Medicare and Medicaid and directed the Department of Health and Human Services (DHHS) to instill a prospective payment system for hospitals. Capitation through prospective payment was created with diagnosis-related groups (DRGs).
1993 President Clinton Introduced Health Security Act to provide for health care reform and planning based on population needs (not passed).
2000 Congress Home Health Prospective Payment System placed capitation on Medicare home health expenses based on clinical assessment of recipients using the Outcome and Assessment Information Set (OASIS).
2001 Congress Creation of Department of Homeland Security following the terrorist attacks of September 11, 2001. Consolidated selected government departments into one entity for providing national security.
2004 CDC Development of guidelines for distribution of flu vaccine to the U.S. population following flu vaccine recall.
2005 Hurricane Katrina This natural disaster on the Gulf Coast and New Orleans shed light on deficiencies of government for emergency planning at local, state, and national levels.
2010 President Obama Passage into law of the Patient Protection and Affordable Health Care Act (Public Law 111-148).
TABLE 25-1 Historical Development of Health Planning and Evaluation
549CHAPTER 25 Program Management
process shifts from a focus on the agency as a unit to one aspect of the agency. Program planning reflects the desire to imple- ment a reality-based program that can be readily evaluated and can reduce the number of unexpected events that occur in a defined population. There can be numerous programs within an agency, and each needs to engage in program planning and evaluation. A major national program to assist communities to plan, organize, and develop programs specific to their needs is the Centers for Disease Control and Prevention’s program plan- ning model (CDC, 2014).
ASSESSMENT OF NEED Planning for effective and efficient programs must be based on identifying the needs of populations within a community. Iden- tification of at-risk groups and documentation of the health needs of the targeted population provide the basic justification and rationale for the proposed program plan. Such documenta- tion of need is essential if funding will be required to implement the plan. Funding is always required either from the agency or the community at large unless the program is totally voluntary. An assessment of health needs may be approached as either a community assessment or a population needs assessment.
In addition to health planning in the external environment, internal health care agency planning is necessary to meet the goals and objectives of providing efficient, effective health care services to clients at a reasonable cost. Health care planning within the community and national health care planning affect health planning within an agency. For example, following the attack on the World Trade Center in 2001, there was much emphasis on developing national and community health plans for emergency preparedness and to prevent terrorism. In a com- prehensive reorganization of the federal government, President George W. Bush created the Department of Homeland Security. This reorganization consolidated 22 federal agencies into a single department with the goal of protecting America from terrorism. In addition, states and communities have been given federal monies to develop their own plans. Agencies within communities have been asked to develop emergency prepared- ness plans and to be a part of community plans.
Public health personnel have a responsibility to participate in internal planning and evaluation to solve the problems of a client population and to ensure the delivery of health services that are accessible, acceptable, and affordable. Emphasizing population health means focusing on the health outcomes of a group of persons, including the health outcome distribution in that group (IHI, 2012).
BENEFITS OF PROGRAM PLANNING Systematic planning for meeting the health needs of popula- tions in a community has benefits for clients, nurses, employing agencies, and the community. It ensures that available resources are used to address the actual needs of people in the commu- nity, and it focuses attention on what the organization and health provider are attempting to do for clients. Planning assists in identifying the resources and activities that are needed to meet the objectives of client services. It also reduces role ambi- guity (uncertainty) by giving responsibility to specific providers to meet program objectives (IHI, 2012).
Furthermore, planning reduces uncertainty within the program environment and increases the abilities of the provider and the agency to cope with the external environment. Everyone involved with the program can anticipate what will be needed to implement the program, what will occur during the imple- mentation process, and what the program outcomes will be. Planning helps the provider and the agency anticipate events. Also, planning allows for quality decision making and better control over the actual program results by setting specific goals, examining those goals regularly to determine whether the agency continues with the existing programs or makes changes based on the needs of the population they serve. Today, this type of planning is referred to as strategic planning, and it involves the successful matching of client needs with specific provider strengths and competencies and agency resources. Managers of programs engage in management planning. This type of plan- ning assists managers to determine whether the resources of the agency are used properly to actually implement the agency pro- grams. The type of planning emphasized in this chapter is the program planning process (Kettner et al, 2012). This planning
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency-Quality Improvement Uses data to monitor outcomes of care processes and uses improvement methods to design and test changes to continually improve quality and safety of health care systems • Knowledge: Describe approaches for changing processes of care • Skill: Identify gaps between local and best practice • Attitude: Value measurement and its role in good client care
QI Question The PHN Quad Council has identified a beginning PNH competency as policy development and program planning skills. The beginning PHN participates in developing organizational plans to implement programs and policies and par- ticipates in evaluating programs as a team member. How could the new PHN best contribute to program management? What type of activity might the PHN participate in to determine gaps in existing programs?
Community Assessment A thorough assessment of a community is necessary to provide a clear understanding of the overall health status of a commu- nity, to identify populations at risk, and to document health needs. Public health agencies, health planners, nurses, and agen- cies wishing to address the true needs of a community benefit from accurate and thorough community assessment data. (CDC, 2014b; NACCHO, 2014)
A community assessment is comprehensive. It is a population- focused approach that views the entire community as the client. Community assessment considers all of the people in a commu- nity for the purpose of identifying the most vulnerable popula- tions and determining unmet health needs. All of the services of a community are examined to assess their effect on the health of the population, and the environment is assessed for its
550 PART 4 Issues and Approaches in Population-Centered Nursing
the need for that service in a target population. In this case, an assessment may be focused on determining the needs of a specific population in a community. Population health is the basis for doing the assessment of need, which is defined as a systematic appraisal of type, depth, and scope of problems as perceived by clients or health providers, or both (CDC, 2014; NACCHO, 2014).
A population needs assessment focuses on the characteris- tics of a specific population, its health needs, and the resources available to address those needs. For example, a nurse may want to initiate a health education program for older adults with diabetes, to establish an immunization program for children of a certain age, or to provide health services for migrant workers. In each case, assessment would focus on the characteristics and health status of the target population and the resources avail- able to address the identified need for that group. When assess- ing a population, the same types of data collected for community assessment are collected and entered for the population, such as demographic data.
It is important to avoid planning services that do not focus on the health needs of the target population and services already provided by other agencies. A needs assessment determines gaps in or duplication of needed services (i.e., their availability), examines the quality of existing resources to meet the identified needs (i.e., their adequacy), and identifies barriers to the use of existing resources (i.e., their acceptability).
A number of needs assessment tools exist to assist the nurse in the needs assessment process. The major sources of informa- tion used for needs assessment, summarized in Table 25-2, are census data, key informants, community forums, surveys of existing community agencies with similar programs, surveys of residents of the community to be served (client population), and statistical indicators (Kettner et al, 2012).
impact on the health of the people. For example, some vulnerable groups may lack access to existing services because of lack of transportation, or there may be a high prevalence of asthma because of air pollution from a particular industrial source (see Chapter 18).
Community assessment begins with the collection of exist- ing data (secondary data). Variables related to the characteris- tics of the population in the community include demographic data such as age, sex, ethnic group/race, income, occupation, education, and health status. Such data, which for most com- munities are readily available on the Internet, are derived from census data and morbidity and mortality statistics. Much can be learned about a community through use of secondary data found on the Internet (UNC, 2014). In addition, data about communities may be found in local libraries, courthouse records, service agencies, newspapers, the phonebook, and other local resources. Public health departments are also good sources of secondary data.
New data about the community may be collected through surveys or interviews with community members and key infor- mants. When community members have a voice in clarifying norms and values of their community, in identifying needs, and in planning programs, community acceptance and use of that program are likely to be increased (CDC, 2014b).
Variables related to people, resources, and the environment of a community may be determined by using existing models that provide an organizing framework for the collection and analysis of data. (For more information about community assessment and the community-as-partner model, see Chapter 18.)
Population Needs Assessment Agencies or health care providers are frequently interested in providing a specific service in a community and want to assess
Name Definition Advantages Disadvantages
Community forum Community, group, organization, open meeting
Low cost Learn perspectives of large number of persons
Limited data Limited expression of views Discourages less powerful Becomes arena to discuss political issues
Focus groups Open discussion with small representative groups
Low cost Clients participate in identification of need Initiates community support for the program
Time consuming Allows focus on irrelevant or political
issues
Key informant Identify, select, and question knowledgeable leaders
Provides picture of services needed Bias of leaders Community characteristics may be
incorrectly perceived by informants
Indicators approach
Existing data used to determine problem
Excellent data on problems and characteristics of client groups
Growth and change in population may make data outdated
Survey of existing agencies
Estimates of client populations via services used at similar community agencies
Easy method to estimate size of client group Know extent of services offered in existing
programs
Records and data may be unreliable All cases of need may not be reported Exaggeration of services may occur
Surveys Measurement of total or sample client population by interview or questionnaire
Direct and accurate data on client population and their problems
Expensive Technically demanding Need many interviews or observations Interviews may be biased
TABLE 25-2 Summary of Needs Assessment Tools
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problem using past and present data to project future popula- tion needs.
Needs assessment is a key component of the planning process in the formulating stage. The target population or client to be served by any program must be identified and involved in every stage of designing the program. To avoid duplication or gaps in services, program planners must verify that a current health problem exists and is being either ignored or unsuccessfully treated in a client group. Data provide the rationale to establish a new program or revise existing programs to meet the needs of the client group. The client population should be defined specifically by its demographic and psychosocial char- acteristics, by geographic location, and by problems to be addressed (Figure 25-1).
For example, in a community with a large number of pre- school children who require immunizations to enter school, the client population may be described as all children between 4 and 6 years of age residing in Central County who have not had up-to-date immunizations. A health education program may be necessary to alert the population to the existing need. In the example of the need for immunizing preschool children, public service announcements on television and radio and in newspa- pers may be used to alert parents to laws requiring immuniza- tions, to the continuing problems with communicable diseases, and to the outcomes of successful immunizing programs, such as vaccination programs that have been successful in eliminat- ing smallpox worldwide. A good example of the use of media can be found in a press release by the Centers for Disease Control and Prevention highlighting the threat of measles to health security locally and globally (CDC, 2013).
Specifying the size and distribution of a client population for a program involves more than counting the number of persons in the community who may be eligible for the program. It involves determining the number of persons with the problem who are not being served by existing programs and the numbers of eligible persons who have and have not taken advantage of existing services. For example, consider again the community
Nurses working in community agencies who identify unmet needs among vulnerable populations can initiate program development and find funding to provide needed services and modify health disparities. For example, staff public health nurses in one community identified a need for schools to have more school health nurses, especially to meet the needs of unserved children in poverty. The nurses held a series of meet- ings with key informants, surveyed health departments of sur- rounding counties, and found an unknown source of funds through the state Medicaid program that would reimburse public health nurses for providing school health services. The result was the development of a program to increase the numbers of school health nurses in the community.
PLANNING PROCESS Health program planning is affected by government control over licensure and funding by political forces, and by the culture and belief system of the population in which the program must function. Program planning is required by federal, state, and local governments; by philanthropic organizations; and by the employing agency. Planning programs and planning for the evaluation of programs are two very important activities, whether the program being planned is a national health insur- ance program such as Medicare, a state health care program such as an early childhood development screening program, or a local program such as vision screening for elementary school children. Regardless of the type of program, the planning process is the same.
Nutt (1984) describes a basic planning process that is reflected in the steps of most planning methods and remains a great influence on strategic planning for population health and health programs today (Issel, 2013). The process includes five planning stages: formulating, conceptualizing, detailing, evalu- ating, and implementing (Table 25-3).
Basic Program Planning Model Using a Population-Level Example Formulating The initial and most critical step in planning a health program is defining the problem and assessing client need. This stage in the planning process can be preactive, projecting a future need; reactive, defining the problem based on past needs; inactive, defining the problem on the basis of the existing health state of the population to be served; or interactive, describing the
Basic Planning Elements
1. Formulating Client identifies problems. 2. Conceptualizing Provider group identifies solutions. 3. Detailing Client and provider analyze available solutions. 4. Evaluating (the plan) Client, providers, and administrators select
best plan. 5. Implementing Best plan is presented to administrators for
funding.
TABLE 25-3 Basic Planning Process
FIG 25-1 Steps in the needs assessment process.
Identify size and distribution of client population
Identify needs
Identify program
resources
Clarify program
perspectives
Identify client population
Set group
boundaries
552 PART 4 Issues and Approaches in Population-Centered Nursing
need for a preschool immunization program. In planning the program, the size of the population of preschool children in the county may be obtained from census data or state vital statistics. The nurse then must determine the number of children unserved and the number of children who have not used ser- vices for which they are eligible. Today there are many oppor- tunities to locate the unserved children through early start programs for preschool children.
Boundaries for the client population are primarily estab- lished by defining the size and distribution of the client popula- tion. The boundaries will stipulate who is included in and who is excluded from the health program. If the fictional immu- nization program were designed to serve only preschool chil- dren of low-income families, all other preschool children would be excluded.
Perspectives on the program, or what people think about the need for a program, might differ between health providers, agency administrators, policy makers, and potential clients. These groups are considered the stakeholders in the program. Collecting data on the opinions and attitudes of all persons, whether directly or indirectly involved with the program, is necessary to determine if the program is feasible, if there is a need to redefine the problems, or if a new program should be developed or an existing program should be expanded or modified. If a new or changed program is to be successful, it must not only be available, but also be accessible and acceptable to the people who will use it. For example, policy makers in the 1970s decided that neighborhood health clinics were the answer to providing services for low-income residents. They discovered that their perspective was not the same as those of most health providers and clients, who did not support devel- opment of neighborhood clinics.
The neighborhood health clinics have evolved over time to better reflect clients’ perspectives. It is important for policy makers to explore the perspectives of the clients when planning the program. Clients might choose another type of service to offer rather then the one the policy maker or provider thinks best for them. The needs to be met for the client population must be identified by both the client and the health provider if the program is to be accepted by the client population. If the client population does not recognize the need, the program will usually be unsuccessful. Today community health centers have replaced the concept of the neighborhood health centers, and these centers are being supported and increased in number by health care reform (Shin, 2015).
Before implementing a health program, the nurse must also identify available resources. Program resources include financing, personnel, facilities, and equipment and supplies. The source and amount of funds must be adequate to support the program. The number and kinds of personnel required and available must be determined. There must be a place for the program to operate, and up-to-date equipment and supplies are essential. If any one of the four categories of resources is unavailable, the program is likely to be inadequate to meet the needs of the client popula- tion. If planners consider the problem to be a critical one, funding may be sought by seeking donations or by writing a proposal for grant funds to support the program. A well-done
From Ruffolo DC, Andresen PA, Winn KL: Meeting the needs of a community: teaching evidence-based youth violence prevention initiative to members of strategic communities. J Trauma Nurs 20(1):24–30, 2013.
The prevention of youth violence is a priority community health concern across the nation. A thorough community needs assessment of suburban Cook County (SCC), Illinois, revealed the leading cause of death for people aged 15 to 25 years was homicide, at a rate three times the national rate. Furthermore, significant health disparities existed with African Americans nearly 15 times more likely and Hispanics five times more likely to die of homicide than whites. The Cook County Health Department of Public Health (CCDPH) set a goal to reduce the incidence of violence in communities suffering from disproportion- ate rates of violent acts.
The CCDPH sought to introduce community stakeholders, including key com- munity leaders, social service workers, and nurses, to the Blueprints for Vio- lence Prevention program. Blueprints is a web-based program that provides communities with a set of evidence-based youth violence prevention programs and an interactive system for selecting population-specific programs. The focus of this project was to provide the CCDPH Prevention Services Unit and community members with the tools necessary to select evidence-based vio- lence prevention programs. Blueprints and current available funding sources were presented through hands-on workshops. A nurse practitioner from the Loyola University Medical Center served as the project director. The 2 12 -hour educational program sessions provided participants with an overview of the Blueprints program, an opportunity to use the interactive program search feature, and reviewed available funding sources for youth violence prevention programs. At the end of the educational program, participants evaluated the program by completing a 5-point Likert survey in which participants evaluated the program content, delivery of the content, and its relevance to the partici- pant and their community. To assess program impact telephone interviews of program participants were also conducted three weeks after the session. These interviews consisted of open-ended questions focused on progress toward adopting a youth violence prevention program. Three themes emerged from the program evaluation: (1) hands-on, interactive sessions were an effec- tive learning strategy; (2) participants voiced a need for collaboration and the formation of partnerships for effective programing within the districts; and (3) for sustainability of the program, community members must have access to “live” experts on the Blueprints program.
Nurse Use Educational workshop programs are an effective strategy for informing the community about available resources. Nurses can teach leaders in the com- munity how to identify and evaluate evidence-based prevention programs. By educating key stakeholders, community mobilization on priority health needs is strengthened.
EVIDENCE-BASED PRACTICE
assessment provides direction and suggests strategies for appro- priate interventions (see the Evidence-Based Practice box).
Conceptualizing The need and demand for a program are determined through the formulating process. The conceptualizing stage of planning creates options for solving the problem and considers several solutions. Each option for program solution is examined for its uncertainties (risks) and consequences, leading to a set of out- comes. The outcomes sought are improvements in the health status of the population served by the program.
553CHAPTER 25 Program Management
self-pay for the immunizations, costs to the taxpayer and to the community are low.
Detailing In this phase, the provider, with client input, considers the pos- sibilities of solving a problem using one of the solutions identi- fied. The provider details (or is specific about) the costs, resources, and program activities needed to choose one of the solutions from the conceptualizing phase. For each of the three proposed alternatives shown in the immunization scenario in Figure 25-2, the program planner lists the activities that would need to be implemented. Using the proposed solution of encour- aging families to see their private physicians for the vaccine (the best consequence), examples of activities include developing a script for a health education program and implementing a tele- vision program to encourage parents to see a physician. If an alternative that produced the second, third, fourth, or fifth best consequence was chosen, offering a clinic at the health depart- ment or providing a mobile clinic to each daycare center to provide the immunizations would be possible activities.
For each alternative, the nurse lists the resources needed to implement each activity. The resources to be considered include all costs of personnel, supplies, equipment, and facilities, and the potential acceptance by the clients and the administrators of the program. In the example, personnel could include nurses, volunteers, and clerks; supplies might include handouts, Band- Aids, vaccines, records, and consent forms; equipment might include syringes, needles, stethoscopes, and blood pressure cuffs; and facilities might include a television studio for a media blitz on the education program and a room with examination tables, chairs, and emergency carts. The total costs of each solu- tion must be considered. As indicated, clients should review each solution for acceptance.
A first step in the conceptualizing process is a review of the literature to determine what approaches have been used in other places with similar problems, and with what success. Such review can assist nurses to improve the quality, effectiveness, and appropriateness of health programs by synthesizing the evidence and translating it into practice (evidence-based practice). Review of the literature should be guided by the fol- lowing question: What can be learned from the experience of others in similar circumstances?
Some alternative solutions to the problem will have more risks or uncertainties than others. The nurse must decide between a solution that involves more risk and a solution that is free of risk. A “do nothing” decision is always the decision with the least risk to the provider. When choosing a solution, the nurse looks at whether the desired outcome can be achieved. After careful thought about each possible solution to the problem, the nurse rethinks the solutions. The assessment data compiled during the formulation stage should be used to develop alternative solutions.
Decision trees are useful graphic aids that give a picture of the solutions and the risks of each solution. Such a picture graph of the process of identifying a solution helps clients and administrators rank the consequences of a decision (Sanders, 2009). Figure 25-2 shows an example of a decision tree.
As shown in Figure 25-2, the best consequence would be for each low-income child to be given flu immunization by their private physician. One must consider the value of this action to the person, the odds that immunizations will be obtained, the cost to families as opposed to the taxpayer, and the cost to the community. Costs to the community include the possibility of increased incidence of communicable disease or mortality and increased need for more expensive services to treat the diseases if vulnerable people are not immunized. Conversely, if families
FIG 25-2 Ranking of solutions to a problem: providing a preschool immunization program to low-income children using a decision tree.
Provide nursing clinics in daycare centers, parents pay
Set up health department nursing clinics for all ages of children Some private pay/some taxpayer pays
Provide education program and ask parents to provide for child’s immunizations All parents will take children
to private physician
Of the children enrolled, some will be immunized
Children enrolled in daycare will be immunized
Some children will be immunized
Children will not be immunized
All children will be immunized
Fourth best consequence
Fifth best consequence
Third best consequence
Second best consequence
Worst consequence
Best consequence
Provide program
Solution Alternatives Uncertain risks Consequences
554 PART 4 Issues and Approaches in Population-Centered Nursing
target population, and therefore the greater the probability that the program will achieve its objectives and result in positive changes in health (Issel, 2013). The planning process may be compared with the nursing process (Table 25-4).
Objectives Development for Program Planning and Evaluation The most important step in the planning and evaluation process is the writing of program objectives. The objectives provide direction for conducting the program, and they provide the mechanism for evaluating specific activities and the total program. The following discussion addresses the development of well-written objectives. Development of program objectives begins with the initial phases of program planning.
Specifying Goals and Objectives A program may begin with a mission statement. This is a broad general statement of the overall conceptual framework or phi- losophy of the program. The mission statement clarifies the values and overall purpose of the program and provides a framework for the goals and objectives that follow.
A goal is a statement that describes the general direction of logical response to a demonstrated need. One or two goals are often sufficient for a program to state how it will resolve or lessen the problem defined in the need statement. The goals should be consistent with the values and overall intent set forth in the mission statement. Their purpose is to focus on the major reason for the program, to support the mission. The goals are also the basis for writing the objectives for the program and the action steps that reflect the overall goal accomplishment. • Mission—statement of values • Goal—overall aim
Evaluating In the evaluation phase of the plan, each alternative is weighed to judge the costs, benefits, and acceptance of the idea to the client population, community, and providers. The information outlined in the detailing phase would be used to rank the solu- tions for choice by the client population and provider on the basis of cost, benefit, and acceptance. Consideration must be given to the solution that will provide the desired outcomes. Review of the literature or interviews might disclose whether someone else had previously tried each of the options in another place, and what costs and outcomes occurred. The experience of others in similar circumstances is helpful in deciding whether a chosen solution would be useful.
Implementing In the planning process, the clients, providers, and administra- tors selected the best plan to solve the original problem. Provid- ing reasons why a particular solution was chosen will help the provider get the approval of the agency administration for the plan. Once approved, the plan is implemented.
Implementation requires obtaining and managing the resources required to operationalize the program in a way that is consistent with the plan. Program implementation requires accountability and responsibility (Issel, 2013). Change theory can be useful to help create an environment in which the program is supported.
Community members may participate in implementing the program either as volunteers or as paid staff. Program success will be increased if community residents are included in the work of the program and if they are on advisory boards and participate in program evaluation. The greater the participation of community members in developing a program, the greater the sense of ownership of that program by members of the
Nursing Process Basic Planning Process
Assessment Formulation Subjective and objective data are systematically collected. Assess the client’s need and define the problem.
Nursing Diagnosis Conceptualization Client’s problem is defined by using the assessment data to guide the
nurse in looking for similar patterns in the systematically collected subjective and objective data.
Provider group identifies solutions; each solution is examined for its risks, consequences, and expected outcomes.
Detailing Client and provider analyze solutions proposed in the conceptualizing phase for
costs, resources, and program activities.
Evaluation of the Plan Client, providers, and administrators select best plan based on costs, benefits,
and acceptability of the plan to the client and provider.
Implementation Best plan (solution) based on input from the client and provider is presented to
administration and implemented.
Program Evaluation Implemented best plan (solution) is evaluated.
Nursing Intervention Any direct care treatment or nursing action based on the nursing diagnosis
is performed by a nurse and includes rationale that justifies the treatment or nursing action. Treatment or action is evaluated by the nurse for its appropriateness and acceptability to the client before implementation.
Implementation Direct care treatment or nursing action established in the intervention is
implemented.
Evaluation Implementation of the nursing intervention is evaluated.
TABLE 25-4 Comparison of the Nursing Process and Program Planning
555CHAPTER 25 Program Management
• Objectives—specific measurable outcomes • Action steps—explicit actions to accomplish objectives
Objectives are concise statements describing in measurable and time-bound terms precisely what specific outcome is to be accomplished. Measurable means that the objective contains the specific outcome anticipated that could be documented with collectable data. Time-bound means that the objective contains the target date when the specific outcome will be accomplished. Objectives should be realistic and attainable means to meet the program goal (CDC, 2014; UNC, 2014).
Clear, concise, and measurable objectives help with evaluat- ing the program. If the objectives are too general, program evaluation becomes impossible. The objectives must be specific and stated so that anyone reading them could conduct the program without further instruction. The document Healthy People 2020 (USDHHS, 2010) may be used as a template to guide the development of more specific objectives that are tai- lored to address the needs of a given community.
Useful program objectives include a statement of the specific behaviors that the program will accomplish, and success crite- ria, or expected results, for the program. Each program objec- tive requires a strong, action-oriented verb to specify the behavior; a statement of a single purpose; a statement of a single result; and a time frame for achieving the expected result.
For example, a general program goal may be to reduce the incidence of low-birth-weight babies in Center County by 2020 by improving access to prenatal care. Several specific objectives are required to meet a general program goal. A specific objective for this program may be to open (action verb) a prenatal clinic in each health department within the county by January 2015 (time frame) to serve the population within each census tract of the county (purpose) to improve pregnancy outcomes (result).
As objectives are developed, an operational indicator for each objective should be considered so the evaluator knows when and if the objective has been met. For instance, an operational indicator for the previous objective would be a 10% to 25% increase in the use of prenatal care by women in Center County. Such indicators provide a target for persons involved with implementing programs. A review of Healthy People 2020 health objectives will give the reader examples of objectives that include all the elements just listed.
Action steps are written for each program objective. An action step is defined as a concise statement describing precisely how (by what method), when, and by whom each activity will be accomplished to achieve the objective for which it was written. These activities address resources, such as number of nurses, equipment, supplies, and location. A time frame is planned for each activity. It is assumed that as each specific objective is met, progress is made toward achieving the general program objective (or goal) (Box 25-1).
PROGRAM EVALUATION Benefits of Program Evaluation Program evaluation is a method of ensuring that a program has met its goals (CDC, 2014). It is a means of documenting accountability by the program managers to the clients and the
Excerpted from Jefferson Area Board of Aging: What we do and who we are. JABA facts, 2010. Available at http://www.jabacares.org/. Accessed January 31, 2011.
The Jefferson Area Board for Aging (JABA) has created a vision for the one- city, five-county planning district. In concert with 85 public and private orga- nizations and more than 500 individuals, they developed a comprehensive community plan, known as the “2020 Community Plan on Aging.” The plan started with a comprehensive community assessment that addressed the livability for elders in the community. The “2020 Community Plan on Aging” has been an asset for the community in providing guidance for specific pro- grams at JABA and throughout the community. In September 2005 the city of Charlottesville and the surrounding counties were honored when presented with the U.S. Department of Health and Human Services, Administration on Aging (AOA), “Livable Communities for All Ages” award. Seven communities received the award for their model efforts to make their communities more supportive places to live and grow for seniors and all populations. The competition was administered by the Center for Home Care and Policy Research, Visiting Nurse Service of New York, with the participation of the American Planning Association and the International City/County Manage- ment Association.
BOX 25-1 Planning Programs for Elders in the Community
funding sources. The major benefit of program evaluation is that it shows whether the program is fulfilling its purpose and whether the program addresses merit or quality, worth or value (such as cost effectiveness), and significance or importance (CDC, 2012). It should answer the following questions: 1. Are the needs for which the program was designed being
met? 2. Are the problems it was designed to solve being solved? This is critical information for program managers, funding agencies, top-level decision-makers, program accreditation reviewers, health providers, and the community. Evaluation data are used to make judgments about a program and may be used to justify sustaining the program, making adjustments in the program, expanding or reducing the program, or even dis- continuing it.
Process evaluation, also referred to as formative evaluation or the evaluation of implementation, occurs while the program is being implemented. This type of evaluation makes it possible to do mid-program corrections to ensure achievement of program goals. Designing the evaluation during the planning phase of the program allows the evaluation to be guided by the program goals (Issel, 2013). Brownson, Fielding, and Maylahn (2009) describe process evaluation as an ongoing function of examining, docu- menting, and analyzing the progress of a program. Changes are required when there is an unacceptable difference between what was observed and what was anticipated from the implementa- tion of program activities. Corrective action may then be taken to get the program back on track. This description of process evaluation is consistent with what the USDHHS (2011) refers to as implementation evaluation. Four critical questions are addressed when monitoring a program (USDHHS, 2011): (1) Are the activities taking place, (2) Who is conducting the activi- ties, (3) Who is reached through the activities, and (4) Have sufficient inputs been allocated or mobilized?
556 PART 4 Issues and Approaches in Population-Centered Nursing
USDHHS: Healthy People 2020: A Roadmap for Health. Washington, DC, 2010, U.S. Government Printing Office.
HEALTHY PEOPLE 2020
Focus Area Overall Goal Objective Measuring the Objective
IID-23: Immunization and infectious diseases
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
IID-11: Increase routine vaccination coverage levels for adolescents.
IID: 11-1: Increase (action verb) to one dose of tetanus-diphtheria-acellular pertussis (Tdap) booster vaccine by 13 to 15 years (purpose) for 80% of this age group (operational indicator) by 2020 (time frame).
Example of Healthy People 2020 Goals for Program Planning
HOW TO Develop a Program Plan
Developed by M. Stanhope and based on the Basic Program Planning Model (Nutt, 1984: Issel, 2013)
A. Define the problem B. Formulate the plan
1. Assess population need a. Who is the program population? b. What is the need to be met? c. How large is the client population to be served? d. Where are they located? e. How does the target population define the need? f. Are there other programs addressing the same need?
(Describe.) g. Why is the need not being met?
2. Establish program boundaries a. Who will be included in the program? b. Who will not be included? Why? c. What is the program goal?
3. Program feasibility a. Who agrees that the program is needed (stakeholders:
administrators, providers, clients, funders)? b. Who does not agree?
4. Resources (general) a. What personnel are needed? What personnel are available? b. What facilities are needed? What facilities are available? c. What equipment is needed? What equipment is available? d. Is funding available to support the project? Is additional
funding needed? e. Are resources being donated (space, printing, paper, medical
supplies)? (1) Type (2) Amount
5. Tools used to assess need a. Census data b. Key informants c. Focus groups d. Community forums e. Existing program surveys f. Surveys of client population g. Statistical indicators (e.g., demographic and morbidity/
mortality data) C. Conceptualize the problem
1. List the potential solutions to the problem. 2. What are the risks of each solution? 3. What are the consequences?
4. What are the outcomes to be gained from the solutions? 5. Draw a decision tree to show the problem-solving process
used. D. Detail the plan
1. What are the objectives for each solution to meet the program goal?
2. What activities will be done to conduct each of the alternative solutions listed under C1 and based on objectives?
3. What are the differences in the resources needed for each of the alternative solutions?
4. Which of the alternative solutions would be chosen if the resources described under B4 were the only resources available?
5. Who would be responsible or accountable for implementing the plan?
E. Evaluate the plan 1. Which of the alternative solutions is most acceptable to the
following: a. The client population b. The agency administrator c. You d. The community
2. Which of the alternative solutions appears to have the most benefits to the following: a. The client population b. The agency administrator c. You d. The community
3. On the basis of cost, which alternative solution would be chosen by the following: a. The client population b. The agency administrator c. You d. The community
F. Implement the program plan 1. On the basis of data collected, which of the solutions has been
chosen? 2. Why should the agency administrator approve your request?
Give a rationale. 3. Will additional funding be sought? 4. When can the program begin? Give date.
557CHAPTER 25 Program Management
FIG 25-3 Six steps in planning for program evaluation.
Plan methodology for evaluation
Review literature
Hold meeting to discuss pros and cons of evaluation
Make decision to evaluate
Identify relevant people for evaluation
Write plan for evaluation process
Quality assurance programs are prime examples of program evaluation in health care delivery. Evaluation data are used to justify continuing programs in public health. Program evalua- tion focuses on whether goals were met and the efficiency and effectiveness of program activities. Many methods of program evaluation are described in the literature. One of the primary methods of evaluation used in health care today is Donabedi- an’s (1982; updated in 2003) classic evaluative framework, which examines the structure, process, and outcomes of a program. Other models and frameworks have been developed using this approach (McDonald, 2007). The tracer method and case register are examples of other methods applied to program evaluation. (See Chapter 26 for further discussion.)
Program records and a community index serve as the major source of information for program evaluation. Surveys, inter- views, observations, and diagnostic tests are ways to assess client and community responses to health programs. Cost studies help identify program benefits and objectiveness (Refer to chapter 5) (CDC, 2012).
As financial resources become scarce, nursing and the health care system must be able to justify their existence, prove that their services are responsive to client needs, and show their concern for being accountable. Planning and evaluation will assist in meeting these objectives.
Planning for the Evaluation Process Planning for the evaluation process is an important part of program planning. When the planning process begins, the plan for evaluating the program should also be developed. All persons to be involved in implementing a program should be a part of the plan for program evaluation. Assessment of need is one component of evaluation. The basic questions to be answered, after carefully considering the data collected from a census, key informants, community forums, surveys, or health statistics indicators, are as follows: 1. Will the objectives and resources of this program meet the
identified needs of the client population? 2. Is the program relevant?
Once need has been established and the program is designed, the nurse must continue plans for program evaluation. As a part of the planning process, Posavac (2011) described six steps to use for continuing program evaluation (Figure 25-3): 1. Identify the key people for evaluation. Program personnel,
program funders, and the clients of the program should be included in planning for evaluation.
2. Arrange preliminary meetings to discuss the question of how the group wants to evaluate the program and where to start. If the program planners and others agree on an evaluation, the resources needed to do the evaluation must be identified. Evaluation is necessary even though some may not be inter- ested in it. Nurses can help others see that without evaluation, money to support programs will not be available, or the need for a new nurse to help with the work cannot be justified. In health care today, there is great emphasis on outcomes of care. The only way to see outcomes is through evaluation.
3. After the key people have met and considered the questions in the previous steps, they are ready to begin the evaluation
process. Even though evaluation may be desired, the decision to conduct the evaluation may be an administrative one, based on available resources and existing circumstances. For example, if a program evaluation were attempted in a situation in which program personnel wanted it but clients chose to be uncoop- erative, evaluation efforts would be unsuccessful.
4. Examine the literature for suggestions about the appropriate methods and techniques for evaluation and their usefulness in program evaluation. If an agency has chosen to use an external evaluator, this person may make suggestions about the questions to be answered in the evaluation process. These questions are based on the program goals. Nurses who have reviewed the literature and communicated with others affected by the evaluation can determine whether the evalu- ation suggestions are appropriate for the situation.
5. Plan the method to be used, including decisions about what goals and objectives will be measured, how they will be mea- sured, and for what population.
6. Write a plan that outlines the mission and goals of the overall program, the type of evaluation to be done, the operational measures to be used to evaluate the program goals, the choice of who will do the evaluation (i.e., internal or external person- nel), the available resources for conducting the evaluation, and the readiness of the organization, personnel, and clients for program evaluation. Nurses at all levels of education and prepa- ration can participate in program planning and evaluation.
Evaluation Process A framework for evaluation in public health has been developed by the Centers for Disease Control and Prevention (CDC) to
558 PART 4 Issues and Approaches in Population-Centered Nursing
guide understanding about program evaluation and to facilitate integration of evaluation in the public health system. This framework defines program evaluation as a systematic way to improve and to account for public health actions by using methods that are useful, feasible, ethical, and accurate. Six inter- dependent steps are identified that must be part of an evalua- tion process (USDHHS, 2011): 1. Engage stakeholders—This includes those who are involved
in planning, funding, and implementing the program, those who are affected by the program, and the intended users of its services.
2. Describe the program—The program description should address the need for the program and should include the mission and goals. This sets the standard for judging the results of the evaluation.
3. Focus the evaluation design—Describe the purpose for the evaluation, the users who will receive the report, how it will be used, the questions and methods to be used, and any necessary agreements.
4. Gather credible evidence—Specify the indicators that will be used, sources of data, quality of the data, quantity of infor- mation to be gathered, and the logistics of the data gathering phase. Data gathered should provide credible evidence and should convey a well-rounded view of the program.
5. Justify conclusions—The conclusions of the evaluation should be validated by linking them to the evidence gathered and then appraising them against the values or standards set by the stakeholders. Approaches for analyzing, synthesizing, and interpreting the evidence should be agreed on before data collection begins to ensure that all needed information will be available.
6. Ensure use and share lessons learned—Use and dissemination of findings require deliberate effort so that the lessons learned can be used in making decisions about the program (CDC, 2012).
Sources of Program Evaluation Both quantitative and qualitative methods may be used to conduct an evaluation; however, the strongest evaluation designs combine both qualitative and quantitative methods. Major sources of information for program evaluation are the program clients, program records, and community indexes.
Qualitative methods such as site visits, structured observa- tions of interventions, or open-ended interviews may be used (Trickett et al, 2011). The program participants, or clients of the service, have a unique and valuable role in program evaluation. Whether the clients, for whom the program was designed, accept the services will determine to a large extent whether the program achieves its goal. Thus, their reactions, feelings, and judgments about the program are very important to the evalu- ation. For example, to garner feedback from participants in a program, an evaluator may use a written survey in the form of a questionnaire or an attitude scale. Interviews and observa- tions are other ways of obtaining feedback about a program. Attitude scales are probably used most often, and they are usually phrased in terms of whether the program met its objec- tives. The client satisfaction survey is an example of an attitude
scale often used in the health care delivery system to evaluate the program objectives (Finkelstein et al, 2011). Client input into the development of evaluation tools ensures that the ques- tions and approaches are more acceptable to the clients and that the tools effectively elicit the information needed.
The second major source of information for program evalu- ation is program records, especially clinical records. Clinical records provide the evaluator with information about the care given to the client and the results of that care. To determine whether a program goal has been met, one might summarize the data from a group of records. For example, if one overall goal were to reduce the incidence of low-birth-weight babies through prenatal care, records would be reviewed to obtain the number of mothers who received prenatal care and the number of low-birth-weight babies born to them. Records would be reviewed from the beginning of the program and at the end of a specific time frame, such as at the end of each year. Care must be taken to ensure that any review and use of clinical records complies with HIPAA regulations. (For details about HIPAA compliance, see http://aspe.hhs.gov/admnsimp/index.shtml.)
The third major source of evaluation is epidemiologic data. Mortality and morbidity data measuring health and illness are probably cited more frequently than any other single index for program evaluation. These health and illness indicators are useful in evaluating the effects of health care programs on the total community. Incidence and prevalence data are valuable indexes for measuring program effectiveness and impact, and these data are readily available on the Internet. Useful sites for such data include vital statistics available at state department of health sites, the CDC, and the U.S. Census site. Most counties and communities have their own sites, and many of these contain very useful demographic and health data.
An example of a national program based on a needs assess- ment of the U.S. population is the national health objectives program Healthy People 2020 (USDHHS, 2010). Healthy People documents have been published every 10 years since 1980. The data gathered from each 10-year period have been used to eval- uate the population needs met and the assessment of needs for the next Healthy People document.
The Healthy Communities Program (USDHHS, 2010) and named community health status indicators project suggests activities to evaluate national health objectives related to com- munities. The example shown in the Healthy People 2020 box on p. 559 highlights injury and violence prevention. This box shows that objectives include an action verb, a result, an opera- tional indicator, and a time frame for implementing the objec- tive (10 years, begun in 2010).
The Levels of Prevention box provides examples of applying levels of prevention to program planning and evaluation.
Aspects of Evaluation The aspects of program evaluation include the following (USDHHS, 2011): 1. Relevance—Need for the program 2. Adequacy—Program addresses the extent of the need 3. Progress—Tracking of program activities to meet program
objectives
559CHAPTER 25 Program Management
4. Efficiency—Relationship between program outcomes and the resources spent
5. Effectiveness—Ability to meet program objectives and the results of program efforts
6. Impact—Long-term changes in the client population 7. Sustainability—Enough resources to continue the program The How To box suggests questions that may be asked about program evaluation using this process.
The following paragraphs provide an explanation of each step in program evaluation.
Relevance. Evaluation of relevance is an important compo- nent of the initial planning phase. As money, providers, facili- ties, and supplies for delivering health care services are more closely monitored, the needs assessment done by the nurse will determine whether the program is needed.
Adequacy. Evaluation of adequacy looks at the extent to which the program addresses the entire problem defined in the needs assessment. The magnitude of the problem is determined by vital statistics, incidence, prevalence, and expert opinion.
Progress. The monitoring of program activities, such as hours of services, number of providers used, number of refer- rals made, and amount of money spent to meet program objec- tives, provides an evaluation of the progress of the program. This type of evaluation is an example of formative or process evaluation, which occurs on an ongoing basis while the program exists. This provides an opportunity to make effective day-to- day management decisions about the operations of the program. Progress evaluation occurs primarily while implementing the program. The nurse who completes a daily or weekly log of clinical activities (e.g., number of clients seen in clinic or visited at home, number of phone contacts, number of referrals made, number of community health promotion activities) is contrib- uting to progress evaluation of the nursing service.
Efficiency. If the reason for evaluation is to examine the effi- ciency of a program, it may occur on an ongoing basis as forma- tive evaluation or at the end of the program as a summative evaluation. The evaluator may be able to determine whether the program provides better benefits at a lower cost than a similar program, or whether the benefits to the clients, or number of clients served, justify the costs of the program.
USDHHS: Healthy People 2020: A Roadmap for Health. Washington, DC, 2010, U.S. Government Printing Office.
HEALTHY PEOPLE 2020
1. Access to Health Services 2. Adolescent Health 3. Arthritis, Osteoporosis, and Chronic Back Conditions 4. Blood Disorders and Blood Safety 5. Cancer 6. Chronic Kidney Diseases 7. Dementias, including Alzheimer’s 8. Diabetes 9. Disability and Health
10. Early and Middle Childhood 11. Educational and Community-Based Programs 12. Environmental Health 13. Family Planning 14. Food Safety 15. Genomics 16. Global Health 17. Healthcare-Associated Infections 18. Health Communication and Health IT 20. Hearing and Other Sensory or Communication Disorders (Ear, Nose,
Throat—Voice, Speech, and Language) 21. Heart Disease and Stroke 22. HIV 23. Immunization and Infectious Diseases 24. Injury and Violence Prevention 26. Maternal, Infant, and Child Health 27. Medical Product Safety 28. Mental Health and Mental Disorders 29. Nutrition and Weight Status 30. Occupational Safety and Health 31. Older Adults 32. Oral Health 33. Physical Activity and Fitness 34. Preparedness 35. Public Health Infrastructure 36. Respiratory Diseases 37. Sexually Transmitted Diseases 38. Sleep Health 40. Substance Abuse 41. Tobacco Use 42. Vision
Objectives Focus Areas
Three other objectives are under development: numbers 19, 25, 39.
USDHHS: Healthy People 2020: A Roadmap for Health. Washington, DC, 2010, U.S. Government Printing Office.
HEALTHY PEOPLE 2020
In the Healthy People focus area of injury and violence prevention, one objec- tive is: • IPV-5: Increase (action verb) the number of States and the District of
Columbia where 90% of deaths of children aged 17 years and under (operational indicator) due to external causes are reviewed by a child fatal- ity review team (purpose), by 2020 (time frame).
Example of a Measurable National Health Objective
LEVELS OF PREVENTION
Primary Prevention Plan a community-wide program with the local school system and health department to serve healthy meals and snacks in all schools to promote good childhood nutrition.
Secondary Prevention Develop screening programs for all school children to determine the incidence/ prevalence of childhood obesity before implementing the program.
Tertiary Prevention Evaluate the incidence/prevalence of obesity among school children after the implementation of the program and provide programs to reduce complications from the condition.
Program Planning and Evaluation
560 PART 4 Issues and Approaches in Population-Centered Nursing
c. Although this program costs more/less than expected, is it needed? Why?
2. Productivity (may use national or state averages for comparison) a. How many clients does each type of staff see per day
(e.g., registered nurses, clinical nurse specialists, nurse practitioners)?
b. How does this compare with similar programs? c. Although the productivity level of this program is low/high,
is the program needed? Why? 3. Benefits
a. What are the benefits of the program to the clients served? b. What are the benefits to the community? c. Are the benefits important enough to continue the program?
Why? (Look at cost, productivity, and outcomes of care.) E. Program effectiveness (summative)
1. Satisfaction a. Is the client satisfied with the program as designed? b. Are the providers satisfied with the program outcomes? c. Is the community satisfied with the program outcomes?
2. Goals a. Did the program meet its stated goal? b. Are the client needs being met? c. Was the problem solved for which the program was
designed? F. Impact (summative)
1. Long-term changes in health status (1 year or more) a. Have there been changes in the community’s health? b. What are the changes seen (e.g., in morbidity or mortality
rates, teen pregnancy rates, pregnancy outcomes)? c. Have there been changes in individuals’ health status? d. What are the changes seen? e. Has the initial problem been solved or has it returned? f. Is new or revised programming needed? Why? g. Should the program be discontinued? Why?
G. Sustainability 1. Was the program funded as a demonstration or by an external
agency? 2. Can money and resources be found to continue the program
after the initial funding is gone? Depending on the answers to the questions, the program can be
found to be successful or unsuccessful.
HOW TO Do a Program Evaluation To do a program evaluation, first choose the type of evaluation you wish to conduct. Second, identify the goal and objectives for the evaluation. Third, decide who will be involved in the evaluation. Fourth, answer the questions related to the type of evaluation as follows: A. Program relevance: needs assessment (formative)
1. Use answers to all questions listed in section B of How To Develop a Program Plan.
2. On the basis of the needs assessment, was the program necessary?
B. Adequacy 1. Is the program large enough to make a positive difference in
the problem/need? 2. Are the boundaries of the services defined so that the problem/
need can be addressed for the target population? C. Program progress (formative)
1. Monitor activities (circle which this reflects: daily, weekly, monthly, annually). a. Name the activities provided. b. How many hours of service were provided? c. How many clients have been served? d. How many providers are there? e. What types of clients have been served? f. What types of providers were needed? g. Where have services been offered (e.g., home, clinic,
organization)? h. How many referrals have been made to community sources? i. Which sources have been used to provide support
services? 2. Budget
a. How much money has been spent to carry out activities? b. Will more/less money be needed to conduct activities as
outlined? c. Will changes to objectives and activities be needed to
sustain the program? d. What changes do you recommend and why?
D. Program efficiency (formative and summative) 1. Costs
a. How do costs of the program compare with those of a similar program to meet the same goal?
b. Do the activities outlined in C1 compare with the activities in a similar program?
Effectiveness and impact. An evaluation of program effective- ness may help the nurse evaluator determine both client and provider satisfaction with the program activities, as well as whether the program met its stated objectives. However, if eval- uation of impact is the goal, long-term effects such as changes in morbidity and mortality must be investigated. Both effective- ness and impact evaluations are usually summative evaluation functions primarily performed as end-of-program activities.
Sustainability. A program can be continued only if there are resources for the program. Ongoing evaluation of sustainability is important!
ADVANCED PLANNING METHODS AND EVALUATION MODELS After a need and a client demand for a program have been determined through the needs assessment process, the next step
in the development of the program is to choose a procedural method that will assist the nurse in planning the program to be offered. The following is offered for students who are more advanced in their career and need to consider several methods of program planning plus more extensive evaluation models for program management.
Five planning methods are discussed in this section: 1. Program planning method (PPM) 2. Multi-attribute utility technique (MAUT) 3. Planning Approach to Community Health (PATCH) 4. Assessment Protocol for Excellence in Public Health
(APEXPH) 5. Mobilizing for Action through Planning and Partnership
(MAPP) PPM is a more general approach to program planning,
whereas MAUT offers guidelines for identifying and tracking specific program activities essential to program success. PATCH,
561CHAPTER 25 Program Management
Basic Planning PPM PATCH APEXPH MAUT MAPP
Formulating Problems identified by client.
Community members identify health priorities.
Assess community capacity to address health problems.
Identify target populations and program objectives.
Assess community themes and strengths, health status, and strategic issues.
Conceptualizing Provider group identifies solution.
Stakeholders use data to develop program activities.
Assess with community the strengths and health problems.
Identify alternative problem solutions.
Formulate goals and strategies.
Detailing Analyze available solutions.
Design comprehensive program to meet identified health priorities.
Choose plan based on community capacity resources.
Identify criteria for choice; rank and weight; calculate value.
Develop plan for action; engage in visioning.
Evaluating Clients, providers, and administrators select best plan.
Use process evaluation to improve program.
Support recommendations for program change.
Choose best alternatives.
Evaluate the plan.
Implementing Best plan presented to administrators for funding.
Partners implement the plan.
Assess community ability to change and implement the plan.
TABLE 25-5 Planning Methods Compared with Basic Planning Process
APEXPH, and MAPP are PPMs that were designed by the CDC and the National Association of County Health Officials with input from local and state health departments. All of these approaches establish the basis for program evaluation.
Program Planning Method PPM is a technique using the nominal group technique described by Delbecq and Van de Ven in 1971. The nurse can use this method to involve clients more directly in the planning process. PPM is a five-stage process to identify program needs. It focuses on three levels of planning groups composed of clients, providers, and administrators. The client or consumer group relays a list of problems to the provider group, who in turn aids the client group by presenting the solutions to the problems to the administrative group (Issel, 2013).
The stages of PPM are compared with MAUT’s planning process in Table 25-5. The five stages are as follows: 1. Problem diagnosis. Each client in the group works with all
other members of the group to develop a written problem list, one problem at a time. After all problems have been shared and recorded, they are discussed by the total client group. After the discussion, clients select the problems with the highest priority by voting on the ranking of each problem.
2. Expert provider group identifies solutions for each of the prob- lems identified by the clients.
3. Client and provider groups present their problems and sug- gested solutions to the administrative group to determine the possibilities of developing a program to resolve one or more of the problems using one or more of the solutions. In this phase, clients and providers are seeking acceptance from the administrators who control the program resources.
4. Alternative solutions to the problem are identified, and the pros and cons of each are analyzed.
5. Clients, providers, and administrators select the best plan for program implementation. In this phase, the link between
the planned solutions and the problem is evaluated, pointing out strengths and limitations of the proposed program plan. A nurse might use this technique for developing school
health services within the total community or in one school. A nurse working with a senior citizens group might use this method to identify the priority needs for nursing clinic services at the health department. It is important to note that this method is used to obtain consensus among all persons involved in the program: clients, providers, and administrators. Consen- sus is most helpful in having a successful program. The process may also be used in a community decision-making activity in which community representatives come together to decide health care service needs for the entire community.
Multi-Attribute Utility Technique MAUT is a planning method based on decision theory (Saaty and Vargus, 2013). This method can be adapted for making decisions about the care of a single client or about national health care programs. Recently it has been used to evaluate nursing practice. The purpose of MAUT is to separate all ele- ments of a decision and to evaluate each element separately for its effects on the overall decision, considering available options.
If money is no object, then the option with the highest use value is the best decision. However, if this option exceeds the budget, the next best option may be the alternative to choose. The steps of MAUT (listed in Box 25-2) relate closely to the basic planning process described by Nutt (1984) as shown in Table 25-5.
Steps 1 and 2 of MAUT relate to problem formulating. Step 3 involves conceptualizing the program alternatives, and steps 4 through 9 focus on detailing and the implications of each option. Step 10 involves the evaluating phase of planning or the choice of the best solution as identified in steps 4 through 9. Placing quantitative values on solutions to meet program needs is most helpful in the implementing phase of planning
562 PART 4 Issues and Approaches in Population-Centered Nursing
(e.g., convincing administrators of the need for such a program). However, caution must be taken in using all planning methods, because the best solution reflects the bias of the planner.
Planning Approach to Community Health (PATCH) The PATCH model, which has not been emphasized as much in recent years, was developed in the 1980s by the CDC with input from state and local health departments. The model was developed using as a framework the PRECEDE model devel- oped by Laurence Green in the 1970s. The PRECEDE model was used originally for planning health education programs (Glanz and Bishop, 2010).
Although this model was originally developed to strengthen health promotion activities, the PATCH model is used by communities and agencies to plan, develop, implement, and
Kabassi K, Vroom M: MAUT and adaptive techniques for web based educational software. Instruct Sci 34(2):313–358, 2006.
1. Identify the person or aggregate for whom a problem is to be solved. Who is the client for whom the program is being planned?
2. Identify the issue(s) or decision(s) that is (are) relevant. This step involves the identification of the program objectives.
3. Identify the options to be evaluated. The program planner identifies the available options or action alternatives to accomplish the program goals.
4. Identify the relevant criteria related to the value of each option. The program planner places a value on competing options or alternatives or identifies criteria to be considered in making a choice between them.
5. Rank the criteria in order of importance. The program planner decides which of the criteria are most important and which are least important for meeting program goals.
6. Rate criteria in importance. In this step the program planner assigns an arbitrary rating of 10 to the least important criterion. In considering the next least important criterion, the planner decides how many times more important it is than the least important criterion. If it is considered twice as important, the dimension will be assigned a 20. If it is only considered half as important, it will be assigned a 15. If it is considered four times as important, it will be assigned a 40. The process is continued until all criteria have been rated.
7. Add the importance rate, divide each by the sum, and multiply by 100. This process is called normalizing the weights. It is recommended that the number of criteria be kept between 6 and 15. Therefore, in this initial process, the planner can be concerned with only general criteria for choosing action alternatives.
8. Measure the location of the option being evaluated by each criterion. The planner may ask a colleague or expert to estimate on a scale of 0 to 100 the probability that a given option from step 3 will maximize the value of the criterion from step 4.
9. Calculate the use of options. The program planner will obtain the useful- ness of each identified action alternative by multiplying the weight for each criterion (step 7) by the rating of an option for each criterion (step 8) and adding the products. The sum of the products for each action is termed the aggregate utility.
10. Decide on the best alternative to meet the program objective. The action alternative with the highest aggregate use is considered the best decision for meeting the program objectives.
BOX 25-2 Ten Basic Steps of the Multi- Attribute Utility Technique Method
evaluate both health promotion and disease prevention pro- grams. Application of PATCH emphasizes community partici- pation and ownership by all who are involved. The PATCH process includes the following: • Mobilizing the community • Collecting and analyzing data to support local health issues • Choosing health priorities • Setting objectives and standards to denote progress and
success • Developing and implementing multiple intervention strate-
gies to meet objectives • Evaluating the process to detect the need for change • Securing support of the public health infrastructure within
the target community These elements are essential to the success of any community-
based program: • Participation in the planning process by community
members (stakeholders) • Use of data to help stakeholders select health priorities and
develop and evaluate program activities • Development by stakeholders of a comprehensive approach
to design the program to meet the identified health needs • Use of process (formative) evaluation to improve the
program and provide feedback to the stakeholders • Increase in the capacity of the community to address a
variety of health priorities by improving the health program planning skills of the stakeholders The PATCH model has been useful in developing programs
to address Healthy People 2020 goals (http://www.cdc.gov). PATCH materials are available online at the CDC.
Assessment Protocol for Excellence in Public Health (APEXPH) Following the development of the PATCH model in 1987, the CDC, partnering with the National Association of City and County Health Officers (NACCHO) and other organizations, developed its APEXPH model. The model was introduced for use in 1999.
The APEXPH model incorporates the three core functions of public health in assessment, assurance, and policy develop- ment. Although the model was developed for use by local health departments, it can be adapted to fit other situations and resources. The model framework includes the following: • Process for assessing agency organization and management • Process for working with communities to assess the health
of a community as well as a community’s strengths and health problems
• Process for integrating plans for resolving health problems based on the capacity, resources, and community members partnering to implement the plan This model uses the strategic planning process of Nutt
(1984) and has three elements: 1. Assessing internal organization capacity to address the com-
munity’s health problems 2. Assessing and priority setting for the community’s health
problems 3. Implementing the plan to address these problems
563CHAPTER 25 Program Management
C. Engage in four assessment processes. 1. Assess community themes and strengths.
a. Identify issues. b. Identify interest to community. c. Explore quality of life perceptions. d. Identify community assets.
Application of the APEXPH process is useful for the following: • Supporting recommendations for change in programs/
services • Highlighting the need for improvements in program
functions If APEXPH is applied along with the project budget process,
key stakeholders may unite to discuss health and program pri- orities and options for providing services as well as to make plans for the year (http://www.cdc.gov). Workbooks and other resources are available through NACCHO at their website (http://www.naccho.org).
Mobilizing for Action through Planning and Partnership (MAPP) The strategic planning model MAPP can be applied at the com- munity level to improve the community’s health. Application of this model helps to identify public health issues and priorities and to identify resources to address the priorities.
As with PATCH and APEXPH, it is important that the com- munity feels ownership of the process. The community’s strengths, needs, and wishes are integral to the process.
Two figures (Figures 25-4 and 25-5) show the MAPP process and the community roadmap to a healthier community. The phases of the MAPP process are as follows: A. Organize for success/partnership development.
1. Organize agencies. 2. Recruit partners. 3. Prepare to implement MAPP.
B. Visioning. 1. Work toward long-range goals through a shared vision
and common values. FIG 25-4 MAPP process.
Visioning
Organize for success
Partnership development
Four MAPP assessments
Identify strategic issues
Formulate goals and strategies
Implement
Action
Evaluate Plan
Com munity themes and
stre ngths assessment
F o rc
e s
o f ch
a n g e
a ss
e ss
m e n t
L o ca
l p u b lic h
e a lth
syste m
a sse
ssm e nt
Community healthstatus assessmen t
FIG 25-5 MAPP roadmap to community’s health.
MAPP: Your community roadmap to health!
A Healthier
Community
Action Cycle
Formulate goals and strategies
Identify strategic issues
Our vision
Local public health
system assessm
ent
Community health status assessment
4 M AP
P as
se ss
me nts
Comm unity themes
and sy stem assessment
Forces of change assessment
Evalu ate
Implement Plan
564 PART 4 Issues and Approaches in Population-Centered Nursing
could be expressed in a broader sense through health promo- tion behaviors such as weight control, exercise, and absti- nence from tobacco and alcohol. Donabedian’s model of evaluating program quality is a
popular model and is widely used for evaluation in the health care field. It can be useful in evaluating program effectiveness. The Center for Medicare and Medicaid Services and other third-party payers are currently placing more emphasis on outcome evaluation. It is essential that nurses begin to develop outcome criteria for client interventions.
Tracer Method The Board of Medicine of the National Academy of Sciences developed a program to evaluate health service delivery called the tracer method (Papanicolas and Smith, 2013). The tracer method of evaluation of programs is based on the premise that health status and care can be evaluated by viewing specific health problems called tracers. Just as radioactive tracers are used to study the thyroid gland, specific health problems are selected to evaluate the delivery of health and nursing services. Examples of conditions selected as tracers are cardiovascular disease, diabe- tes, obesity, smoking patterns, and breast and cervical cancer. This approach can be used to compare the following: • Health status among different population groups and in dif-
ferent geographic locations • Health status in relation to social status, economic level,
medical care, nursing care, and behavioral variables • Various arrangements for health care delivery
The tracer method is a useful technique for looking at the efficiency, effectiveness, and effect of a program.
Case Register Systematic registration of a contagious disease has been a prac- tice for many years. Denmark began a national register of tuber- culosis in 1921 (Friis and Sellers, 2010). Its contribution to the reduction in the incidence of contagious diseases has been widely recognized. Case registers (Issel, 2013) are also used for acute and chronic diseases (e.g., cancer and myocardial infarction).
Registers collect information from defined groups, and the information may be used for evaluating and planning services, preventing disease, providing care, and monitoring changes in patterns and care. The method is described here because of its use in evaluation of services. The answers to the questions listed in Box 25-3, asked before and after implementing a program, give information about the effects of the program. A tubercu- losis register indicates the degree to which infection is being controlled. Cancer registers make state, regional, national, and international comparisons possible, and they provide clues to causes of disease. They are also used to direct the development of programs specific to population needs.
PROGRAM FUNDING Providing adequate funding for programs to meet the needs of populations can be a challenge to nurse managers in communi- ties. When money is not available to support endeavors that
2. Assess local public health system. a. Identify all agencies and other partners who contribute
to the public’s health. b. Measure each partner’s capacity to participate; what
can each partner contribute? c. Measure the performance of each partner; how have
they addressed issues in the past? 3. Assess the health status of the community.
a. Assess available data. b. Assess quality of life. c. Assess community risk factors.
4. Assess ability of community to change. a. Identify forces for change. b. Identify forces against change.
D. Identify strategic issues. 1. What are the health issues that need to be addressed? 2. Which are the most important? 3. Where should the community begin?
E. Formulate goals and strategies. 1. Which goals will be met? 2. Which strategies will be used to meet the goals?
F. Act. 1. Participants develop plan for action. 2. Implement the plan. 3. Evaluate the implementation. Two products are available to assist in implementing the
MAPP process (Figure 25-4): the NACCHO website (see the WebLinks on this book’s Evolve site) and the MAPP toolbox (http://www.naccho.org).
The five models of program planning presented here may be adapted to use with a single program or with a community.
Evaluation Models and Techniques Structure-Process-Outcome Evaluation The method for evaluation of programs by Donabedian (1982) was initially directed primarily toward medical care but is applicable to the broader area of health care. He describes three approaches to assessment of health care: structure, process, and outcome. • Structure refers to settings in which care occurs. It includes
materials, equipment, qualification of the staff, and organi- zational structure (Donabedian, 1982). This approach to evaluation is based on the assumption that, given a proper setting with good equipment, good care will follow. However, this assumption is not strongly supported.
• Process refers to whether the care that was given was “good” (Donabedian, 1982), competent, or preferred. Use of process in program evaluation may consist of observing practice but more likely consists of reviewing records. The review could focus on whether documentation of preventive teaching was on the clinical record. Audits using specific criteria are exam- ples of the use of process.
• Outcome refers to results of client care and restoration of function and survival (Donabedian, 1982), but is also used in the sense of changes in health status or changes in health- related knowledge, attitude, and behavior. Thus program outcomes may be expressed in terms of mortality, morbidity, and disability for given populations, such as infants, but they
565CHAPTER 25 Program Management
within both the public and private sectors. Identification of duplication or gaps in services that result in unmet needs should be addressed.
The second component is the description of the program that is being proposed. The program description should provide details about what is planned, how it will be done, where it will be done, and by whom. This section should present the reviewer with a clear understanding of the details of the program structure and function. It should be apparent that the program is realistic and can be accomplished. This section includes goals, objectives, action steps, and anticipated outcomes that describe how, when, and by whom each activ- ity will be accomplished to achieve the outcome of the objec- tive for which it was written.
Plans for evaluation address the method that will be used to ensure ongoing and timely review of the specific action steps and objectives involved in achieving the stated goal (formative) and to assess program outcomes (summative).
Applicants for grant funds should develop a realistic operat- ing budget that is appropriate to the requirements of the project. The budget represents the plan for how the program will be implemented and reflects the project’s proposed spend- ing plan.
serve the public good, nonprofit organizations may seek funding from outside the organization. Such funding may be in the form of gifts, contracts, or grants.
Gifts are philanthropic contributions from individuals, foundations, businesses, religious or civic organizations, or vol- untary associations. Many organizations engage in extensive development efforts to solicit monetary gifts that support the agency’s goals. Contracts are awarded for the performance of a specific task or service, usually to meet guidelines specified by the organization making the award. Contracts are frequently used by the government to purchase services of others to perform certain services. Grants are awards to nonprofit orga- nizations to allow recipients to implement activities of their own design that address the interests of the funding agency. Grants are given by the government, foundations, and corporations.
Nurse leaders working in nonprofit agencies may write grants to fund community programs that meet the needs of at-risk populations. Development of a proposal is guided by concepts and principles of program planning and evaluation that have been discussed in this chapter. Successful grant writing meshes the plan for the envisioned program of the applying organization with the criteria set forth by the funding agency. A grant proposal is a means of recording plans for establishing, managing, and evaluating a program into a written document. Funding agencies provide guidelines for grant appli- cations, and it is essential to follow those specific guidelines if grant funding is to be acquired. In general, however, most grant proposals include certain essential components.
First, it is important to identify the target population and define the problem(s) that the project intends to address. Spe- cific data, conditions, or circumstances that illustrate the problem and that document the need (e.g., environmental char- acteristics, economic conditions, population characteristics, and health status indicators) should be included and discussed. Health services should be discussed in relationship to availabil- ity, accessibility, and acceptability to the target population
1. What is the incidence of disease? What is the prevalence? What differ- ences in incidence and prevalence are there between one community and another?
2. What percentage of clients recover? What percentage die? 3. Where does death occur? 4. How long do clients wait before contacting a health care provider? 5. How long is it before they are seen by a health care provider? 6. How many cases are associated with other major risk factors? 7. How many cases are associated with environmental factors such as water
hardness or air pollution? 8. What happens after clients leave the hospital and when they return to
work? Are there rehabilitation programs? 9. How many clients had been seen by a health care provider shortly before
the problem occurred? 10. What prevention measures are taken for persons considered
susceptible?
BOX 25-3 Examples of Questions Asked About Cases for Case Register
LINKING CONTENT TO PRACTICE
Program planning skills and knowledge are essential for public health nurses. In Public Health Nursing: Scope and Standards of Practice (ANA, 2013), the first standard is that of assessment. This addresses the issue of conducting needs assessments and having the ability to collect multiple sources of data, analyze population characteristics, problem solve, and set priorities based on the data collected. Standard 2 speaks to using the assessment data to diag- nosis health problems with input from the client population. Standards 3 through 5 address the nurses’ roles in identifying health status outcomes, planning and implementing processes to address the health problem, and directing strategies to meet the outcomes. Standard 6 discusses the nurses’ role in evaluation including participating in process and outcome evaluation by monitoring activities in programs.
The four professional organizations dedicated to public health nursing—The Association of State and Territorial Directors of Nursing (now APHN), The Association of Community Health Nursing Educators, The Public Health Nursing section of the APHA, and the American Nurses Association—have banned together to form an organization called the Quad Council. This council developed a document identifying the domains of practice for public health nurses. One of the domains is Policy Development and Program Planning Skills. The competencies the nurse needs for this domain of practice related to program management are: • Manages public health programs consistent with public health laws and
regulations. • Develops a plan to implement policy and programs. • Develops mechanisms to monitor and evaluate programs for their effective-
ness and quality (Quad Council, 2011). New baccalaureate nurses will want to be knowledgeable and be able to
participate in program management; graduate nurses will want to be able to direct programs. Appendix B describes a Program Planning and Design process to use for practicing the content from this chapter. Try out this process on the development of a small program of interest to you and the client population you want to serve and the community level health problem of interest to you.
566 PART 4 Issues and Approaches in Population-Centered Nursing
P R A C T I C E A P P L I C A T I O N The following is a real-life example of the application of the program management process by an undergraduate nursing student. This activity resulted in the development and imple- mentation of a nurse-managed clinic for the homeless. This example shows how students as well as providers can make a difference in health care delivery. It also illustrates that no mystery surrounds the program management process.
Eva was listening to the radio one Sunday afternoon and heard an announcement about the opening of a soup kitchen within the community for the growing homeless population. She was beginning her public health nursing course and wanted to find a creative clinical experience that would benefit herself as well as others. The announcement gave her an idea. Although it mentioned food, clothing, shelter, and social services, nothing was said about health care.
Eva was interested in finding a way to provide nursing and health care services at the soup kitchen. Which of the following should she do? A. Talk with key leaders to determine their interest in her idea. B. Review the literature to find out the magnitude of the
problem. C. Survey the community to determine if others are providing
services. D. Discuss the idea with members of the homeless
population. E. Consider potential solutions to the health care problems. F. Consider where she would get the resources to open a clinic. G. Talk with church leaders and nursing faculty members to
seek acceptance for her idea. Answers can be found on the Evolve site.
K E Y P O I N T S • Planning and evaluation are essential elements of program
management and vital to the survival of the nursing disci- pline in health care delivery.
• The program management process is population focused and is parallel to the nursing process. Both are rational decision- making processes.
• The health care delivery system has grown in the past century, making health planning and evaluation very important.
• Comprehensive health planning grew out of a need to control costs.
• A program is an organized approach to meet the assessed needs of individuals, families, groups, populations, or com- munities by reducing or eliminating one or more health problems and addressing health disparities.
• Planning is defined as selecting and carrying out a series of actions to achieve a stated goal.
• Evaluation is defined as the methods used to determine if a service is needed and will be used, whether a program to meet that need is carried out as planned, and whether the service actually helps the people it intended to help.
• To develop quality programs, planning should include four essential elements: assessment of need and problem diagno- sis, identification of problem solutions, analysis and com- parison of alternative methods, and selection of the best plan and planning methods.
• The initial and most critical step in planning a health program is assessment of need. Assessment focuses on the needs of the population who will use the services planned.
• Some of the major tools used in needs assessment are census data, community forums, surveys of existing community agencies, surveys of community residents, and statistical indicators about demographics, morbidity, and mortality of the population.
• The major benefit of program evaluation is to determine whether a program is fulfilling its stated goals. Quality assur- ance programs are prime examples of program evaluation.
• Plans for implementing and evaluating programs should be developed at the same time.
• Program records and community indexes and health data serve as major sources of information for program evaluation.
• Planning programs and planning for their evaluation are two of the most important ways in which nurses can ensure suc- cessful program implementation.
• Cost studies help identify program benefits, effectiveness, and efficiency.
• Program planning helps nurses and agencies focus attention on services that clients need.
• Planning helps everyone involved understand their role in providing services to clients.
• The assessment of need process provides an evaluation of the relevance that a new service may have to clients.
• A decision tree is a useful tool to choose the best alternative for solving a problem.
• Setting goals and writing objectives to meet the goals are necessary to evaluate program outcomes.
• Healthy People 2020 is an example of a national program based on needs assessment that has stated goals and objec- tives on which the program can be evaluated.
• Program planning models include PPM, MAUT, PATCH, APEXPH, and MAPP.
• Program evaluation includes assessing structure, process, and outcomes of care.
• Grant writing is a tool used by nurse managers to provide resources for needed services.
• Grant proposals are documents that incorporate principles of program planning and evaluation.
567CHAPTER 25 Program Management
C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Choose the definitions that best describe your concepts of a
program, planning, and evaluation. Explain how each of these definitions can help you in accomplishing planning and evaluation.
2. Apply the program planning process to an identified clinical problem for a client group with whom you are working in the community. Give specific examples. A. Assess the client needs and existing resources. B. Choose tools appropriate to the assessment of unmet
needs. C. Analyze the overall planning process of arriving at deci-
sions about implementing a program. D. Summarize the benefits for program planning that apply
to your situation. 3. Given the situation just described, choose three or four of your
classmates to work with you on the following projects:
A. Plan for evaluation of the program in activity 2. B. Apply the evaluation process to the situation. C. Identify the measures you will use to gather data for eval-
uating your program. D. Identify the sources you will tap to gain information for
program evaluation. E. Analyze the benefits of program evaluation that apply to
your situation. F. Talk with a nurse or an administrator working in the
community about the application of program planning and evaluation processes at the local agency. Compare their answers to your research. What are some of the dif- ficulties that your group and the agency had in evaluating a program?
REFERENCES American Nurses Association: ANA’s
nurses’ efforts pay off in historic health care bill signing, March 2010. Available at www .nurseworld.com/healthcarereform. Accessed February 18, 2011.
American Nurses Association: Public Health Nursing: Scope and Standards of Practice, ed 2. Silver Springs, MD, 2013, American Nurses Association.
American Planning Association: Planning and community health research center 2013 annual report, National Centers for Planning, 2013. Available at https://www .planning.org/nationalcenters/health/ pdf/planningandcommhealthan nualreport.pdf. Accessed July 31, 2014.
Brownson RC, Fielding JE, Maylahn CM: Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health 30:175–201, 2009.
Centers for Disease Control and Prevention: A framework for program evaluation, 2012. Avalilable at: www.cdc.gov. Accessed 10/12/2014.
Centers for Disease Control and Prevention: Measles still threatens health security, press release, 12/5/ 2013. Avaliable at: www.cdc.gov. Accessed 10/12/2014.
Centers for Disease Control and Prevention: A planning model, 2014. Available at www.cdc.gov. Accessed 10/12/2014.
Centers for Disease Control and Prevention: Conducting a community needs assessment, field guidelines, 2014b. Available at www.cdc.gov. Accessed 10/12/2014.
Delbecq A, Van de Ven A: A group process model for problem identification and program planning. J Appl Behav Sci 7:466, 1971.
Donabedian A: Explorations in Quality Assessment and Monitoring, vol 2. Ann Arbor, MI, 1982, Health Administration Press.
Donabedian A: An Introduction to Quality Assurance in Health Care. New York, 2003, Oxford University Press.
Finkelstein SM, Speedie SM, Zhou X, et al: Perception, satisfaction and utilization of the VALUE home telehealth service. J of Telemedicine and Telehealth 17(6):288–292, 2011.
Friis RH, Sellers T: Epidemiology for Public Health Practice, ed 4. Sudbury, MA, 2010, Jones and Bartlett Publishers.
Glanz K, Bishop DB: The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health 31:399– 418, 2010.
IHI: Population health management 2012. Available at www.ihealthtran .com. Accessed 10/12/2014.
Issel LM: Health Program Planning and Evaluation: A Practical, Systematic Approach for Community Health, ed 3. Boston, 2013, Jones and Bartlett.
Jefferson Area Board of Aging: What we do and who we are. JABA facts, 2010. Available at http:// www.jabacares.org/. Accessed January 31, 2011.
Kabassi K, Vroom M: MAUT and adaptive techniques for web based educational software. Instruct Sci 34(2):313–358, 2006.
Kettner PM, Moroney RM, Martin LL: Designing and Managing Programs: An Effectiveness-Based Approach. Thousand Oaks, CA, 2012, Sage.
McDonald KM: Closing the quality gap: a critical analysis of quality improvement strategies (vol 7 care coordinators), 2007. Available at www.ncbi.nim.nih.gov. Accessed 10/12/2014.
NACCHO: Definitions of community health assessments and community health improvement plans, 2014. Avaliable at: www .naccho.org. Accessed 10/12/2-14.
Nutt P: Planning Methods for Health and Related Organizations. New York, 1984, Wiley.
Papanicolas I, Smith PC: Health System Performance Comparison: An Agenda for Policy, Information and Research. New York, NY, 2013, Open University Press.
Posavac EJ: Program Evaluation: Methods and Case Studies, ed 8. Englewood Cliffs, NJ, 2011, Prentice Hall.
Quad Council of Public Health Nursing Organization: Quad Council competencies for public health nursing, Summer 2011. Available at http://www.resourcenter.net/ images/ACHNE/Files/QuadCouncil CompetenciesForPublic HealthNurses_Summer2011.pdf. Accessed July 11, 2014.
Royse D, Thyer BA, Padgett DK: Program Evaluation: An Introduction, ed 5. Belmont, CA, 2010, Wadsworth.
Ruffolo DC, Andresen PA, Winn KL: Meeting the needs of a community: teaching evidence- based youth violence prevention
initiative to members of strategic communities. J Trauma Nurs 20(1):24–30, 2013.
Saaty TL, Vargas LG: Decision Making with the Analytic Network Process, ed 2. New York, NY, 2013, Springer.
Sanders G: Introduction to medical decision making and decision analysis, Duke University Raleigh, NC, 2009. Available at www.hsrd.research.va.gov. Accessed 10/12/2014.
Shin P, Sharac B, Barber Z, et al: Community Health Centers: A 2013 Profile and Prospects as ACA Implementation Proceeds Mar 17, 2015, Accessed at KFF.org. 4/1/2015.
Sparer MS: Health policy and health reform. In Kovner AR, Knickman JR, editors: Jonas and Kovner’s Health Care Delivery in the United States, ed 10. New York, 2011, Springer.
Trickett EJ, Beehler S, Deutsch C, et al: Advancing the science of community-level interventions. Am J Publ Health 101(8):1410–1419, 2011.
University of North Carolina Health Services Library: Finding information for a community health assessment, 2014. Available at http://www.hsl.unc.edu/services/ guides/communityHealth.cfm. Accessed January 31, 2011.
USDHHS: Healthy People 2020: A Roadmap for Health. Washington, DC, 2010, U.S. Government Printing Office.
USDHHS: Introduction to Program Evaluation for Public Health Programs: A Self-Study Guide. Atlanta, GA, 2011, Centers for Disease Control and Prevention.
568
Quality Management
26
Marcia Stanhope, PhD, RN, FAAN Dr. Marcia Stanhope is currently an Associate of the Tufts and Associates Search Firm, Chicago, Ill. She is also a consultant for the nursing program at Berea College, Kentucky. She has practiced community and home health nursing, has served as an administrator and consultant in home health, and has been involved in the development of two nurse-managed centers. At one time in her career, she held a public policy fellowship and worked in the office of a U.S. Senator. She has taught community health, public health, epidemiology, policy, primary care nursing, and administration courses. Dr. Stanhope formerly directed the Division of Community Health Nursing and Administration and served as Associate Dean of the College of Nursing at the University of Kentucky. She has been responsible for both undergraduate and graduate courses in population-centered nursing. She has also taught at the University of Virginia and the University of Alabama, Birmingham. During her career at the University of Kentucky she appointed to the Good Samaritan Foundation Chair and Professorship in Community Health Nursing, and was honored with the University Provost’s Public Scholar award. Her presentations and publications have been in the areas of home health, community health and community-focused nursing practice, as well as primary care nursing.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Explain differences in total quality management/
continuous quality improvement (TQM/CQI). 2. Evaluate the role of QA/QI in CQI. 3. Analyze the historical development of the quality process
in nursing and describe the changes developing under managed care.
4. Evaluate approaches and techniques for implementing CQI and the method of documentation.
5. Plan a model QA/QI program. 6. Identify the purposes for the types of records kept in
community and public health agencies.
K E Y T E R M S accountability, p. 572 accreditation, p. 574 audit process, p. 580 certification, p. 575 charter, p. 575 client-centered care, p. 588 concurrent audit, p. 580 continuous quality improvement, p. 569 credentialing, p. 574 evaluative studies, p. 582 evidence-based practice, p. 588 licensure, p. 574 malpractice litigation, p. 584 managed care, p. 571 managed care organizations (MCOs), p. 570 Nurse Licensure Compact Administrators (NLCA), p. 574
outcome, p. 582 partnerships, p. 571 practice guidelines, p. 578 peer review organization (PRO), p. 573 process, p. 582 professional review organizations (PRO), p. 581 Professional Standards Review Organization (PSRO), p. 581 quality assurance/quality improvement (QA/QI), p. 572 quality improvement, p. 570 quality improvement organization (QIO), p. 573 recognition, p. 575 records, p. 587 report cards, p. 570 retrospective audit, p. 580 risk management, p. 581 safety, p. 588
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • Quiz • WebLinks • Case Studies
• Glossary • Answers to Practice Application • Resource Tools
• Resource Tool 46.A: Core Competencies and Skills Levels for Public Health Nursing
569CHAPTER 26 Quality Management
C H A P T E R O U T L I N E Definitions and Goals Historical Development Approaches to Quality Improvement
General Approaches Specific Approaches
TQM/CQI in Community and Public Health Settings Using QA/QI in CQI Traditional Quality Assurance
Client Satisfaction Malpractice Litigation
Model CQI Program Structure Process Outcome Evaluation, Interpretation, and Action
Records Community and Public Health Agency Records
K E Y T E R M S — cont’d sentinel, p. 582 staff review committees, p. 580 structure, p. 582 teamwork and collaboration, p. 588
total quality management, p. 569 tracer, p. 582 utilization review, p. 580 —See Glossary for definitions
Although the concept of quality assurance has been a part of the health care arena for a number of years, it is only in the last few years that major movement to improve health care quality has begun in the United States. The Institute of Medicine (IOM, 2001), not confident of the health care systems’ ability to deliver the quality of care expected, set forth a series of recommenda- tions to transform systems to meet Americans’ expectations. Very little is known about quality of care in this country for two reasons: (1) a variety of definitions of quality are used, and (2) it is difficult to obtain comparable data from all providers and health care agencies.
However, in the Healthcare Research and Quality Act of 1999 (PL 106-129), Congress mandated that the Agency for Health- care Research and Quality (AHRQ) produce an annual report on health care quality in the United States beginning in fiscal year 2003. This National Healthcare Quality Report (NHQR) is a collaborative effort among the agencies of the U.S. Depart- ment of Health and Human Services (USDHHS) and includes a broad set of performance measures that will be used to monitor the nation’s progress toward improved health care quality. The NHQR represents the broadest examination of quality of health care, in terms of number of measures and number of dimensions of care, ever undertaken in the United States. The report represents progress toward improving quality as well as recommendations for how to improve quality out- comes (USDHHS, 2014).
The NHQR is intended to serve a number of purposes, such as demonstrating the validity (or lack) of concerns about quality; documenting whether health care quality is stable, improving, or declining over time; and providing national benchmarks against which specific states, health plans, and pro- viders can compare their performance (AHRQ, 2014b; NCQA, 2013a).
In a changing health care market, the demand for quality has become a rallying point for health care consumers. All
consumers, including private citizens, insurance companies, industry, and the federal government, are concerned with the highest quality outcomes at the lowest cost (Clancy and Lloyd, 2011). In addition to the demand for higher quality and lower cost, the public wants health care delivered with greater access, and health care that is accountable, efficient, and effective. Moreover, consumers want information about quality. Infor- mation is empowering to the consumer. With the expanded use of the Internet, access to information about quality in health care is readily available, ranging from talking to consumers about quality health care (http://www.talkingquality.gov) to clinical practice guidelines that promise to improve care for all (http://www.guideline.gov). Total quality management (TQM) is a management philosophy that includes a focus on client, continuous quality improvement (CQI), and teamwork (Kelly, 2011). Although relatively new in public health care, the con- cepts of TQM/CQI have been tried and proven in industry at large. The terms total quality management, continuous quality improvement, total quality, and organization-wide quality improvement are often used interchangeably. However, they have different meanings. As indicated, TQM refers to a manage- ment philosophy that focuses on the statistical processes by which to assess work done with the goal of organization-wide quality effectiveness. TQM is often referred to as TQ, and both acronyms have the same meaning. CQI, while different from the other three terms, can be implemented not only to address system problems, but also to maintain and enhance good per- formance through the use of differing techniques. Everyone in the public health or community-based organization is involved in CQI—the leaders, the staff, and the client. By obtaining facts about work processes (e.g., all the steps in certifying a child for the women, infants, and children nutritional program [WIC]), it is possible to discover which steps are unnecessary (i.e., non– value adding) and to eliminate those steps to produce better health outcomes for individuals and communities (Oakland,
570 PART 4 Issues and Approaches in Population-Centered Nursing
designed to monitor and deliver health care services within a specific budget. Currently providers, clients, payers, and policy makers all have input into the quality measurement process. The Health Plan Employer Data and Information Set (HEDIS), a data collection arm of the National Committee for Quality Assurance (NCQA), provides performance information, or report cards, for 90 percent of America’s health plans. In 2012, 538 health insurance plans, including HMOs and PPOs, reported audited HEDIS data to show the level of quality per- formance (NCQA, 2013b). In the ACA (KHN, 2014) account- able care organizations (ACO) are being promoted. The ACO may involve a network of physicians.
Although introduced in the 1990s, report cards for public health agencies are currently being developed and promoted to measure quality health care in communities. The term com- munity health report card refers to different types of reports, community health profiles, needs assessments, scorecards, quality of life indicators, health status reports, and progress reports. All of these reports are critical components of community-based approaches to improving the health and quality of life of communities (UK, 2014).
An example at the national level is the Community Health Status Indicator (CHSI) Project, which is a collaborative effort between the Health Resources and Services Administration (HRSA), the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), and the Public Health Foundation. In 2000, the project published and disseminated community health status reports for all U.S. counties. These reports provided county-level data, including peer county and national compari- sons, for every county in the country. The goal of CHSI is to provide an overview of key health indicators for local communi- ties and to encourage dialogue about actions that can be taken to improve a community’s health. The CHSI report was designed not only for public health professionals, but also for members of the community who are interested in the health of their com- munity. They are designed to support health planning by local health departments, local health planners, community residents, and others interested in community health improvement. The CHSI report contains over 200 measures for each of the 3141 U.S. counties. Although CHSI presents indicators like deaths resulting from heart disease and cancer, it is imperative to understand that behavioral factors such as tobacco use, diet, physical activity, alcohol and drug use, and sexual behavior substantially contribute to these deaths (NICHSR, 2012).
These community health improvement initiatives have grown out of three major trends: (1) an increasing recognition of the importance of local community action to solve local problems, (2) an increasing emphasis on outcomes and accountability, and (3) the Healthy Cities/Healthy Communities movement (see Chapter 20). The Healthy Cities/Healthy Communities movement views community health and its determinants broadly, and they use a set of indicators (to track their progress) that reflects this broad defini- tion. These indicators might include the following: • Physical and mental health status • Educational achievement • Economic prosperity
2014). Box 26-1 presents several abbreviations that are com- monly used in health care and quality management.
Both consumers and providers have a vested interest in the quality of the health care system to do the following: 1. Improve safety of care to save lives 2. Reduce costs by using effective interventions 3. Increase client confidence in health care delivery regardless
of setting (NQF, 2010) Kovner and Jonas state that in health care there is a direct
link between doing a good job and individual and professional survival. Health care providers pride themselves on individual achievement and responsibility for good client outcomes (Kovner and Knickman, 2011). Health care organizations are natural extensions of health care providers and thus can dem- onstrate their responsibility for optimal outcomes through a rigorous quality improvement process. The application of quality improvement strategies through the following six areas of performance could affect both process and outcomes of health care: 1. Consistently providing appropriate and effective care 2. Reducing unjustified geographic variation in care 3. Eliminating avoidable mistakes 4. Lowering access barriers 5. Improving responsiveness to clients 6. Eliminating racial/ethnic, gender, socioeconomic, and other
disparities and inequalities in access and treatment (USDHHS, 2011a) In the 1990s the United States entered a new era of
population-centered, community-controlled delivery of care in which managed care organizations (MCOs) played an integral role. MCOs are agencies such as health maintenance organiza- tions (HMOs) and preferred provider organizations (PPOs)
AACN American Association of Colleges of Nursing ACHNE Association of Community Health Nursing Educators AHRQ Agency for Healthcare Research and Quality (formerly AHCPR) ANA American Nurses Association APHA American Public Health Association CCNE Commission on Collegiate Nursing Education CHAP Community Health Accreditation Program CMS Centers for Medicare and Medicaid Services (formerly HCFA) CQI Continuous Quality Improvement HEDIS Health Plan Employer Data and Information Set IOM Institute of Medicine JCAHO Joint Commission on Accreditation of Healthcare Organizations MCO Managed Care Organization NCQA National Committee for Quality Assurance NHQR National Healthcare Quality Report NLN National League for Nursing NPHPSP National Public Health Performance Standards Program OCQI Outcomes-Based Quality Improvement QA Quality Assurance QI Quality Improvement QIO Quality Improvement Organization TQI Total Quality Improvement TQM Total Quality Management
BOX 26-1 Commonly Used Abbreviations
571CHAPTER 26 Quality Management
power of MCOs by holding them accountable for health out- comes in relation to costs. The ACA’s (KHN 2014) emphasis on ACOs is promoting the managed care approach to health care delivery with quality indicators. Partnerships are using data- based community assessments to improve health and to ensure that communities receive quality services. Projects are being funded to meet this goal (Kresge Foundation, 2014).
Because of managed care agencies and consumer demands for quality nursing, objective and systematic evaluation of nursing care is a priority for the nursing profession. Since orga- nized nursing is committed to direct individual accountability, is evolving as a scientific discipline, and is concerned about how costs of health services limit access, it demands delivery and evaluation of quality service aimed at superior client outcomes (ANA, 2009). In the public health arena, the Quad Council of Public Health Nursing Organizations (2011), which includes four nursing organizations—the ANA, the Association of Com- munity Health Nursing Educators, the APHA public health nurses, and the Association of Public Health Nurses—has identi- fied competencies for public health nursing based on the Council on Linkages Between Academia and Public Health Practice doc- ument of 2008 with the most recent update on these competen- cies occurring in 2014 (Council on Linkages). Other states have developed models to document outcomes attributable to nursing interventions and are adding methods for evaluating total quality (Minnesota Department of Health, 2001; Keller et al, 2004a, 2004b; Sakamoto and Avila, 2004; Smith and Bazini- Barakat, 2004; University of Wisconsin-Madison, 2010). Box 26-2 is a list of the areas of nursing interventions that nurses will want to be able to use. (See Chapter 9 for the most recent updates on the Keller et al model of the Intervention Wheel.)
• Public safety • Adequate housing and transportation • A clean and safe physical environment • Recreational and cultural opportunities (Braunstein and
Lavizzo-Mourey, 2011) Community health report cards can be a useful tool in efforts
to help identify areas where change is needed, to set priorities for action, and to track changes in population health over time. The report card may be used to track leading causes of morbidity and mortality in a community, looking at trends over time to see if public health interventions have improved health care outcomes. The card may also be used to assess a specific chronic disease, like diabetes, to determine the health status of the community for this particular disease (CDC, 2010). The report card may be used as an internal measure of public health program outcomes and CQI measures within the agency (Gunzenhauser et al, 2010).
In 2014, HEDIS measures of care included several that address public health issues, including BMI reduction and maintenance, smoking or tobacco use quit rates, and physical activity levels (NCQA, 2014).
As a part of a movement to provide quality health care in communities, health departments are increasingly examining their place in promoting quality (CDC, 2014). Sollecito and Johnson (2013) state that public health and CQI are connected because of the use of systems approaches that public health takes in identifying problems and developing interventions. Aspects of planning, implementing, and evaluating by TQM fall under each of the core public health functions of assessment, assurance, and policy development. However, it is with the assurance core function, related to ensuring available access to the health care services essential to sustain and improve the health of the population, that TQM programs must be under- taken. Public health cannot ensure services that improve health if those services lack quality. Public health will want to maintain quality in its workforce and continually evaluate the effective- ness of its services whether service is delivered to the individual, the community, or the population.
At least four documents provide report cards on how well the United States is performing on improving safety of health care delivery, quality of and access to care across population groups, progress and opportunities for improving health care quality, and the state of health care quality. These reports are published regularly by the Agency for Health Care Research and Quality, the National Quality Forum, and the National Com- mittee for Quality Assurance.
Nurses are in a perfect position to implement strategies to improve population-centered health care. Community assess- ments, identification of high-risk individuals, use of targeted interventions, case management, and management of illnesses across a continuum of care are strategies suggested as part of the focus in improving the health of communities (Quad Council of Public Health Nursing Organizations, 2011). These strategies have long been used by nurses.
The growth of the managed care industry has changed the face of health care in the United States, both in how health care is delivered and in how it is received by consumers. Consumers are forming partnerships in communities to counteract the
Interventions Chapter
Advocacy 5, 6, 10, 16, 22, 30, 32, 34, 37, 46 Case finding 22, 32, 33, 42 Case management 19, 22, 30, 32, 33, 42, 46 Coalition building 8, 18, 20 Collaborating 21, 22, 26, 32, 39, 41, 45 Community organizing 18, 20 Consulting 40, 41 Counseling 9, 14, 30, 32, 36, 39, 42, 45, 46 Delegated functions 40, 41 Disease and health
event investigation 12, 13, 14, 23, 24
Health teaching 9, 13, 14, 16, 17, 20, 36, 38, 39, 40, 42, 43, 44, 45 Outreach 33, 35, 46 Policy development
and enforcement 1, 8, 10, 18, 27, 30, 33
Referral and follow-up 10, 22, 27, 28, 32, 46 Social marketing 13, 18, 34, 38 Survey 18, 24
BOX 26-2 The Areas of Public Health Nursing Interventions for Quality Population- Centered Health Care
From Minnesota Department of Health, Division of Community Health Services: Public health interventions: applications for public health nursing practice, St Paul, MN, March 2001, p 1, Public Health Nursing Section.
572 PART 4 Issues and Approaches in Population-Centered Nursing
the question of access to appropriate and needed services, a well-prepared workforce, and improvement in the status of the population’s health. Client satisfaction and well-being and the processes of client–provider interaction should be considered as well.
TQM is a process-driven, customer-oriented management phi- losophy that includes leadership, teamwork, employee empower- ment, individual responsibility, and continuous improvement of system processes to yield improved outcomes (Oakland, 2014). Under TQM, quality is defined as customer satisfaction. Quality assurance/quality improvement (QA/QI) is the promise or guar- antee that certain standards of excellence are being met in the delivery of care. Van den Heuvel, Niemeijer, and Does (2013) discuss what is called the Juran trilogy. This consists of quality planning, quality control, and quality improvement. This trilogy combines components of QA as well as CQI to improve client outcomes in health care delivery.
QI is defined as “systematic and continuous actions that lead to measureable improvement in health care services and the health status of targeted patient groups” (USDHHS, 2011b). QI in public health is the use of a deliberate and defined improvement process, such as plan-do-check-act (PDCA), which is focused on activities that are responsive to community needs and improving popula- tion health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, perfor- mance, accountability, outcomes, and other indicators of quality in services or processes that achieve equity and improve the health of the community (Bialek et al, 2010).
QA is concerned with the accountability of the provider and is only one tool in achieving the best client outcomes. Account- ability means being responsible for care and answerable to the client (Sollecito and Johnson, 2013). Under QA/QI, quality may have a variety of definitions. According to Kaplan and col- leagues (2010), QA should consist of peer review leading to QI to improve health care delivery. Client standards of care and safety issues are the core of QA.
The AHRQ has indicated that the assurance of quality is organized around four dimensions (effectiveness, client safety, timeliness, and client centeredness) and is assessed using four stages of care [staying healthy (primary prevention), getting better (secondary prevention), living with illness or disability, and coping with end of life (tertiary prevention)] (AHRQ, 2014b, 2014c).
Quality traditionally has been an important issue in the delivery of health care. QA programs historically have ensured this accountability. The goals of QA and QI are on a con- tinuum of quality, and in public health they are (1) to con- tinuously improve the timeliness, effectiveness, safety, and responsiveness of programs, and (2) to optimize internal resources to improve the health of the community (Riley et al, 2010).
Under a CQI philosophy, QA and QI are but two of the many approaches used to ensure that the health care agency fulfills what the client thinks are the requirements for the service. QA focuses on finding what providers have done wrong in the past (e.g., deviations from a standard of care found through a chart audit). CQI operates at a higher level on the quality continuum
The competencies for public health leadership developed by the Council on Linkages (2001, updated 2014) are crucial to ensure the quality and performance of the public health work- force. See Resource Tool 46.A on the Evolve website for a list of the competencies.
Records are maintained on all health care system clients to provide complete information about the client and to show the quality of care being given to the client within the system. Records are a necessary part of a CQI process, as are the tools and methods for evaluating quality. Electronic health records are becoming more common and are aiding in decreas- ing errors, increasing quality, and monitoring interventions (Keyser et al, 2009).
DEFINITIONS AND GOALS The IOM definition of quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (2001, p. 1000; 2011). The AHRQ defines quality health care as doing the right thing, for the right client, and having the best possible results (2014a). Quality in public health is defined as “the degree to which policies, pro- grams, services, and research for the population increase desired health outcomes and conditions in which the population can be healthy” (IOM, 2013, p. 3).
However, a definition of quality rests largely on the percep- tion of the client, the provider, the care manager, the purchaser, the payer, or the public health official. Whereas the physician views quality in a more technical sense, the client may look at the personal outcome; the manager, purchaser, or payer may consider the cost-effectiveness; and the public health official will look at the appropriate use of health care resources to improve population health (AHRQ, 2012).
According to the AHRQ (2012), problems with quality of care were divided into five groups: variation of service, unde- ruse of service, overuse of service, misuse of service, and dis- parities in quality. Variation in service refers to the lack of standards of practice continuity. This variation is often seen between regional, state, and local health care services and stems from lack of evolutionary health care practice and not keeping abreast of the constant changes taking place in health care (evidence-based practice) (NCQA, 2013b; IOM, 2011). Underuse of service refers to conservative treatment practices. As an example, there is a lack of immunizations for pneumonia given to Asians 65 years or older as a preventive measure as com- pared with immunization levels of whites (AHRQ, 2014b). Overuse of service refers to the over-ordering of unnecessary tests, surgeries, and treatments. This overuse drives up the cost of already expensive health care. Misuse of service refers to client safety issues and how disability and mortality can be reduced. With diligent care by health care providers, client injury and death can be avoided (IOM, 2011). Disparities in quality refer to racial, ethnic, and socioeconomic disparities in accessibility and affordability of health care (AHRQ, 2014b).
The term health services applies to a wide range of health delivery institutions. Of particular interest to public health is
573CHAPTER 26 Quality Management
After World War II, the attention of the emerging nursing profession focused on establishing a scientific method of prac- tice. The nursing process was the chosen method and included evaluation of how nursing activities helped clients (Maibusch, 1984). QA/QI was the evaluative step in the nursing process.
The 1950s brought the development of QA measurement tools. One of the first tools was Phaneuf ’s nursing audit method (1965), which has been used extensively in population-centered nursing practice.
In 1966, the American Nurses Association (ANA) created the Divisions on Practice. As a result, in 1972, the Congress for Nursing Practice was charged with developing standards to institute QA programs. The Standards for Community Health Nursing Practice were distributed to ANA Community Health Nursing Division members in 1973. In 1986, 1999, and in 2005, with updates in 2007 and 2013, the scope and standards were again revised with a change in focus from community health nursing to public health nursing.
In 1972, the Joint Commission on Accreditation of Hospitals (JCAH) clearly stated the responsibilities of nursing in its description of standards for nursing services. The JCAH called on the nursing industry to clearly plan, document, and evaluate nursing care provided. In the mid-1980s, the JCAH became the Joint Commission on Accreditation of Healthcare Organiza- tions (JCAHO) and began developing quality control standards for hospital and home health nursing. JCAHO is now known as The Joint Commission (TJC) and presently incorporates CQI principles in its standards.
Also in 1972, the Social Security Act (PL 92-603) was amended to establish the Professional Standards Review Orga- nization (PSRO) and to mandate the process review of the delivery of health care to clients of Medicare, Medicaid, and maternal and child health programs. The PSRO program later became the Peer Review Organization (PRO) under the 1983 Social Security amendments. The purpose of the PROs was to monitor the implementation of the prospective reimbursement system for Medicare clients (the diagnosis-related groups [DRGs]). Although PSROs were intended for physicians, PROs made QI a primary issue for all health care professionals. The PRO was renamed the QIO, or the quality improvement orga- nization (QIO), and is mandated to improve the quality and efficiency of Medicare funded services (CMS, 2014a).
In response to increasing charges of malpractice, the govern- ment passed the National Health Quality Improvement Act of 1986. Although it was not funded until 1989, its two major goals were to encourage consumers to become informed about their practitioner’s practice record and to create a national clearing- house of information on the malpractice records of providers. The emphasis of this act continued to be on the structure of care rather than the process or outcomes of care (NAHQ, 1993; Zale and Selvan, 2009). (See Chapter 25 for discussion of struc- ture, process, and outcome.)
Efforts to strengthen nursing practice in the community have been carried out by several nursing organizations, including the ANA, the Public Health Nursing Section of the American Public Health Association (APHA), the Association of State and Territorial Directors of Nursing (now APHN), and
but requires the commitment of more organization resources to move in a positive direction. CQI focuses on the sources of differences in the ongoing process of health care delivery and seeks to improve the process (Kelly, 2011; Sullivan, 2013).
The process of health care includes two major components: technical interventions (e.g., how well procedures are accom- plished, accurate assessments, and effective interventions) and interpersonal relationships between public health practitioner and client. Both contribute to quality care, and both can be evaluated. Several approaches and techniques are used in quality programs. Approaches are methods used to ensure quality, and techniques are tools for measuring differences in quality (Kovner and Knickman, 2011).
Traditional approaches to quality focus on assessing or mea- suring performance, ensuring that performance conforms to standards, and providing remedial work to providers if those standards are not met. Such a definition of quality is too narrow in health care systems that try to meet the needs of many clients, both internal and external to the agency. CQI requires constant attention and should involve surveillance of all records while there is still the opportunity to intervene in both the client’s care and the practitioner’s actions. Comprehensive data analysis is necessary to detect process failure. Many agencies use some of the TQM/CQI concepts, such as client satisfaction question- naires, but have not adopted the entire management philoso- phy. However, because QA/QI methods have traditionally been used and are still in use in many agencies, the QA/QI concepts will be covered.
HISTORICAL DEVELOPMENT Improving the quality of care has been a part of nursing since the days of Florence Nightingale. In 1860 Nightingale called for the development of a uniform method to collect and present hospital statistics to improve hospital treatment. Nightingale was a pioneer in setting standards for nursing care. The move- ment to establish nursing schools in the United States came in the late 1800s from a desire to set standards that would upgrade nursing care. In the early 1900s efforts were begun to set similar standards for all nursing schools. From 1912 to 1930 interest in quality nursing education led to the development of nursing organizations involved in accrediting nursing pro- grams. Licensure has been a major issue in nursing since 1892. By 1923 all states had permissive or mandatory laws directing nursing practice.
HEALTHY PEOPLE 2020
Goal of Improving Access to Comprehensive, High-Quality Health Care, and Examples of Objectives to Eliminate Health Disparities • AHS-1: Increase the proportion of persons with health insurance. • AHS-5: Increase the proportion of persons who have a specific source of
ongoing care. • AHS-7: Increase the proportion of persons who receive evidence-based
clinical preventive services.
From U.S. Department of Health and Human Services: Healthy People 2020, Washington, DC, 2010, U.S. Government Printing Office.
574 PART 4 Issues and Approaches in Population-Centered Nursing
These mechanisms are used to evaluate the agency structure through which care is provided and the outcomes of care given by the provider. Credentialing can be mandatory or voluntary. Mandatory credentialing requires laws. State nurse practice acts are examples of mandatory credentialing. Voluntary credential- ing is performed by an agency or an institution. The certifica- tion examinations offered by the ANA through the American Nurses Credentialing Center are examples of voluntary creden- tialing. Licensing, certification, and accreditation are all exam- ples of credentialing (ANCC, 2014).
Licensure is one of the oldest general QA approaches in the United States and Canada. Individual licensure is a contract between the profession and the state. Under this contract, the profession is granted control over entry into, and exit from, the profession and over quality of professional practice (NCSBN, 2014a).
The licensing process requires that written regulations define the scope and limits of the professional’s practice. Job descrip- tions based on these regulations set minimum and maximum limits on the functions and responsibilities of the practitioner. Licensure of nurses has been mandated by law since 1903. Today all 50 states have mandatory nurse licensure, which requires all individuals who practice nursing, whether it be for money or as a volunteer, to be licensed. A new approach to interstate practice requires a pact between states so that nurses can practice across state borders (NCSBN, 2014b). Although reciprocity (which means nurses can have their license accepted through an appli- cation process if there is agreement between the states requiring application) exists among states for nursing licensure, interstate practice without approval is an issue for state boards of nursing. The states’ compact agreements were to reduce the barriers for interstate practice. The mutual recognition model of nurse licensure allows a nurse to have one license (in his or her state of residency) and to practice in other states (both physically and electronically when giving advice through programs like “ask a nurse”), subject to each state’s practice law and regulation. Under mutual recognition, a nurse may practice across state lines unless otherwise restricted. This is referred to as a multi- state nurse licensure model, specifically referred to as the Nurse Licensure Compact (NLC). All states that currently belong to the NLC also operate the single-state licensure model for those nurses who do not reside legally in an NLC state or do not qualify for multistate licensure. To achieve mutual recognition, each state must enact legislation or regulation authorizing the NLC. States entering the compact also adopt administrative rules and regulations for implementation of the compact.
Once the compact is enacted, each compact state designates a Nurse Licensure Compact Administrator to facilitate the exchange of information between the states relating to compact nurse licensure and regulation. On January 10, 2000, the Nurse Licensure Compact Administrators (NLCA) were organized to protect the public’s health and safety by promoting compliance with the laws governing the practice of nursing in each party state through the mutual recognition of party state licenses (NCSBN, 2014b).
Accreditation, a voluntary approach to QI, is used for insti- tutions. Since 1954 the National League for Nursing (NLN), a
the Association of Community Health Nursing Educators (ACHNE). The quality of nursing education is a major concern of the ACHNE, which was established in 1978. In 1993, 2000, 2003, and 2007, five reports published by this organization identified the curriculum content required to prepare nursing students for practice in the community (ACHNE, 1993, 2000a/2009, 2000b, 2003, 2007). In 2005, and again in 2007, the Quad Council reviewed scopes and standards of population- focused (public health) and community-based nursing practice and developed new standards to guide the profession in obtain- ing the best health outcomes for the populations they serve. These standards were updated again in 2013. QA/QI programs remain the enforcers of standards of care for many agencies that have not elected to engage in a program of CQI. These activities are called assurance activities because they make certain that those policies and procedures are followed so that appropriate quality services are delivered.
The Council on Linkages between Academia and Public Health Practice (the Council) is a coalition of representatives from 17 national public health organizations. Since 1992, the Council has worked to further academic/practice collaboration to ensure a well-trained, competent workforce and a strong, evidence-based public health infrastructure. The Council is funded by the CDC and staffed by the Public Health Founda- tion. The most recent core competencies were updated in 2014. These competencies are used in QA/QI as performance mea- surements of providers to ensure quality of services (Council on Linkages, 2014).
APPROACHES TO QUALITY IMPROVEMENT Two basic approaches exist in QI: general and specific. The general approach involves a large governing or official body’s evaluation of a person’s or agency’s ability to meet criteria or standards. Specific approaches to QI are methods used to manage a specific health care delivery system in an attempt to deliver care with outcomes that are acceptable to the consumer. QA/QI programs that evaluate provider and client interaction through compliance with standards historically have been used alone to monitor quality care. In a TQM approach, CQI with QA/QI methods are an integral, but not the only, tool for ensur- ing quality or customer satisfaction.
General Approaches General approaches to protect the public by ensuring a level of competency among health care professionals are credentialing, licensure, accreditation, certification, charter, recognition, and academic degrees. Although there has been a long history of public oversight of quality in the United States, this public oversight increasingly involves the private sector. Public over- sight for quality emerged when the private market failed to focus on health care quality. Previously mentioned reports about quality are indicators of public sector involvement in public oversight of quality.
Credentialing is generally defined as the formal recognition of a person as a professional with technical competence, or of an agency that has met minimum standards of performance.
575CHAPTER 26 Quality Management
partners, of PHAB. The goal is for the accreditation program and the accrediting process, which began in 2011, to be self sustaining.
Certification, another general approach to quality, combines features of licensure and accreditation. Certification is usually a voluntary process within professions. Educational achieve- ments, experience, and performance on an examination deter- mine a person’s qualifications for functioning in an identified specialty area. The American Nurses Credentialing Center pro- vides certification in several areas of nursing (ANCC, 2014). Many other professional nursing specialty credentialing organi- zations also provide for individual certification.
Although usually a voluntary process, certification can also be a quasi-voluntary process. For example, to function as a nurse practitioner in all but three states, one must show proof of educational credentials and take an examination to be certified to practice within the boundaries of the state (Fitzgerald, 2013).
Major concerns exist about certification as a QA mechanism. Data are lacking about the clinical competence of the practitio- ner at the time of certification because clinical competency is usually not measured by a written test. Although better data exist about the quality of the practitioner’s work after the cer- tification process, the American Nurses Credentialing Center conducted a research program to look at how certification is related to the work of the certified nurse (Blegen, 2012; Boltz et al, 2013; Kendall-Gallagher et al, 2011; Martinez, 2011). Except for occupational health nurses and nurse anesthetists, certification has not been universally recognized by employers as an achievement beyond basic preparation, so financial rewards have been few (Keefe, 2010).
Although the nursing profession has accepted the certifica- tion process as a mechanism for recognizing competence and excellence, certifying bodies must help nurses communicate the importance of certified nurses to the public.
Charter, recognition, and academic degrees are other general approaches to QA. Charter is the mechanism by which a state government agency, under state laws, grants corporate status to institutions with or without rights to award degrees (e.g., university-based nursing programs).
Recognition is a process whereby one agency accepts the credentialing status of and the credentials conferred by another. For example, most state boards of nursing accept nurse practi- tioner credentials that are awarded by the American Nurses Credentialing Center or by one of the specialty credentialing agencies. Academic degrees are titles awarded to individuals recognized by degree-granting institutions as having com- pleted a predetermined plan of study in a branch of learning. There are four academic degrees awarded in nursing, with some variety at each degree level: Associate of Arts/Sciences; Bachelor of Science in Nursing; master’s degrees, such as Master of Science in Nursing and Master of Nursing; and doc- toral degrees, such as Doctor of Philosophy and Doctor of Nursing Practice.
Although these general quality management methods are important and should continue, newer and better approaches must be devised. If performance in the area of quality health
voluntary organization, has had established standards for inspecting nursing education programs. In 1997 the NLN board established an accrediting body as an independent organiza- tion: the NLN Accrediting Commission (NLNAC). The name of this organization is now the Accreditation Commission for Nursing Education (ACEN) (NLN, 2014). In 1997 the American Association of Colleges of Nursing (AACN), also a voluntary organization supporting baccalaureate and higher degree pro- grams, established an affiliate—the Commission on Collegiate Nursing Education (CCNE)—to accredit baccalaureate and higher degree nursing programs (CCNE, 2014). In 1966 com- munity health/home health program standards were established by the NLN for the purpose of accrediting these programs through their Community Health Accreditation Program, now an independent organization (CHAP, 2014). In addition, state boards of nursing accredit basic nursing programs so that their graduates are eligible for the licensing examination. In some states, state boards of nursing accredit graduate programs.
The accreditation function is quasi-voluntary. Although accreditation appears to be a voluntary program, it is often linked to government regulation that encourages programs to participate in the accrediting process. Examples include the federal Medicare regulations restricting payments only to accredited public health and home health care agencies (CMS, 2014b).
Accreditation, whether voluntary or required, provides a means for effective peer review and an opportunity for in-depth review of program strengths and limitations. Accreditation applies external pressure and places demands on institutions to improve quality of care. In the past, the accreditation process primarily evaluated an agency’s physical structure, organiza- tional structure, and personnel qualifications. However, begin- ning in 1990, more emphasis was placed on evaluation of the outcomes of care and on the educational qualifications of the person providing the care.
In the past there has not been a mechanism for accrediting public health agencies. In 2007 the Public Health Accreditation Board (PHAB) was incorporated, after public health leaders explored the feasibility of a national accreditation program. The field saw the need for, and value of, public health accredita- tion, and advocated for the implementation of a national voluntary program. The PHAB was developed in accordance with the recommendations generated by the Exploring Accredi- tation Steering Committee. The Steering Committee was com- prised primarily of state and local public health officials, including boards of health. The committee called on the expertise from other specialty areas engaged in accreditation. The PHAB is a nonprofit organization and is developing and testing national standards and processes that will be used to assess the strengths and areas for improvement in public health (PHAB, 2014).
The PHAB mission is to promote and protect the health of the public by advancing the quality and performance of all public health departments in the United States. The PHAB works toward creating a high-performing public health system that will make the United States the healthiest nation. The CDC and the Robert Wood Johnson Foundation are funders, and
576 PART 4 Issues and Approaches in Population-Centered Nursing
care is to advance, better diagnosis of performance problems and corrective strategies that are effective will be necessary (USDHHS, 2011a). The National Network of Public Health Institutes (2010) a toolkit designed to improve quality perfor- mance in public health, developed a toolkit.
An approach to recognition is the Magnet nursing services recognition status given by the American Nurses Credentialing Center to agency nursing services that, after an extensive review, are considered excellent. This program began with recognition of excellent hospital nursing services. The Magnet program has expanded to include nursing home and home health agencies, Reapplication for Magnet status must occur every 4 years to ensure that Magnet organizations stay at the top of their games (ANCC, 2014).
Specific Approaches Historically, QA programs conducted by health care agencies have measured or assessed the performance of individuals and how they conformed to standards set forth by accrediting agen- cies. TQM as a management philosophy uses CQI methods that incorporate many tools, including QA, to increase customer satisfaction with quality care. According to the AHRQ, quality health care means doing the right thing, at the right time, in the right way, for the right people—and having the best possible results (AHRQ, 2012, 2014b). To the Institute of Medicine (IOM, 2001, p. 3), quality health care is care that is as follows: • Effective—Providing services based on scientific knowledge
to all who could benefit and refraining from providing ser- vices to those not likely to benefit
• Safe—Avoiding injuries to clients from the care that is intended to help them
• Timely—Reducing waits and sometimes harmful delays for both those who receive and those who give care
• Client-centered—Providing care that is respectful of and responsive to individual client preferences, needs, and values and ensuring that client values guide all clinical decisions
• Equitable—Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
• Efficient—Avoiding waste, including waste of equipment, supplies, ideas, and energy QA seeks to eliminate errors before negative outcomes can
occur rather than waiting until after the fact to correct indi- vidual performance.
Health care agencies have only recently paid heed to the tenets of TQM. This management philosophy has been used in Japanese industry since the post–World War II era when W. Edwards Deming was invited to Japan to help rebuild its broken economy. In addition to Deming, people associated with the total quality concept are Walter Stewart (who first published on the subject), Joseph M. Juran, Armand F. Feigenbaum, Phillip B. Crosby, Genichi Taguchi, and Kaoru Ishikawa. Unlike tradi- tional QA programs, the focus of CQI is the process of delivering health care. This focus on process avoids placing personal blame for less-than-perfect outcomes. Applying TQM in health care allows management to look at the contribution of all systems to outcomes of the organization.
Deming’s (1986, p. 23) guidelines are summarized by his 15-point program:
1. Create, publish, and give to all employees a statement of the aims and purposes of the company or other organization. The management must demonstrate constantly their com- mitment to this statement.
2. Learn the new philosophy, top management, and everybody.
3. Understand the purpose of inspection, for improvement of processes and reduction of costs.
4. End the practice of awarding business on the basis of price tag alone.
5. Improve constantly and forever the system of production and service.
6. Institute training. 7. Teach and institute leadership. 8. Drive out fear. Create trust. Create a climate for innovation. 9. Optimize toward the aims and purposes of the company
the efforts of teams, groups, and staff areas.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Quality Improvement Use data to monitor the outcomes of intervention processes, and use improve- ment methods to design and test changes to continuously improve the quality and safety of health care systems.
Important aspects of quality improvement include: • Knowledge: Recognize that nursing and other health professions students
are parts of systems and intervention processes that affect outcomes for clients and families
• Skills: Identify gaps between local practices and best practice • Attitudes: Value own and others’ contributions to outcomes in local com-
munity settings
Quality Improvement Question You are working as a home care nurse and are discovering a trend of frequent readmissions to the hospital of many of your clients with heart failure. Using the quality assurance approach, consider the following questions: • What is being done now? • Why is it being done? • Is it being done well? • Can it be done better? • Should it be done at all? • Are there improved ways to deliver service? • How much is it costing? • Should certain activities be abandoned or replaced?
To which aspects of your clients’ quality of life and care transitions will you apply these questions?
Answer It would be helpful to look at a group of clients discharged from the hospital. Are they receiving adequate education and preparation to return home? You could also gather data about how clients are being managed by the commu- nity. How often are they following up with their primary care clinician? Are clients adequately educated to monitor their own fluid status, weight, and dietary restrictions? Are there community-based cardiovascular care programs that can help clients maintain optimum health and avoid exacerbations?
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
577CHAPTER 26 Quality Management
flow chart, the Pareto chart (used to compare the importance of differences between groups of data), cause-and-effect dia- grams, check sheets (see p. 583 for a client satisfaction check sheet), histograms, control charts, regression, and other statisti- cal analyses (e.g., QA data and techniques, risk management data, risk-adjusted outcome measures, and cost-effectiveness analysis) (Sollecito and Johnson, 2013). Steps 3, 4, and 5 are self-explanatory.
Joseph Juran built on Deming’s initial quality work and became a supporter of building quality into all processes. The Juran trilogy provides an effective way to compare the tasks of quality planning, QA, and QI. Quality planning involves deter- mining who the clients are, the needs of those clients, the service that fulfills the needs, and the process to produce that service. QA evaluates the performance of that service, compares it with the service goals, and then makes corrections if necessary. QI makes sure the infrastructure exists to enable individuals to identify improvement projects. Management of QI establishes project teams and provides those teams with the resources needed to carry out improvement projects (Van den Heuvel et al, 2013).
TQM/CQI IN COMMUNITY AND PUBLIC HEALTH SETTINGS Guidelines provided by the 1991 APHA Model Standards linked standards to meeting the health goals for the nation in the year 2000 (Sollecito and Johnson, 2013). Healthy People 2000 and APHA Model Standards (APHA, 1991) provided not only lists of priority health objectives for the nation and a way for public health to implement TQM/CQI, but also the most current sta- tistics and scientific knowledge about health promotion and disease prevention. Healthy People in Healthy Communities (USDHHS, 2001) provided the objectives with their stated targets, measurement tools, and reflected intended performance expectations.
Healthy People 2010 built on Healthy People 2000 and con- tained modified and additional objectives for promoting health and preventing disease (USDHHS, 2000). An important part of the framework of Healthy People 2010 was eliminating health disparities and ensuring access to quality health care for all. After extensive review of the Healthy People 2010 objectives, new goals and objectives were developed for Healthy People 2020 (USDHHS, 2010). The goals for Healthy People 2020 are as follows: • Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death. • Achieve health equity, eliminate disparities, and improve the
health of all groups. • Create social and physical environments that promote good
health for all. • Promote quality of life, healthy development, and healthy
behaviors across all life stages. Although all of the goals speak to quality of life and health,
goal two specifically addresses issues related to quality of health care delivery.
In addition, the Planned Approach to Community Health (PATCH) (CDC, 1995 with update in 2010); the Assessment Protocol for Excellence in Public Health (APEXPH), APEXPH
10. Eliminate exhortations for the workforce. 11. Eliminate numerical quotes for production. Instead, learn
and institute methods for improvement. 12. Eliminate management by objective. Instead, learn the
capabilities of processes and how to improve them. 13. Remove barriers that rob people of pride of workmanship. 14. Encourage education and self-improvement for everyone. 15. Take action to accomplish the transformation.
Deming’s first point emphasizes that an organization must have purpose and values. Health care providers have a clear idea of their values and have been committed to quality in the past, as demonstrated by codes of ethics and standards of care. However, successful TQM and CQI processes rely on a cultural change within an organization and the full support of manage- ment. With respect to providing quality health care, a paradigm shift from individual provider responsibility to team responsi- bility must occur (Sollecito and Johnson, 2013). A guiding prin- ciple is a customer orientation focused on positive health outcomes and perceived satisfaction. Customer (client) satisfac- tion surveys must be done for both internal and external users of services.
Personnel policies that are motivating as well as continuous training/learning opportunities are crucial to any CQI program. Deming’s eighth point addresses driving out fear. Fear in this context means the fear of being fired for being innovative or taking risks. In the CQI process, individuals are not blamed for failures in the system and therefore are motivated through the group to continually look for problems and improve system performance.
TQM works best in a flat organizational structure. This means there are very few supervisors between the staff and the director. This organization operates with an interprofessional team approach and a separate but parallel management quality council that monitors strategy and implementation. Teams are empowered to solve problems and locate opportunities for system improvement. Shewhart’s plan-do-check-act cycle serves as a guideline for the team approach to problem solving. This approach is also known as the Demming wheel. Steps include the following (Deming, 1986, p. 88; Deming Institute, 2014): 1. PLAN: Ask questions, such as: What could be the most
important accomplishments of this team? What changes might be desirable? What data are available? Are new obser- vations needed? If yes, plan a change or implement a test. Decide how to use the observations.
2. DO: Carry out the change or test decided upon. 3. CHECK: Observe the effects of the change. Study the results.
What did we learn? What can we predict? 4. ACT: Repeat the cycle, if the changes worked, or implement
a different strategy if the first plan was flawed, or revise the initial strategy based on the changes needed. A suggested way to start the problem-solving process with a
team in step 1 is brainstorming (Simon, n.d.). Brainstorming is getting everyone’s input about a possible process situation with no team member criticizing the suggestion. Because TQI orga- nizations are data driven, moving to step 2 requires that ongoing statistics be collected. Differences from the mean (average) or norm are detected through consistent use of tools, such as the
578 PART 4 Issues and Approaches in Population-Centered Nursing
Home health care agencies have increasingly adopted QI programs because of the competition that exists. Congruent with the TQM philosophy, meeting customer expectations is essential for home health care agencies. Models for QA/QI in home health care have been developed to improve the quality of care in TQM frameworks emphasizing processes, empower- ment, collaboration, consumers, data and measurement, and standards and outcomes (Oakland, 2014). Datasets of clinical information, such as those developed through the Omaha System (see Chapter 40) and the OASIS toolkit from the National Association of Home Care and Hospice (NAHC, 2010), are useful in measuring quality of care. In 2003 the Home Health Care Quality Initiative (HHQI) was developed by the USDHHS to provide consumers with data on the quality of home health services. Home Health Compare, posted on the Medicare website, is a home health report card available to consumers nationwide (USDHHS, 2014).
Finally, in the area of standards and guidelines, Honoré and Scott (2010) address six priority areas of performance that need improvement. One of these areas is consistently providing appropriate and effective care. This area is applicable to all health care practitioners, including nurses. Evidence-based practice guidelines are one way to deliver consistent, up-to- date care and to improve outcomes for individuals, communi- ties, and populations. Every year the American Cancer Society (ACS) provides a summary of current cancer screening guide- lines for health care professionals and updates the guidelines at least every five years, or sooner if new evidence warrants an
in Practice (NACCHO, 1995, 2014); and most recently the Mobi- lizing for Action through Planning and Partnerships (MAPP) process (NACCHO, 2014) provide methods of assessing com- munity needs to see how well health departments are operating to meet existing standards (see Chapter 25).
As health care reform continues, especially with the imple- mentation of the Affordable Care Act, public health agencies face competition and are trying to reform themselves. A prom- ising outcome of reform is how private health care and public health can come together in a community-level effort to monitor performance and improve health (see Chapter 3).
Recognizing the many factors that cause health problems and the fragmenting that continues to exist in the health care system, the public-private collaborative framework supported by the Healthy People documents involves many stakeholders, including public health, in monitoring the health of entire com- munities. Performance monitoring is defined as “a continuing community-based process of selecting indicators that can be used to measure the process and outcomes of an intervention strategy for health improvement (making the results available to the community as a whole) to inform assessments of an effective intervention and the contributions of accountable agencies to this” (Healthy People, 2020, 2011). These indicators would measure processes or states that contribute to health, and thus the processes are potentially alterable. As previously noted, there are four documents that monitor the quality and safety of health care, including the contributions of public health. Box 26-3 provides highlights from each of these reports.
Name of Report Most Recent Results
The National Health Care Quality Report, Agency for Healthcare Research and Quality, began publication in 2003 and has published for ten years
Assesses four dimensions of quality: effectiveness, client safety, timeliness, and client centeredness. Between 2003-2013: • Health care quality is getting better. • Large variation in quality across states. • 70% of recommended care actually received. • Access is fair and getting worse. • There has been no change in the disparities in health care over time and it is poor.
The State of Health Care Quality, 2013; The National Committee for Quality Assurance
Has been published annually for 18 years. Assesses HEDIS to determine quality improvement across third-party payers. • Reports after more than a decade of progress in quality of care • There is stagnant or declining performance in appropriate use of antibiotics. • Childhood obesity measures improving. • Childhood immunization results mixed. • Sustained decline in initiation of alcohol and drug treatment. • Better care in Medicaid HMOs.
National Healthcare Disparities Report, 2013; The Agency for Healthcare Research and Quality
Published since 2000 for 13 years. Assesses 11 dimensions of quality including safety: • Findings indicate disparities in quality and access remain common, with blacks, Hispanics, and Asians
receiving worse care then whites. • Poor people receive worse care then high income persons. • For some quality measures, persons with limited activity receive poorer care.
Safe Practices for Better Healthcare, 2010; The National Quality Forum
Published first in 2003, then in 2006 and 2009. The 2010 update report presents 34 safe practices with descriptions of their safety impact. • Adverse health care events continue to be a leading cause of death and injury. • Evidence indicates that the 34 safe practices identified are effective in improving safety. • Although many of the 34 practices can be adapted to public health, two can be specifically applied in
public health: a quality workforce and influenza prevention.
BOX 26-3 National Quality and Safety Reports
579CHAPTER 26 Quality Management
update (Smith et al, 2014). The use of guidelines helps in gath- ering data on the effectiveness and outcomes of nurse interven- tions (Matthew-Maich et al, 2013). The AHRQ, formerly the Agency for Healthcare Policy and Research (AHCPR), has played a major role in developing clinical practice guidelines.
Guidelines are protocols or statements of recommended practice developed by governmental and health care agencies, and by professional organizations; they are based on the distill- ing of scientific evidence and expert opinion that guide a clini- cian in decision making. Guidelines provide research-based evidence for interventions and promote improved health out- comes. Using research findings as guidelines or frames of refer- ence can improve nurses’ awareness of new or better ways to practice, allow for documentation of nurse interventions, and improve outcomes at all levels of public health nursing practice (Matthew-Maich et al, 2013) (see Chapter 9). Keystones of evidence-based practice guidelines arise from client concerns, clinical experience, best practices, and clinical data and research (Malloch and Porter-O’Grady, 2010). Clinical practice guide- lines are systematically developed statements to assist practitio- ner and client decisions about appropriate health care for specific clinical circumstances (as discussed in Chapter 15). An example of criteria for clinical practice guidelines are those set forth by the AHRQ and available on the Internet at the National Guideline Clearinghouse (NGC) website (http://www .guideline.gov/) (NGC, 2010). • The practice guideline contains systematically developed
statements that include recommendations, strategies, or information that assists health care practitioners and clients make decisions about appropriate health care for specific health care circumstances.
• The practice guideline was produced under the auspices of spe- cialty associations; relevant professional societies, public or private organizations, government agencies at the federal, state, or local level; or health care organizations or plans. A practice guideline developed and issued by an individual not officially sponsored or supported by one of the above types of organiza- tions does not meet the inclusion criteria for the NGC.
• Corroborating documentation can be produced and verified that a systematic literature search and review of existing scientific evidence published in peer reviewed journals was performed during the guideline development. A guide- line is not excluded from the NGC if corroborating docu- mentation can be produced and verified detailing specific gaps in scientific evidence for some of the guideline’s recommendations.
• The full text guideline is available upon request in print or electronic format (for free or for a fee) in English. The guide- line is current and the most recent version produced. Docu- mented evidence can be produced or verified that the guideline was developed, reviewed, or revised within the last 5 years (http://www.guideline.gov/contact/coninclusion .aspx). One of the quality reports published by the clearinghouse
each year is the National Healthcare Disparities Report, the most recent being 2013. The most recent guideline development and updates are related to cancer control.
Primary care practice guidelines are available in the Guide to Clinical Preventive Services (USPSTF, 2014) and the population- based Guide to Community Preventive Services available on the CDC website. This guide is an ongoing process of the Taskforce on Community Preventive Services that offers information on changing risk behaviors; reducing specific diseases, injuries and impairments, and environmental concerns; and state-of-the-art public health activities. Nurses need guidelines to reduce differ- ences in care practices, to improve outcomes on the basis of the best research available, and to deliver effective care to individu- als, communities, and populations.
Using QA/QI in CQI QA/QI methods and tools help agencies conform to standards required by external accrediting agencies. QA/QI provides a way to identify examples of substandard care and to improve that care when standards are not met. QA is focused on problem detection, whereas CQI is focused on problem prevention and continuous improvement. In QA, little attention is paid to pre- venting errors or problems and finding out who owns the quality issues. Furthermore, the QA process may stop unless another problem is found. Sollecito and Johnson (2013) point out differences in traditional management models that use per- formance standards versus those that use TQM (Table 26-1). The most important difference is in the emphasis on QA, or simply identifying the problem in the traditional management model versus the emphasis on CQI in the total quality manage- ment model. In TQM the problem is identified and measures are implemented to correct the problem. The TQM model is required in health care delivery because of the standards set by the national accrediting agencies such as TJC. Public health, through the public health accrediting process begun in 2011, is required to emphasize TQM.
Positive steps of a known QA program can be integrated into a CQI approach. Strengths of QA include a history of expertise in developing evaluation of structure, identifying high-priority problems, and developing knowledge in QA and information systems (de Jonge et al, 2011). These strengths can be used advantageously in a CQI effort.
Traditional Quality Assurance Traditional QA programs can fit well with the CQI process. The overall goal of specific QA approaches is to monitor the process and outcomes of client care. The goals of CQI are as follows:
Traditional Model TQM Model
Legal or professional authority Collective or managerial responsibility Specialized accountability Process accountability Administrative authority Participation Meeting standards Meeting process and performance
expectations Longer planning horizon Shorter planning horizon Quality assurance Continuous improvement
TABLE 26-1 Traditional Management Model Compared with Total Quality Management (TQM) Model
580 PART 4 Issues and Approaches in Population-Centered Nursing
a program or as an audit of the long-term impact of a program within the health care system. The advantages of the retrospec- tive audit are that it provides the following: • Comparison of actual practice to standards of care • Analysis of actual practice findings • A total picture of care given to a population or group of
clients • More accurate data for planning corrective action
Disadvantages of the retrospective audit method are as follows: • The focus of evaluation is directed away from ongoing care. • Client problems (group or population or community) are iden-
tified after care is offered through the program; thus corrective action can be used only to improve the care of future clients. Currently in public health, program record audits are done
to determine the processes and outcomes of care, such as family planning audits, WIC audits, breast and cervical cancer screen- ing audits, billing coding (to audit costs) and registration audits. Programs regarding physical activity, nutrition, obesity, arthri- tis, smoking cessation, and others are all designed to address the major causes of morbidity and mortality locally, statewide, and nationwide. The audits assist in determining the progress being made in reducing morbidity and mortality.
Utilization Review The purpose of utilization review is to ensure that care is needed and that the cost is appropriate. Utilization review is more likely used in HMOs, other MCOs, and ACOs including Medicaid or Medicare state-level managed care programs. There are three types of utilization review: 1. Prospective: An assessment of the necessity of care before
giving service
1. To identify problems between provider and client through QA methods
2. To intervene in problem cases 3. To provide feedback regarding interactions between client
and provider 4. To provide documentation of interactions between client
and provider Specific approaches are often implemented voluntarily by
agencies and provider groups interested in the quality of inter- actions in their setting. However, state and federal governments require mandatory programs within public health agencies. For example, periodic utilization review, peer reviews (audits), and other QA measures are required in public health agencies that receive funds from state taxes, Medicaid, Medicare, and other public funding sources. Examples of specific approaches to QA are agency staff review committees for peer review (Banner Health, 2012), utilization review committees for Medi- care and Medicaid, research studies, quality improvement organization (QIO) monitoring, client satisfaction surveys, risk management, and malpractice lawsuits.
Staff Review Committee Staff review committees are the most common specific approach to QA in the United States. Staff review committees are designed to monitor client-specific aspects of certain levels of care. The audit is the major tool used to evaluate quality of care.
The audit process (Figure 26-1) consists of six steps: 1. Select a topic for study. 2. Select explicit criteria for quality care. 3. Review records to determine whether criteria are met. 4. Do a peer review for all cases that do not meet criteria. 5. Make specific recommendations to correct problems. 6. Follow-up to determine whether problems have been
eliminated. Two types of audits are used in nursing peer review: concur-
rent and retrospective. The concurrent audit is a process audit that evaluates the quality of ongoing care by looking at the nursing process. Concurrent audit is used by Medicare and Medicaid to evaluate care being received by public health/home health clients. The audit data look at the group, population, or community served. The advantages of this method are as follows: • Identification of problems at the time care is given • Provision of a mechanism for identifying and meeting client
needs during the intervention • Implementation of measures to fulfill professional
responsibilities • Provision of a mechanism for communicating on behalf of
the client The disadvantages of the concurrent audit are as follows:
• It is time consuming • It is more costly to implement than the retrospective audit • Because the intervention is ongoing, it does not present the
total picture of the outcomes of the intervention that the client ultimately will receive The retrospective audit, or outcome audit, evaluates quality
of care through evaluation of the nursing process at the end of
FIG 26-1 The audit process.
Follow-up of problems
Records reviewed
Peer review of all cases
not meeting criteria
Recommendations for correcting deficiencies
Topic for study
selected
Explicit criteria
selected for quality care
581CHAPTER 26 Quality Management
clinic at the health department or as a result of an accident while making a home visit. Incident reports are reviewed by the risk management committee for appropriate, accurate, and thor- ough documentation of any problem that occurs relating to clients or personnel. In addition, patterns are identified from looking at program data that may require changes in policy or staff development to correct the problem. As a part of risk management, grievance procedures are established for both clients and personnel.
Professional Review Organizations/ Quality Improvement Organizations The Professional Standards Review Organization (PSRO) was established in 1972 in an amendment to the Social Security Act (PL 92-603) as a publicly mandated utilization and peer review program. This law provided that medical, hospital, and nursing home care under Medicare, Medicaid, and Title V Maternal and Child Health Programs would be reviewed for appropriateness and necessary care to be reimbursed.
In 1983 Congress passed the Peer Review Improvement Act (PL 97-248), creating professional review organizations (PROs). PROs replaced PSROs and are directed by the federal government to reduce hospital admissions for procedures that can be performed safely and effectively in an ambulatory surgi- cal setting on an outpatient basis. The goal was to reduce inap- propriate or unnecessary admissions or invasive procedures by
2. Concurrent: A review of the necessity of services while care is being given
3. Retrospective: An analysis of the necessity of the services received by the client after the care has been given Each of these reviews assesses the appropriate cost of care.
Prospectively, care can be denied and money saved. Concur- rently, services can be cut if they are not found to be essential. Retrospectively, payment can be denied to the provider if the care was not necessary.
Utilization review began in the middle part of the twentieth century out of concern for increasing health care costs. The first committees were developed by insurance companies and profes- sional groups. Utilization review committees became mandatory under the 1965 Medicare law as a way to control hospital costs.
The utilization review process includes development of explicit criteria regarding the need for services and the length of service. Utilization review has been used primarily in hospi- tals to establish the need for client admission and to determine the length of hospital stay. In community and public health, especially home health care, utilization review establishes crite- ria for admission to agency service, the number of visits a client may receive, the eligibility for client services (e.g., a nursing aide or physical therapist), and discharge.
Utilization review has several advantages: • It helps clients avoid unnecessary care. • It may encourage clients to consider alternative care options,
such as home health care rather than hospital care. • It can provide guidelines for staff and program development. • It provides for agency accountability to the consumer.
The major disadvantage of utilization review is that not all clients fit the classic picture presented by the explicit criteria used to determine approval or denial of care. For example, an older adult client was admitted to a home health care agency for management after hospital discharge. The client was para- plegic as a result of a cerebrovascular accident. After several weeks of physical and speech therapy, the client showed little sign of progress. The utilization review committee considered the client’s condition to be stable and did not recognize the continued need for management to prevent future complica- tions; therefore, Medicare payment was denied.
Appeal mechanisms have been built into the utilization review process used by Medicare and Medicaid. The appeal allows providers and clients to present additional data that may help to reverse the original decision to deny payment.
Risk Management Risk management committees are often a part of the CQI program of a community agency. Risk management seeks to reduce the agency’s liability because of grievances brought against them. The risk management committee reviews all risks to which an agency is exposed. It reviews client and personnel safety policies and procedures and determines whether person- nel are following the rules. Examples of problems reviewed by a risk management committee in public health clinics include administering incorrect vaccination dosage, pediatric client injury caused by a fall from an examination table, or injury to the nurse from a needlestick in the sexually transmitted diseases
From Davis MV, Mahanna E, Joly B, et al: Creating quality improvement culture in public health agencies. Am J Public Health 104(1):e98–e104, 2014.
This mixed-methods study sought to identify factors that support or hinder the development of a quality improvement culture in public health agencies. The researchers conducted case studies of ten agencies that participated in early quality improvement efforts. Agency staff who participated in National Asso- ciation of County and City Health Officials (NACCHO)-sponsored quality improvement trainings were invited to complete a survey. Health directors and quality improvement teams from these agencies were also interviewed. The investigators found that agencies that were successful in creating a positive quality improvement culture had the following characteristics: had leadership support; had participated in national quality improvement initiatives; had a greater number of staff trained in quality improvement; had quality improve- ment teams that met regularly with decision-making authority; reported that accreditation was a major driver to quality improvement work; and had a history of evidence-based decision making and use of quality improvement to address emerging issues. The investigators reported that the role of accredita- tion preparation as a driving force in quality improvement appears to diminish as an agency develops a quality improvement culture. The researchers noted that common barriers to creating a quality improvement culture included lack of time and resources and relevance of quality improvement to daily work. However, they also reported that staff used quality improvement to overcome these barriers.
Nurse Use Leadership and teamwork within an organization plays a key role in creating a positive quality improvement environment. Community health nurses are in a prime position to be leaders in their organizations in developing a quality improvement environment.
EVIDENCE-BASED PRACTICE
582 PART 4 Issues and Approaches in Population-Centered Nursing
characteristics for implementing the tracer method (Papanico- las and Smith, 2013; Kelly, 2011): 1. A tracer, or a problem, that has a definite impact on the cli-
ent’s level of functioning 2. Well-defined and easily diagnosed characteristics 3. Population prevalence high enough to permit adequate data
collection 4. A known variation resulting from use of effective health care 5. Well-defined management techniques in prevention, diag-
nosis, treatment, or rehabilitation 6. Understood (documented) effects of nonmedical factors on
the tracer Client groups selected for tracer outcome studies in nursing
would have the following: 1. A shared health problem 2. Receiving a similar intervention 3. Sharing similar needs 4. Located in the same community 5. Having a similar lifestyle 6. Being at the same illness stage
The tracer method provides nurses with data to show the differences in outcomes as a result of nursing care standards.
The sentinel method of quality evaluation is based on epi- demiologic principles. This method is an outcome measure for examining specific instances of client care (Kelly, 2011). Changes in the sentinel indicate potential problems for others. For example, increases in encephalitis in certain communities may result from increases in mosquito populations. Data may be collected at the health department through a state or local required disease reporting system. The health department would be notified and an immediate mosquito control strategy would be put into place. Such an intervention would include, for example, nurses notifying the population to remove stand- ing water around the outside of homes, such as animal water bowls, rain barrels, and gutter downspout water collec- tion pools. Flyers may be sent home with school children or given to clients visiting the public health clinics, and media announcements may be used. In addition, the environmental office at the health department may inspect local swimming pools and may also implement a nighttime mosquito spraying program throughout the community.
specific practitioners or hospitals. Quality measures include reducing unnecessary admissions caused by previous substan- dard care, avoidable complications and deaths, and unnecessary surgery or invasive procedures (Chassin and Loeb, 2011). The PRO is now known as the Quality Improvement Organization.
Institutions contracting with QIOs for quality reviews are usually state organizations that establish criteria for care on the basis of local patterns of practice, and they are private contrac- tors to CMS and mostly not-for-profit organizations. They may have on their board health care providers who are independent from the QIO and the board must have at least one consumer. QIOs must define their operational objectives, monitor access to care, cost of care, and quality concerns, and protect the Medicare Trust. Professionals working under the regulation of QIOs should develop accurate and complete documenting procedures to ensure compliance with the criteria of the QIO (CMS, 2014a).
Debate has occurred over the limits and benefits of the feder- ally mandated quality review process. Limits include jeopardiz- ing professional autonomy because decision making regarding care includes professionals, consumers, and government repre- sentatives. Another limitation of this process is the development of a costly control mechanism whereby client care activities may be determined by cost rather than by professional criteria. The benefit of the QIO system has been the development of stan- dards and the peer review mechanisms to increase account- ability for care provided.
TQM provides direction for managing a system of care, whereas CQI using QA/QI focuses on the care a client receives within the system.
Evaluative Studies Evaluative studies for quality health care increased during the twentieth century. Studies demonstrate the effect of nursing and health care interventions on client populations. Three key models have been used to evaluate quality: Donabedian’s structure-process-outcome model, the tracer method, and the sentinel method.
Donabedian’s model (1981, 1985, 2003) introduced three major methods for evaluating quality care: 1. Structure: Evaluating the setting and instruments used to
provide care; examples of structure are facilities, equipment, characteristics of the administrative organization, client mix, and the qualifications of health providers
2. Process: Evaluating activities as they relate to standards and expectations of health providers in the management of client care
3. Outcome: The net change or result that occurs as a result of health care
The three methods may be used separately to evaluate a part of care. However, to get an overall picture of quality of care, they should be used together.
The tracer method described by Kessner and Kalk (1973) is a measure of both process and outcome of care and is used today. This method is more effective in evaluating health care of groups than of individual clients. It is also more effective in evaluating care delivered by an institution than care delivered by an individual provider. The following are essential
HOW TO Conduct a Sentinel Evaluation • Identify cases of unnecessary disease, disability, and complica-
tions (for example, tuberculosis). • Count the deaths from these causes. • Examine the circumstances surrounding the unnecessary event
(or sentinel), in detail. • Review morbidity and mortality rates as an index for comparison;
determine the critical increase in the untimely event, which may reflect changes in quality of care. Example: Compare the inci- dence and prevalence of TB cases before the increased popula- tion occurred.
• Explore health status indicators, such as changes in social, eco- nomic, political, and environmental factors that may have an effect on health outcomes. Example: Overcrowding in the shelter where migrant workers stay (environmental) and the inability to follow-up on testing because of the transient nature of the popu- lation (social).
583CHAPTER 26 Quality Management
which the care was received. Clients are often more critical of interpersonal and situational components of care than of the interventions of care.
Satisfaction surveys are an essential aspect of QA. Survey data provide clues to reasons for client compliance or noncom- pliance with plans of care. Although consumers may not view quality in the same light as the health professional, surveys provide data about health-seeking behaviors, the probability of malpractice litigation, and the likelihood of continuing client- provider-agency relationships—always an important measure for community-based and public health agencies (Oakland, 2014) (Figure 26-2).
CLIENT SATISFACTION Client satisfaction is another approach to measuring quality of care. Client satisfaction can be assessed using in-person or telephone interviews and mailed questionnaires. Satisfaction surveys are used to assess care received during an admission to a specific agency, to assess a client’s personal nursing care, or to assess the total care that the client received from all services.
Satisfaction surveys may measure the interventions used for client care, attitudes about the care received and the providers of care, and perceptions of the situation (environment) in
FIG 26-2 Client satisfaction tool domains and examples.
Affective support
Please mark the following questions using the scale.
Health information
Decision control
Technical competencies
Overall satisfaction
Accessibility
Strongly AgreeExampleDomain
Somewhat Agree Agree
Somewhat Disagree
Strongly Disagree
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
The visiting nurse was understanding of my health concerns.
The nurse gave me encouragement in regard to my health problems.
I got my questions answered in an individual way.
The information I received from the nurse helped me to take care of myself at home.
I was included in decision making.
I was included in the planning of my care.
The care I received was of high quality.
Decisions regarding my health care were of high quality.
The nurse was available when I needed help.
The nurse was on time.
Overall, I was satisfied with my health care.
The care I received was of high quality.
584 PART 4 Issues and Approaches in Population-Centered Nursing
Malpractice Litigation Malpractice litigation (i.e., a lawsuit) is a specific approach to QA imposed on the health care delivery system by the legal system. Malpractice litigation typically results from client dis- satisfaction with the provider and with the content of the care received. Nursing is not immune from malpractice litigation. Nursing must continue to have a sound QA program that ensures quality care. This will reduce the risk of quality control measures being imposed by an external source, such as the legal system. As a true example, a public health nurse was individually sued by a new family to the community because the nurse repeated an immunization the child had already received prior to moving to the community. The result was Guillain-Barré syn- drome. The nurse was found at fault even though the parents did not provide the physician’s record of immunizations to the nurse. It was the nurse’s responsibility to follow standard guide- lines and to obtain the essential records prior to proving the immunization. The public health department was dismissed from the lawsuit because of immunity granted to state agencies.
MODEL CQI PROGRAM The primary purpose of a QA/QI program is to ensure that the results of an organized activity are consistent with the expecta- tions. All personnel affected by a QI program should be involved in its development and implementation. Although administra- tion and management are responsible for the quality of services, the key to that quality is in the personnel who deliver the service: their knowledge, skills, and attitudes.
Figure 26-3 shows a model that identifies the basic compo- nents of a QI program. QI programs answer the following ques- tions about health care services and nursing care: 1. What is being done now? 2. Why is it being done? 3. Is it being done well? 4. Can it be done better? 5. Should it be done at all? 6. Are there improved ways to deliver the service? 7. How much does it cost? 8. Should certain activities be abandoned or replaced?
FIG 26-3 Model quality improvement programs.
Identify structure standards and criteria
Philosophy Objectives Resources Policies
Procedures Job description Personnel qualifications
Client mix
Standards and criteria to evaluate outcome
Change in client health status Client disposition Personnel/client safety Client/personnel satisfaction Malpractice suits Documentation of care Effectiveness, efficiency
of services
Identify process standards and criteria
Professional standards application Nursing process application Nursing care procedures Client satisfaction Personnel performance
evaluation
Structure
O u tco
m es P
ro ce
ss
Identify alternative problem-solving choices
Take action and evaluate
Identify strengths and limits
Identify values
585CHAPTER 26 Quality Management
FIG 26-4 The plan-do-check-act (PDCA) model of continuous quality improvement. The concept of the PDCA cycle was origi- nally developed by Walter Shewhart, the pioneering statistician who developed statistical process control in the Bell Laborato- ries in the United States during the 1930s. It is often referred to as the “Shewhart Cycle.” It was adopted in the 1950s by W. Edwards Deming, and is often referred to as the “Deming Wheel.”
CHECK
D O
PLAN
A C
T
LINKING CONTENT TO PRACTICE
The PDCA model is being used in public health to promote CQI. A brief example of how to apply this model is given below.
This approach was designed to improve new mother and baby outcomes by improving nurse/client communication processes. This model for improvement includes four components recommended by the Institute of Healthcare Improve- ment: (1) aims and goals, (2) performance measures, (3) strategies and ideas for changes, and (4) the use of PDCA cycles. 1. The goal of the project is to improve health outcomes for at-risk new mothers
and babies involved in the nurse home visiting program by offering a daily telephone consultation to answer questions and provide support up to 3 months after the baby’s birth.
2. The performance measures include: A. An assessment of the numbers of nurses on the home visiting team who
could successfully answer the questions of the mothers who received the daily consultation.
B. The second measure is a retrospective record audit at 6 months to assess the progress of the mothers who had access to the daily call as compared with mothers who were involved in the program prior to the daily phone consult.
3. The strategies include: A. A work session of the nurses to review their knowledge about parenting
and caring for a new baby up to 3 months using a simple pretest. B. An update on what new mothers need to know to bond with their babies
and to provide for the new babies’ needs followed by a post-test of the nurses’ knowledge.
C. The development of the process for the daily phone consultation including a checklist of assessment questions the nurse might ask and time built in to respond to parent’s questions.
Plan: Plan a mock “daily consult” call to a public health nurse (or a fellow student) with her first baby. Develop different scenarios for the public health nurse to respond to in order to assess each home visiting nurse’s ability to
respond to the mother’s questions, such as feeding techniques, bathing, crying, and holding the baby.
Do: Engage each of the home visiting nurses in participating in the mock calls. Check: Assess the abilities of each of the nurses to respond to the questions
from the new mother by having the public health nurse use a simple yes/no checklist of prepared questions.
Assess how efficient the nurse is in completing the consultation. Can answers to the questions be noted immediately, or does help need to be sought from others prior to answering the mother’s question? Use a checklist to identify the time on the call, and ability to independently answer the questions.
Act: If the nurses were able to provide the consultation efficiently and without assistance, implement the process with new mothers and babies, use PDCA for the implementation to identify any problems with the process.
If the nurses were unable to efficiently provide the consult, provide additional education and tools to increase their efficiency. Use the PDCA process until the nurses are able to efficiently provide the consult.
The PDCA cycle is continuously repeated until the administration, the nurses, and the clients are satisfied that the process is working.
Data from these small tests will provide realistic estimates of the percentage of the nurses who can successfully engage in consultation via phone. The purpose in the initial assessment and education of the nurses is to ensure faster consults so more mothers and babies can be contacted in a short period without adding to the nurses’ workload, while potentially reducing the amount of time for the home visit because the mother may be better prepared to care for the baby’s needs with this support. The improvement process may enlist the support of all nursing staff and administration and create a change in the work environ- ment through the development of a planned phone consultation process for all clients who may receive home visits.
As students develop questions, they also develop a PDCA approach to answer- ing those questions.
As a part of answering the questions and determining changes that can improve services, public health can use the PDCA model. The steps of the model are shown in Figure 26-4.
The PDCA is a model for continuous improvement and can be used after an audit of a program, for example to begin a new improvement project or when developing a new or improved
design of a process, product, or program. It can also be used to define a repetitive work process or for planning data collection and analysis to verify and prioritize problems or root causes, which are actually the system problems that lead to the problem. It is also used to implement change.
The PDCA procedure involves the following steps: 1. Plan. Recognize an opportunity and plan a change. 2. Do. Test the change. Carry out a small-scale study. 3. Check. Review the data, analyze the results, and identify
what has been learned. 4. Act. Take action based on what was learned in the check/
study step: If the change did not work, go through the cycle again with a different plan. If successful, incorporate what you learned from the test into wider changes. Use what was learned to plan new improvements, and begin the cycle again. Beginning the cycle again defines the continuous program of CQI. This is also referred to as a rapid cycle improvement process in health care. Donabedian’s framework for evaluating health care pro-
grams using the components of structure, process, and outcome can be used in developing a QI program. Outcome is the most important ingredient of a program because it is the key to evaluating providers and agencies by accrediting bodies, by insurance companies, and by Medicare and Medicaid through QIOs, report cards, and other accrediting agencies.
From Cronenwett L, Sherwood G, Barnsteiner J, et al: Quality and safety education for nurses, Nurs Outlook 55(3):122-131, 2007.
586 PART 4 Issues and Approaches in Population-Centered Nursing
Structure The vision, values, philosophy, and objectives of an agency serve to define the structural standards of the agency. Evaluation of structure is a specific approach to looking at quality. In evaluat- ing the structure of an organization, the evaluator determines whether the agency is adhering to the stated philosophy and objectives and to its vision and stated values. Is the agency pro- viding services to populations across the life span? Are primary, secondary, and/or tertiary preventive services offered? Stan- dards of structure are defined by the licensing or accrediting agency (e.g., the Community Health Accreditation Program’s [CHAP’s] standards for accrediting home health agencies).
Identifying values, the first step in a QA program, serves to define the beliefs of the agency about humanity, nursing, the community, and health. The beliefs of the community, the pop- ulation to be served, and the providers of care are equally important to the agency, and all need to be considered to provide quality service.
Identifying standards and criteria for QA begins with writing the philosophy and objectives of the organization. Program objectives define the intended results of nursing care, descrip- tions of client behaviors, and/or change in health status to be demonstrated on discharge.
Once objectives are formulated, the resources needed to accom- plish the objectives should be identified. The personnel, supplies and equipment, facilities, and financial resources that are needed should be described. Once resources are determined, policies, pro- cedures, and job descriptions should be formed to serve as behav- ioral guides to the employees of the agency. These documents should reflect the essential nursing and other health provider quali- fications needed to implement the services of the agency.
Standards of structure are evaluated internally by a committee composed of administrative, management, and staff members for the purpose of doing a self-study. Standards of structure are also evaluated by a utilization review committee, often composed of an external advisory group with community representatives for all services offered through an agency, such as a nurse, a public health physician, an environmental engineer, a sanitation engi- neer, a health educator, a board member, and an administrator from a similar agency. The data from these committees identify the strengths and weaknesses of the agency structure.
Process The evaluation of process standards is a specific look at the quality of care being given by agency providers, such as nurses. Agencies use a variety of methods to determine criteria for evalu- ating provider activities: conceptual models; the standards of care of the provider’s professional organization, such as the ANA’s Scope and Standards of Public Health Nursing Practice (ANA, 2013) (see Chapter 1); or the nursing process. The activities of the nurse are evaluated to see whether they are the same as the nursing care procedures defined by the public health agency.
The primary approaches used for process evaluation include the peer review committee and the client (often community) satisfaction survey. The techniques used for process evaluation are direct observation, focus groups, questionnaire, interview,
written audit, and video or digital recordings of client and provider encounters.
Once data are collected to evaluate nursing process stan- dards, the peer review committee reviews the data to identify strengths and weaknesses in the quality of care delivered. The peer review committee is usually an internal committee com- posed of representatives of the nursing staff who are trained to administer audit instruments and conduct client interviews.
Outcome The evaluation of outcome standards, or the result of nursing care, is one of the more difficult tasks facing nursing today. Identifying changes in the client’s health status that result from nursing care provides nursing data that demonstrate the con- tribution of nursing to the health care delivery system. Research studies using the tracer or sentinel method to identify client outcomes and client satisfaction surveys can be used to measure outcome standards. Measures of outcome standards include client data about the changes in the community in low-birth- weight babies as a result of improved prenatal care and client compliance with care through the WIC program.
From these data, strengths and weaknesses in nursing care delivery can be determined. The most common measurement methods are direct physical observations and interviews. Instru- ments have also been developed to measure general health status indicators in home health. The Omaha Visiting Nurse Association problem classification system includes nursing diagnosis, protocols of care, and a problem rating scale to measure nursing care outcomes. In addition, the ANA has developed 10 areas for data collection of outcome criteria in community-based, non–acute care settings, including pain management, consistency of communication, staff mix, client satisfaction, prevention of tobacco use, cardiovascular disease prevention, caregiver activity, identification of primary care- giver, activities of daily living, and psychosocial interactions (Rowell, 2001). Nursing has been involved primarily in evaluat- ing program outcomes to justify program expenses rather than in evaluating client outcomes.
Outcome evaluation assumes that health care has a positive effect on client status. The major problem with outcome evalu- ation is determining which nursing care activities are primarily responsible for causing changes in client status. Recently, studies have been conducted on nurse-sensitive indicators, such as failure to rescue, that show the importance of nurse staffing in adverse client outcomes (Doran, 2011; McCormack et al, 2010). In nursing, many uncontrolled factors in the field, such as envi- ronment, community services, and family relationships, have an effect on client status. Often it is difficult to determine whether these factors are the cause of changes in client status or whether nursing interventions have the most effect.
Types of problems studied in a QA program include reasons for the following: • Client death (population mortality) • Client injury (population morbidity) • Personnel and client safety • Agency liability • Increased costs
587CHAPTER 26 Quality Management
Taking action is the final step in the QA/QI model. Once the alternative courses of action are chosen to correct problems, actions must be implemented for change to occur in the overall operation of the agency. Follow-up and evaluation of actions taken must occur to improve quality of care. Although health provider evaluation will continue to be included in a QI effort, the focus of a CQI effort emphasizes the process and not the person. The assumption here is that health care professionals and other employees customarily want to do the best job pos- sible for the client, and problems or differences in a process should not be automatically attributed to their behavior. Although frequent feedback should be given to all employees, the hallmark of QI is continuous learning. Staff development must be ongoing for all employees. (The Levels of Prevention box shows prevention levels related to quality management.)
• Denied reimbursement by third-party payers (decreased program funding by government)
• Client complaints • Inefficient service • Staff noncompliance with standards of structure • Lack of resources • Unnecessary staff work and overtime • Documenting of care • Client health status (population health status)
Table 26-2 summarizes QA measures.
Evaluation, Interpretation, and Action Interpreting the findings of a quality care evaluation is an important part of the process. It allows differences between the quality care standards of the agency and the actual practice of the nurse or other health providers to be identified. These pat- terns reflect the total agency’s functioning over time and gener- ate information for decisions to be made about the strengths and limits of the agency. Regular intervals for evaluation should be established within the agency, and periodic reports should be written so that the combined results of structure, process, and outcome efforts can be analyzed and health care delivery patterns and problems can be identified. These reports should be used to establish an ongoing picture of changes that occur within an agency to justify nursing services.
Identifying choices of possible courses of action to correct the weaknesses within the agency should involve both the administration and the staff. The courses of action chosen should be based on their importance, cost, and timeliness. For example, if there is a nursing problem in the recording of client health education, the agency administration and staff may analyze the problem to see why it is occurring. Reasons for lack of record-keeping given by the nurses include a lack of time to do paperwork properly, workloads that reduce the amount of time spent with clients, and lack of available resources for health education. If such reasons are given, it would not be appropriate for management to deal with the problem by providing a staff development program on the importance of doing and record- ing health education; it would be more important to assess how to provide the time and resources necessary for the nurses to offer health education to the clients. Economically, it may be more beneficial to provide personal data assistants or laptop computers and clerical assistance so that nurses can make notes at the point of implementation, thereby providing more client contact time, or it may be more beneficial economically to employ an additional nurse and reduce workloads.
Structure Process Outcome
Internal agency Peer review committees Internal agency committees Self-study Prospective audit Evaluative studies Review agency
documents Concurrent audit Retrospective audit
Survey health status
External agency Client Client Regulatory audit Satisfaction survey Malpractice suits
Utilization review Satisfaction survey
TABLE 26-2 Quality Assurance Measures
LEVELS OF PREVENTION
Primary Prevention The nurse participates in a parent education program to improve the immuni- zation level of children in the local elementary school and develops a strategy for follow-up.
Secondary Prevention Agency evaluation, using a retrospective audit of records of the immunization program, determines that the vaccine-preventable infectious disease rates have declined in the elementary school after the implementation of the parent education program.
Tertiary Prevention A review of the public health report card indicated that community incidence of complications from vaccine-preventable diseases have declined over a 2-year period after the implementation of the parent education program.
Quality Management
Documentation is essential to evaluating quality care in any organization. The following section focuses on the kinds of documentation that normally occur in a community agency.
RECORDS Records are an important part of the communication structure of the health care organization. Accurate and complete records are required by law and must be kept by all government and nongovernment agencies. In most states, the state departments of health stipulate the kinds of records to be kept and their content requirements for community agencies.
Records provide complete information about the client (whether a family, group, population or community), indicate the extent and quality of services being given, resolve legal issues in malpractice suits, and provide information for education and research.
Community and Public Health Agency Records Within the community or public health agency, many types of records are kept and used to predict population trends in a com- munity, to identify health needs and problems, to prepare and justify budgets, and to make administrative decisions. The kinds
588 PART 4 Issues and Approaches in Population-Centered Nursing
of each fiscal year to define the short- and long-term goals of the agency. The annual implementation plan serves as the basis for the agency’s annual summary. The annual summary reflects the success of the agency in meeting the annual objec- tives, the changes in population trends and health status during the year, the actual versus the projected budget requirements, the number of services offered, the number of clients served, and the plans and changes recommended for the future. This plan serves as the basis for the evaluation of agency structure.
As an outgrowth of QA efforts in the health care system, comprehensive methods are being designed to document and measure client progress and client outcome from agency admis- sion through discharge. An example of such a method is the client classification system developed at the Visiting Nurses Association of Omaha, Nebraska (Martin, 2005; The Omaha System, 2014). This comprehensive method for evaluating client care has several components: a classification system for assess- ing and categorizing client problems, a database, a nursing problem list, and anticipated outcome criteria for the classified problem. Such schemes are viewed as having the potential to improve the delivery of nursing care, documentation of care, and the descriptions of client care. Briefly, implementing a com- prehensive documentation method improves nursing assess- ment, planning, implementation, and evaluation of client care; it also allows the organization of important client information for more effective and efficient nurse productivity and com- munication (see Figure 26-2).
of records kept by the agency may include reports of accidents, births, census, chronic disease, communicable disease, mortality rates, life expectancy, morbidity rates, child and spouse abuse, occupational illness and injury, and environmental health.
Other types of records kept within the agency are those used to maintain administrative contact and control of the organiza- tion. Three types of records make up this category: clinical, pro- vider service, and financial. The clinical record is the client health record. The provider service records include information about the number of clinic clients seen daily, the immunizations given, home visits made daily, transportation and mileage, the provid- er’s time spent with the client, and the amount and kinds of supplies used. The service record is completed on a daily basis by each provider and is summarized monthly and annually to indi- cate trends in health care activities and costs related to personnel time, transportation, maintenance, and supplies. The provider service records are used to compare with the agency’s financial records of salaries, overhead, and transportation costs, and they serve as the basis for the cost accounting system. These records are basic to peer review and audit.
Three additional kinds of service records seen in the com- munity agency are the central index system, the annual imple- mentation plan, and the annual summary of agency activities. The central index system is a data filing system that indicates the services requested, services offered, active and inactive clients of the agency, and a profile of the agency’s clients.
The annual implementation plan (often referred to as the strategic plan or tactical plan) is developed at the beginning
LINKING CONTENT TO PRACTICE
The Robert Wood Johnson Foundation (RWJF) funded a project initiative focusing on the development of competencies and resources to enhance the ability of nursing professionals to deliver high-quality and safe nursing care. The Quality Safety Education for Nurses collaboration identified and defined six quality and safety competencies for nursing. In addition, the project allowed for the development of proposed targets for the knowledge, skills, and attitudes of students for each of the six competencies identified by the Institute of Medicine as: client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. The overall goal for the Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems within which they work. The following are the definitions for each of the six competencies and examples of the chapters in the text where content can be found and related to the competency:
Client-centered care: Recognize the client or designee as the source of control and full partner in providing compas- sionate and coordinated care based on respect for client’s preferences, values, and needs. (Chapters 4, 6, 7, 9, 12, 14, 15, 19)
Teamwork and Collaboration: Function effectively within nursing and interprofessional teams, fostering open com- munication, mutual respect, and shared decision making to achieve quality client care. (Chapters 5, 6, 8, 10, 16, 18, 20-22, 26-28, 30, 32-35, 37, 39, 41, 45, 46)
Evidence-Based Practice (EBP): Integrate best current evi- dence with clinical expertise and client/family preferences
and values for delivery of optimal health care. (All chapters, with emphasis in Chapters 15 and 26)
Quality Improvement (QI): Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. (Chapters 3, 8, 10, 12, 14, 18, 20, 24, 25, 26)
Safety: Minimizes risk of harm to clients and providers through both system effectiveness and individual performance. (Chapters 12, 13, 14, 23, 24, 28, 39-46)
Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making. (Chapters 23-26)
All of these competencies are addressed in this text as the competencies relate to public health nursing practice. The knowledge, skills, and attitudes related to QI are addressed in this chapter and one area of the QI competency appears in the following table.
Knowledge Skills Attitudes
Describe approaches for changing processes of care
Design a small test of change in daily work (using an experiential learning method such as PDCA)
Practice aligning the aims, measures, and changes involved in improving care
Use measures to evaluate the effect of change
Value local change (in individual practice or team practice on a unit) and its role in creating joy in work
Appreciate the value of what individuals and teams can to do to improve care
From Institute of Medicine: Health professions education: a bridge to quality, Washington, DC, 2003, National Academies Press.
589CHAPTER 26 Quality Management
P R A C T I C E A P P L I C A T I O N Oscar, a nursing student, has been working in the migrant farm- worker clinic and has noted that each practitioner uses a differ- ent educational method for teaching good nutrition practices to newly diagnosed diabetic clients. The clinic has seen a sub- stantial increase in the number of new diabetic clients in the Hispanic farmworker population. Oscar knows that practice guidelines for teaching nutrition practices exist in his clinical facility and that charts have an area to note nutrition education information. He also knows that for nurses to be most effective and ensure quality client outcomes, research- based practice guidelines should be used by all nurses in the health department.
As part of his course, Oscar must prepare a teaching plan and conduct a class on a health care problem. He obtains per- mission from his instructor and the director of the clinic to conduct an in-service program. The purpose of Oscar’s in-service program is to instruct the nursing staff how to teach newly diagnosed diabetic clients good nutrition practices. He obtains and studies the guidelines about teaching good
nutrition practices from the National Guideline Clearinghouse titled Diabetes Type 1 and 2 Evidence-based Nutrition Practice Guideline for Adults (2010), and he researches the method- ological background for development of the guidelines. Oscar’s native language is Spanish, so this will help him in determining whether brochures for newly diagnosed diabetic clients regard- ing good nutrition convey the appropriate message.
As part of his in-service program, Oscar keeps demographic records on attendees and conducts before-and-after tests of knowledge, adding questions about the present use of the guidelines. He plans to follow up with the nurses in 6 months with a further test and questions about use of the guidelines. The director will help him determine an outcome measure that can be used with the client population to show effective use of the guidelines. A. What outcome measure would be useful in this project? B. How will this help in the overall assessment of quality in the
nursing service? Answers can be found on the Evolve site.
K E Y P O I N T S • The health care delivery system is the largest employing
industry in the United States; society is demanding increased efficiency and effectiveness from the system.
• The actual quality and safety of care in the United States is being assessed regularly and reported in four reports.
• Because of varying definitions, logistics, and data collection methods, quality is difficult to assess accurately.
• Responding to the quality of care question, the federal gov- ernment has instituted several quality improvement pro- grams. Among these are the National Healthcare Quality Report (NHQR) that is used to monitor the nation’s progress toward improved health care quality; the Center for Medi- care and Medicaid Services (CMS) Outcomes Based Quality Improvement (OBQI) for home health; and the National Committee for Quality Assurance (NCQA), which provides performance information, or report cards, for health care agencies.
• Quality improvement is the tool used to ensure effective and efficient care.
• The managed care industry is changing the face of the Amer- ican health care delivery system and how quality is defined and measured.
• Objective and systematic evaluation of nursing care has become a priority within the profession for several reasons, including the effects of cost on health care access, consumer demands for better quality care, and increasing involvement of nurses in formulating public and health agency policy.
• Total quality management is a management philosophy new to the public health care arena. It is prevention oriented and process focused. Its primary focus is to deliver quality health care. One measure of quality is customer satisfaction.
• Public and private sectors are forming partnerships to monitor the performance of all players in health care deliv- ery to improve the health of communities. The different players in the health care system have different perceptions of quality.
• Quality assurance/quality improvement (QA/QI) is the monitoring of client care activities to determine the degree of excellence attained in implementing activities.
• Quality assurance has been a concern of the profession since the 1860s, when Florence Nightingale called for a uniform format to gather and disseminate hospital statistics.
• Licensure has been a major issue in nursing since 1892. • Two major categories of approaches exist in QA/QI today:
general and specific. • Accreditation is an approach to quality control used for
institutions, whereas licensure is used primarily for individuals.
• Certification combines features of both licensing and accreditation.
• Three major models have been used to evaluate quality: Donabedian’s structure-process-outcome model, the senti- nel model, and the tracer model.
• A fourth model to evaluate quality—the PDCA model—has been adopted by the public health system.
• Seven basic components of a quality improvement program are (1) identifying values, (2) identifying structure, process, and outcome standards and criteria, (3) selecting measure- ment techniques, (4) interpreting the strengths and weak- nesses of the care given, (5) identifying alternative courses of action, (6) choosing specific courses of action, and (7) taking action.
590 PART 4 Issues and Approaches in Population-Centered Nursing
K E Y P O I N T S — cont’d • Records are an integral part of the communication structure
of a health care organization. Accurate and complete records are by law required of all agencies, whether governmental or nongovernmental.
• QA/QI mechanisms in health care delivery are the mecha- nisms for controlling the system and requesting account- ability from individual providers within the system. Records
help establish a total picture of the contribution of the agency to the client community.
• Delivering quality care to individuals, communities, and pop- ulations falls under the 10 essential services of public health.
• Evidence-based practice guidelines can help population- centered nurses document the outcomes and effectiveness of their interventions.
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with the one given in the text. Are they the same or different? Give justification for your answer.
2. How does traditional QA/QI fit with the CQI effort? Explain the relative importance of a continuing QA/QI effort.
3. Interview a nurse who is a coordinator of or is responsible for QA/QI in a local health agency. Ask the following ques- tions and add your own. Do the answers to the questions relate to what you have learned about QA/QI? Explain. A. Does the agency subscribe to the TQM approach to
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implement the QA/QI program.
G. How has the QA/QI program changed in the health agency over the past 20 years?
H. What influence has the QA/QI program had on decreas- ing problems attributable to process? To provider accountability?
I. List and describe the types of records usually kept in a community health agency. Explain the purpose of each type of record.
4. Identify partnerships necessary to ensure quality health out- comes for your community from data gathered in a com- munity assessment. Explain why these partners are necessary.
5. Find the Guide to Community Preventive Services on the CDC website, and look for the segments on smoking cessation or tuberculosis control. How could you use this information in your practice in health?
6. Explain the nurse’s responsibilities and role in the CQI program.
591CHAPTER 26 Quality Management
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593
Health Promotion with Target Populations Across
the Life Span
The family is a major influence on the individual’s concept of health and illness. It is within the family that a person’s sense of self-esteem and personal competence is developed. The action taken by or for the person with a health problem depends on this sense of self-worth and the family’s definitions of health and illness. Environmental, social, cultural, and economic factors, as well as the resources of the community to meet health needs, influence the family’s health risks and reaction to health. The goals of the nation for the year 2020 focus on changing the overall health of the nation, with emphasis on the specific health and health care issues of populations. Through family support the individual may develop the responsibility to participate in activities that will lead to a healthier lifestyle.
Major health problems of individuals can be identified and related to their developmental phase. This factor becomes evident when age-specific morbidity data are reviewed. Nurses can influence the actions and reactions to health of all individuals in the community from birth through senescence. The nurse can influence the health of children by introducing healthy parenting behaviors, risk factor appraisal, and age-appropriate interventions.
Women and men are faced with many life changes and challenges, some of which are gender specific. Previ- ous lifestyles and increases in stress from social, environmental, and economic constraints often result in risk for major health problems during adulthood.
The nurse’s primary function with persons of all ages should be to promote quality as well as a long and healthy life. As the elderly segment of the population continues to grow, the health care delivery system and nurses must address and plan strategies to cope with increasing longevity and chronic health problems.
Attention is also focused on the needs of compromised populations. Healthy People 2020 has a specific goal to promote the health and well-being of compromised populations. Over 15% of the United States population has some type of long-lasting condition. Nursing interventions must be refined to assist this group in meeting their health care needs. As the nurse studies and gathers evidence about the health issues of populations such as children, women, men, and the elderly, he/she can better understand how to assess and plan for care of individuals who are members of these compromised populations. Community-oriented nurses assess the risk of age-related issues in populations, promote the development of programs and policies that will promote initiatives to enhance population health status, and ensure that such programs are available to address the health risks of these target populations.
P A R T 5
594
27 Working with Families in the Community for Healthy Outcomes
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Explain the multiple ways public health nurses work with
families and communities. 2. Identify challenges to working with families in the
community. 3. Describe family function and structure.
4. Describe family demographic trends and demographic changes that affect the health of families.
5. Compare and contrast three social science theoretical frameworks nurses use when working with the family in the community.
6. Work with families using a strength-based approach to assess, develop, and evaluate family action plans.
A D D I T I O N A L R E S O U R C E S Evolve website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • Quiz • Case Studies • WebLinks • Glossary • Answers to Practice Application • Resource Tools
• Resource Tool 5.A: Schedule of Clinical Preventive Services
• Resource Tool 27.A: Family Systems Stressor-Strength Inventory
• Resource Tool 27.B: Case Example of Family Assessment • Resource Tool 27.C: List of Family Assessment Tools
• Appendixes • Appendix E: Freidman Family Assessment Model (Short
Form)
K E Y T E R M S balanced families, p. 603 bioecological systems theory, p. 606 capacity building model, p. 608 chronosystems, p. 608 cohabitation, p. 600 dysfunctional families, p. 603
ecomap, p. 613 exosystems, p. 608 family, p. 596 family as a component of society, p. 605 family as a system, p. 605 family as client, p. 605
Joanna Rowe Kaakinen, PhD, RN Dr. Joanna Rowe Kaakinen has been a family nurse scholar for the last 25 years. She has written extensively about family nursing. She is a reviewer for the Journal of Family Nursing, the Journal of Family Relations, a member of the International Association of Family Nurses, and a member of the National Council of Family Relations. She has presented nationally and internationally on family nursing. Dr. Kaakinen is a Professor in the School of Nursing at the Linfield College School of Nursing in Portland, Oregon.
Jackie Webb has been a practicing family nurse practitioner for over 25 years, working primarily with underserved populations. She was also director for student health services for a small New England college for almost 10 years, serving young adults. She has taught nursing students both at the undergraduate and graduate levels for the past 15 years. Currently she is a professor at Linfield College School of Nursing in Portland, Oregon. She is currently a doctoral student at Oregon Health Sciences University in Portland, Oregon. Her research focus is looking at innovations in health care delivery.
Jackie F. Webb, FNP-BC, MS, RN
595CHAPTER 27 Working with Families in the Community for Healthy Outcomes
K E Y T E R M S — cont’d family as context, p. 603 family cohesion, p. 603 family demographics, p. 599 family developmental and life cycle theory, p. 606 family flexibility, p. 603 family functions, p. 598 family health, p. 603 family health literacy, p. 613 family nursing, p. 595 family nursing theory, p. 605 family policy, p. 616 family structure, p. 598
family systems theory, p. 606 functional health literacy, p. 613 genogram, p. 611 limited services, p. 597 macrosystems, p. 608 mesosystems, p. 608 microsystems, p. 608 social and family policy, p. 616 transitions of care, p. 596 under-insured, p. 597 uninsured, p. 597 —See Glossary for definitions
The health of communities is directly related to the health of its families (ANA, 2007; APHA, 2010; Eddy, Bailey, and Doutrich, 2015). The importance of establishing collaborative relation- ships with families for providing care has been well documented in public health nursing literature (Wald, 1915; Paavilainen and Astedt-Kurki, 1997; Jonsdottir, Litchfield, and Pharris, 2003; Porr, Drummond, and Olson, 2012). Public health nurses must have skills to move competently between working with indi- vidual families, bridge relationships between families and the community, advocate for family and community legislation, and influence policies that promote and protect the health of populations. Therefore, public health nurses must integrate knowledge and practice of family nursing and community health nursing (APHA, 2014) in meeting the needs of families.
Family nursing is a philosophy and a science that is based on the following assumptions: health and illness are family events; what affects one family member affects the whole family; and health care practices, decisions, and behaviors are made within the context of the family (Kaakinen and Hanson, 2015a).
Public health nursing practice has a secondary focus: the “syn- thesis of nursing theory and public health theory applied to promoting, preserving and maintaining the health of popula- tions through the delivery of personal health care services to individuals, families, and groups. The focus of practice is the health of individuals, families and groups and the effect of their health status on the health of the community as a whole” (p. 596) Refer to the inside cover of this text for a table about distinctions in practice.
Nurses practicing in the community use the core competen- cies for public health professionals (PHF, 2011 and the core public health functions of assessment, assurance, and policy development to promote the interconnectedness of individual health with the health of families and communities (Eddy et al, 2015). The Linking Content to Practice box shows the applica- tions of public health nursing practice from a family perspec- tive. The Healthy People 2020 box highlights four new objectives that have been identified as leading health issues that address ways to improve the health of families and the nation. Nurses who practice with a family nursing philosophy and theory base
C H A P T E R O U T L I N E Challenges for Nurses Working with Families in the
Community Definition of Family Transitions of Care Uninsured, Underinsured, and Limited Services
Family Functions and Structures Family Demographics
Living Arrangements Marriage, Divorce, and Cohabitation Births Parenting Immigration Family Caregivers
Family Health Four Approaches to Family Nursing
Family As Context Family As Client
Family As a System Family As a Component of Society
Theories for Working with Families in the Community Family Systems Theory Family Developmental and Life Cycle Theory Bioecological Systems Theory
Working with Families for Healthy Outcomes Pre-encounter Data Collection Determine Where to Meet the Family Making an Appointment with the Family Planning for Your Own Safety Interviewing the Family: Defining the Problem Family Assessment Instruments Family Health Literacy Designing Family Interventions Evaluation of the Plan
Social and Family Policy Challenges
596 PART 5 Health Promotion with Target Populations Across the Life Span
definition of family used in the health care system and by social policy makers and the broader term used by the family. Family, as defined and implemented in the health care system, contin- ues to be based on the legal notions of relationships such as biological/genetic blood ties and contractual relationships such as adoption, guardianship, or marriage. However, the family system and family nurses use the following broader definition of family: “Family refers to two or more individuals who depend on one another for emotional, physical, and/or financial support. The members of the family are self-defined” (Hanson, 2005).
Given the current social and political climate, nurses need to adopt the open definition described above because the families they work with have a wide variety of family structures. Nurses who work with the people in the individual’s everyday world have a higher likelihood of helping them to achieve better health outcomes.
Transitions of Care Nurses have a pivotal role relative to communication of infor- mation in transitions of care between agencies that frequently result in hospital admission or readmission. Nationally, the number of home health care clients who were admitted to the hospital between 2002 and 2006 was 28.3% (AHCRQ, 2008). The majority of these hospital admissions in home health care clients occurred within 7 days of admission to the home health agency (Vasquez, 2008). It is estimated that about 20% of indi- viduals discharged from a hospital in the United States are readmitted within 30 days (Cloonan, Wood, and Riley, 2013). Of the estimated $17.5 billion in Medicare spending on read- missions, approximately $12 billion is potentially preventable (Centers for Medicare and Medicaid Services, 2013). Individu- als most at risk for readmissions are males over 75 years of age, African American, hospitalized with a medical diagnosis, and without insurance other than Medicare (Cloonan et al, 2013).
There are communication issues between health care provid- ers within the community agencies, such as incomplete or missing documentation, that result from rushed assessments. Rushed procedures and failure to follow the plan of action and standards of care are known causes of hospital readmissions (Vasquez, 2008). Persons at high risk for readmission rates par- allel those of the population with low health literacy rates (Cloonan et al, 2013; Berkman et al, 2011). Approximately 35% of adults in the United States have limited literacy skills, with an additional 30 million adults who have below basic lit- eracy skills (Berkman et al, 2011). A systematic review of the literature indicated that low health literacy was associated with increased health care use, inappropriate drug use, low use of preventive services, and overall poorer health (Berkman et al, 2011).
It is crucial that home health care staff have current updates on evidence-based practice, standards of care, and interven- tions to ensure quality health outcomes. Nurses practicing in the community have a significant role in working with multiple health care systems to improve communication and evidence- based design protocols to improve the quality of care and the health of the home health population (Ventura et al, 2010).
will improve the health of families, their members, and the community.
From: US Department of Health and Human Services: Healthy People 2020, Washington DC, 2010, US Government Printing Office.
HEALTHY PEOPLE 2020
New objectives specific to families and family nursing that relate to a leading health issue. • AHS 1: Increase the proportion of persons with health insurance • AH-5-1: Increase the proportion of students who graduate with a regular
diploma 4 years after starting the 9th grade • D-5: Improve glycemic control among persons with diabetes, especially
those with A1C greater than 9% • NWS-9 & 10: Reduce the proportion of adults and children who are obese
LINKING CONTENT TO PRACTICE
In this chapter the public health core functions with the essential services below are applied to family nursing.
Assessment • Monitor health status of families to identify community health problems. • Diagnose and investigate health problems and health hazards in the com-
munity that affect families. • Evaluate effectiveness, accessibility, and quality of personal and population-
based health services.
Policy Development • Develop policies and plans that support family and community health
efforts. • Enforce laws and regulations that protect health and ensure safety of
families in the community. • Research for new insights and innovative solutions to health problems.
Assurance • Link people to needed personal health services and assure the provision of
health care when otherwise unavailable. • Assure a competent public health and personal health care workforce. • Mobilize community partnerships to identify and solve health problems.
CHALLENGES FOR NURSES WORKING WITH FAMILIES IN THE COMMUNITY Numerous challenges exist that affect the practice of family nursing in a community setting. Many of the following chal- lenges have been recognized in the family nursing literature for a long time, yet they persist in the current health care system. One role for the nurse would be to advocate that the following challenges be addressed in federal and state health care policies and programs.
Definition of Family Now more than ever, the traditional definition of family is being challenged with the legalization of same-sex marriages. There is still no universally agreed on definition of family (Kaakinen and Hanson, 2015a).
Public health nurses and family nurses struggle on a daily basis with the conflict between the narrow traditional legal
597CHAPTER 27 Working with Families in the Community for Healthy Outcomes
undocumented immigrants, citizens who choose not to enroll in Medicaid, residents of states that opt out of the Medicaid expansion provision, and citizens whose cost of health care is 8% or more of their total income (USDHHS, 2012). Undocu- mented immigrants, who are prohibited from enrolling in Med- icaid and purchasing coverage through the new health insurance exchanges, are projected to constitute 25% of the uninsured after the major provisions of the ACA are fully implemented (USDHHS, 2012). Providing health care to the uninsured is already a challenge and will continue to require creative solu- tions even after the ACA is fully implemented.
Nurses must be adept at working among health care systems to find resources and services for the large population of unin- sured clients and families. The number of uninsured Americans in 2010 was 49 million or roughly 16.3% of the total population (DHHS, 2011). A 2014 survey by the Commonwealth Fund suggests that the number of uninsured has dropped signifi- cantly since the beginning of the enrollment period in 2013 (Commonwealth Fund, 2014). The percentage of children under the age of 18 without health insurance in 2010 was 9.8%, which significantly decreased from 12% in 1999 due to the expansion of coverage to the Children’s Health Insurance Program (CHIP). Since the enactment of the 2010 Affordable Care Act, children can now remain on their parents’ insurance plans until the age of 26.
Employer-sponsored insurance continues to be the largest source of health insurance coverage, with 55.3% of the U.S. population covered. However, it is important to note the differ- ences in insurance coverage among minority populations. His- panics have the highest uninsured rates at 30.7% and blacks are at 20.8%; only 11.7% of non-Hispanic whites are uninsured (USDHHS, 2011).
The demand for primary care will be driven over the next decade and a half not only by the ACA mandates, but also by an aging population and an overall growth in the size of the U.S. population. This growth in demand also accompanies a shift from acute care services to more chronic care management as the nation’s disease patterns change as the population ages (Dower & O’Neil, 2011). Various studies projecting current or imminent shortages in primary care providers are shifting attention away from the traditional physician model of care to nurse practitioners, who now account for about 19% of the U.S. primary care workforce, and physician assistants, who account for 7% of the U.S. workforce (Green, Savin & Lu, 2013). Nurse practitioners and physician assistants not only provide effective care but they can also meet the growing demands for primary care providers (Green et al, 2013).
The lack of insurance makes finding adequate services for clients and families difficult. In some areas federal and state funding for care in health clinics is free or available for a minimal fee. However, because the number of primary health care clinics is limited, care is often provided based on the number of volunteer health care providers working that day in the clinic. Many clinics are program based, such as family plan- ning clinics, sexually transmitted disease (STD) clinics, and immunizations clinics. Thus, it is difficult to meet the needs of the uninsured or underinsured populations.
Nurses must develop and hone excellent negotiation skills because they spend a significant amount of time arranging for limited services for their under-insured and uninsured clients and families. In working with families, communication and teaching will be more effective if hours of service match the times of day when family members, specifically the family care provider, can attend appointments. Bringing a companion to office visits benefits communication (Wolff et al, 2009; Wolff and Roter, 2008), especially for those with low health literacy (Rosland et al, 2011); enhances shared decision making (Clayman et al, 2005); and improves the sharing of information (Eggly et al, 2006). Involving family in the care of the client improves self-management of health care, results in fewer medi- cation errors (Kinnersley et al, 2007; Wolff et al, 2009), and improves health outcomes (Weinberg et al, 2007). Based on this information about companion participation, it is crucial that nurses involve family as much as possible in their interactions and decisions with clients.
Uninsured, Underinsured, and Limited Services Nursing practice in the community presents various challenges such as knowing how to access health care resources for clients and understanding how recent health care reforms are trans- forming the landscape of our current health care system. Unin- sured clients are those who do not have health insurance for any family member. Underserved are individuals who have minimal insurance coverage and usually have a high deductible. Individuals with limited services are people who may have trouble accessing health care and/or experience barriers to health care. For example, a family with insurance coverage may live in a rural area that does not have a primary health care provider or services near them. The main goals of the Afford- able Care Act (ACA) of 2010 were to provide U.S. citizens with patient protection and affordable health care, and decrease the overall cost of health care (see Chapter 3 for more discussion). The ACA is designed to offer premium subsidies to help eligible individuals and their families purchase insurance coverage when affordable employer sponsored insurance is not available. Questions remain about how this affordability protection will be applied in situations where self-only coverage offered by an employer is affordable but family coverage is not.
The U.S. Supreme Court ruled that the ACA Medicaid expansion is a voluntary program for states. As a result, not all states have expanded Medicaid coverage. What this means for persons living in states that have expanded Medicaid coverage is that they qualify for either Medicaid or reduced costs on a private insurance plan if they earn up to $16,104 a year for one person or $32,913 for a family of four (CMS, 2013). For persons living in states that have not expanded Medicaid coverage it means if their income is more than 100% of the federal poverty level (about $11,490 a year as a single person or about $23,550 for a family of four) they qualify to buy a private health insur- ance plan in the Marketplace and may get lower costs based on their household size and income (CMS, 2013).
The ACA is estimated to insure at least half of the United States population that is currently uninsured (USDHHS, 2012). The individuals that make up the uninsured are predominantly
598 PART 5 Health Promotion with Target Populations Across the Life Span
FAMILY FUNCTIONS AND STRUCTURES Knowledge of family functions and structures is essential for understanding how families influence health, illness, and well- being. Nurses who understand family functions and structures can use this knowledge to empower families through evidence- based interventions.
Family functions are the ways in which families meet the needs of (1) each family member, (2) the family as a whole, and (3) their relationship to society. Throughout history, the follow- ing functions have been performed by families (Kaakinen and Hanson, 2015a): 1. Economic function: Family income is a substantial part of
family economics, but it is also related to family consumer- ism, money management, housing decisions, insurance choices, retirement, and savings. Family economics affect and reflect the nation’s economy.
2. Reproductive function: The survival of a society is linked to patterns and rates of reproduction. The family has been the traditional structure in which reproduction was organized. Today, the reproductive function of family has become more separated from traditional family structure as more children are born outside of marriage and into nontraditional family structures.
3. Socialization function: A major expectation of families is that they are responsible for raising their children to fit into society and take their place in the adult world. In addition, families disseminate their culture, including religious faith and spirituality.
4. Affective function: Families provide boundaries and structure that provide a sense of belonging and identity of who the family members are individually and to their family. The purpose of the affective function is to learn about intimate reciprocal caring relationships, to learn about dependency and how to nurture future generations.
5. Health care function: It is in the family that one learns the concepts of health, health promotion, health maintenance, disease prevention, and illness management. Family members provide informal caregiving to ill family members and are primary sources of support. Family structure refers to the characteristics and demograph-
ics (e.g., sex, age, number) of individual members who make up family units. More specifically, the structure of a family defines the roles and the positions of family members (Box 27-1).
Family structures have changed over time to meet the needs of the family and society. The great speed at which changes in family structure, values, and relationships are occurring makes working with families at the beginning of the twenty-first century exciting and challenging. According to Kaakinen and Hanson (2015a), the following aspects need to be addressed when determining the family structure: 1. The individuals that compose the family 2. The relationships between them 3. The interactions between the family members 4. The interactions with other social systems
As social norms have become more tolerant of a range of choices in relation to managing one’s life, there is no longer a
Nurses need to understand the effects of the ACA reforms and how they are being implemented in their states. Nurses help clients and families negotiate and maneuver through the health care system. They must work closely with the family to remove barriers and provide services and resources that enhance the families’ abilities to provide quality care to family members. To successfully address these challenges, the community health nurses must integrate principles of family nursing with those of community/public health (see Evidence-Based Practice and Levels of Prevention boxes).
LEVELS OF PREVENTION Reduce the proportion of children and adolescents aged 2-19 years who are considered obese (Healthy People 2020 objective NWS 10.4)
Primary Prevention • Educating parents about healthy nutritional choices for young children and
the risks associated with obesity • Provide counseling and weight management for overweight children and
teens • Help mothers who qualify for Women’s Infant and Childhood Program
complete the extensive paperwork
Secondary Prevention • Screen teens for obesity with body mass index (BMI) greater than or equal
to 30 • Analyze children’s height and weight growth as part of annual health
assessments
Tertiary Prevention • Work with schools to improve quality of food offered in school lunch • Help communities establish local farm to school networks, create school
gardens, and ensure that more local foods are used in the school setting.
From: Center for Disease Control: Vital signs: obesity among low income, preschool aged children-United States, 2008–2011, 2013b. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6231a4.htm. Accessed March 22, 2014.
Reducing obesity in the United States is a Healthy People 2020 objective. A study by the Center for Disease Control (2013b) shows that there was a 43% drop in obesity rates among children ages 2 to 5 years of age over the last 10 years. Part of this decline is directly related to the change in the social policy of improvements in the food packages available to these parents through the Woman’s Infant and Children (WIC) Program. The improvements include adding health items like fruits and vegetables and whole grain foods while reducing the amount of fruit juice and whole milk. This change, coupled with nutrition education for families with infants and young children led to parents selecting healthier food choices and improved access to healthy foods for at risk families.
Nurse Use Nurses have a significant role by advocating for social policies that improve the health of families and educating parents of young children to make healthy food choices. Public health nurses should be actively involved in helping to decrease childhood obesity. Refer to the Levels of Prevention box for reducing childhood obesity.
EVIDENCE-BASED PRACTICE
599CHAPTER 27 Working with Families in the Community for Healthy Outcomes
career-oriented woman in her late 30s who elects to have a baby and remain single.
The family structure changes and modifies over time. An individual may participate in a number of family life experi- ences over a lifetime (Figure 27-1). For example, a child may spend the early, formative years in the family of origin (mother, father, siblings); experience some years in a single-parent family because of divorce; and participate in a stepfamily relationship when the single parent who has custody remarries.
This same child as an adult may experience several addi- tional family types: cohabitation while completing a desired education, and then a commuter marriage while developing a career. As an adult, the individual may divorce and become a custodial parent. The adult may eventually cohabitate with another partner and finally marry a different partner who also has children. As couples age, they have to address issues of the aging family, and subsequently the woman may become an older single widow. Thus, nurses work with various families representing different structures and living arrangements.
Prospects for families in the twenty-first century are numer- ous. New family structures that are currently experimental will emerge as everyday “natural” families (e.g., families in which the members are not related by blood or marriage, but who provide the services, caring, love, intimacy, and interaction needed by all persons to experience a quality life).
At times it is helpful to understand families through a narrow framework of family function and structure. However, a family is a system within itself as well as the basic unit of a society. Some would argue that the traditional concept of family is disintegrating based on how the structure and functions of the family have changed over time. On the other side of that debate, families change in response to the societal changes and are ever evolving and thriving as they seek different ways of intercon- nectedness (Kaakinen and Hanson, 2015a).
FAMILY DEMOGRAPHICS Historically, family demographics can be analyzed by looking at data about the families and household structures and the
general consensus that the traditional nuclear family model, consisting of father, mother, and children, is the “best” model. There is no “typical” family model or family structure. For example, the single-mother household may be represented by the unmarried teenage mother with an infant (unplanned preg- nancy), the divorced mother with one or more children or the
FIG 27-1 An individual’s family life structure over time.
Developmental process
Li ve
s in
S po
us e/
pa re
nt
Pa rtn
er
Spouse
biological/stepparent
Married/agingfamily
Widow /
widowe r
Lives in
P artner/parentL
iv e
s in
C u st
o d ia
l p a re
n t
Childhood Adulthood
Family of origin
Single- parent family
Stepfamily Cohabi- tation
Commuter marriage
Single- parent family
Cohabi- tation Stepfamily
Married
Single
Married Family • Traditional nuclear family • Dual-career family • Spouses reside in same household • Commuter marriage • Husband/father away from family • Stepfamily • Stepmother family • Stepfather family • Adoptive family • Foster family • Voluntary childlessness
Single-Parent Family • Never married • Voluntary singlehood (with children, biological or adopted) • Involuntary singlehood (with children) • Formerly married • Widowed (with children) • Divorced (with children) • Custodial parent • Joint custody of children • Binuclear family
Multi-Adult Household (With or Without Children) • Cohabitating couple • Communes • Affiliated family • Extended family • Newly extended family • Home-sharing individuals • Same-sex partners
BOX 27-1 Family and Household Structures
600 PART 5 Health Promotion with Target Populations Across the Life Span
together who are having a sexual relationship without being married. The number of divorces has leveled off and remained constant.
Most Americans do marry. In 2011, 90% of women aged 50 to 54 had been married at least once (U.S. Census Bureau, 2011c). However, the age at marriage continues to be delayed, with the age for first marriage being 26 years for women and 28 years for men (Kreider and Ellis, 2011b). This delay in marriage has implications for the delay in child birthing.
The rapidly escalating divorce rate of families found in the 1970s and 1980s has leveled off and remained relatively con- stant since 1990, with about 43% and 46% of marriages ending in divorce (Schoen and Canudas-Romo, 2006). However, the divorce rates among married people 50 years or older doubled between 1990 and 2010 with 1 in 4 divorces in 2010 being people over 50 years of age (Brown and Lin, 2013). As cohabita- tion has become more acceptable, fewer divorced people are getting remarried and the remarriage rate has dropped 40% in the last 20 years (Jayson, 2013). In 1990 there were 50 per 1000 divorced people remarried; in 2011 that number declined to 29 out of 1000 (Jayson, 2013).
One of the most significant household changes in the second half of the twentieth century in North America was the increase in men and women living together without marrying. Approxi- mately 9% of the households in 2011, representing 7.6 million family groups, are unmarried partner opposite-sex family groups and about 40% of these households included children (U.S. Census Bureau, 2011d). The number of same-sex couples in the United States grew approximately by 80% from 358,390 in 2000 to 646,464 in 2010 (Lofquist, Lugaila, O’Connell, and Feliz, 2012).
Casper et al (2010) suggest that people cohabitate for three reasons: some cohabitants would marry but do not for eco- nomic reasons; others seek a more egalitarian relationship; and others use cohabitation as a trial period to negotiate and assess whether to marry. Younger cohabitants are more likely to view their relationship as a prelude to marriage (King and Scott, 2005). This view is common, with a 65% chance of cohabitation transitioning to marriage within the first 5 years (Goodwin, Mosher, and Chandra, 2010). Phillips and Sweeney (2005) suggest that there is an ethnic factor in the meaning of cohabita- tion, with whites viewing cohabitation as a trial marriage and African Americans and Hispanic Americans viewing cohabita- tion as a substitute for marriage. In 2005 King and Scott found that older adults enjoyed relationships of higher quality and perceived stability despite having fewer plans to marry and were more likely than younger cohabitants to view their relationship as an alternative to marriage.
Different factors were associated with duration of marriage and cohabitation. Duration of marriage was associated with two factors: age of first marriage and timing of first child. Marriage at a younger age had a lower probability of the marriage lasting 10 years. Women who gave birth 8 months or more after the marriage began compared with women who had no first birth during the marriage had a 79% chance versus a 34% chance of the marriage lasting 10 years. Education was a factor in both men’s and women’s duration of cohabitation, with lower
events that alter these structures. Recent trends in family demo- graphics show that there has been a quieting of the rapid changes that were found in family structure and living arrange- ments in the twenty-first century. Nurses draw on family demo- graphic data to forecast and predict family community needs, such as family developmental changes, stresses, and ethnic issues affecting family health, as they formulate possible solu- tions to identified family community problems. In this chapter, major family demographic trends valuable to nurses practicing in the community are presented.
Living Arrangements The number of households in the United States has tripled from 35 million households in 1940 to 117 million households in 2010 (Jacobsen, Mather, and Dupuis, 2012). Of these 117 million households, 67% were considered family households and the remaining 33% being nonfamily households (U.S. Census Bureau, 2012a). Family households include a house- holder and at least one other member related by birth, marriage, or adoption, whereas a nonfamily household is either a person Kreider and living alone or a householder who shares the house only with nonrelatives, such as boarders or roommates (Kreider and Elliot, 2007).
The fastest growth was among persons living alone, with much of this growth occurring during the 1960s and 1970s. The proportion of households with just one person more than doubled from 13% to 27% between 1960 and 2012 (Casper, Florian, and Brandon, 2015).
Family demographic trends have continued in the direction of fewer married couples with children households: 20 million in 2010 compared with 23 million in 2009 and 30 million in 1980 (Jacobsen et al, 2012).
Americans are living longer. By 2009, life expectancy at birth was nearly 79 years for Americans (Arias, 2008). An American woman who reached age 60 in 2009 could expect to live an additional 25 years, on average, and a 60-year-old American man would live another 22 years. The proportion of elderly adults living alone has increased dramatically. Just 15% of widows aged 65 or older lived alone in 1900, whereas 66% lived alone in 2011 (U.S. Census Bureau, 2011a). In 2011, 44% of the population aged 65 and older lived alone (U.S. Census Bureau, 2011b). Elderly women (37%) are twice as likely as elderly men (19%) to live alone (Casper et al, 2015).
Living alone can mean delays in getting attention for illness or injury and can complicate arrangements for informal care or transportation to formal care when needed. What this means is that elderly individuals are more likely to access and need community-based services. In addition, with the geographic mobility of American society, many of these elderly do not live close to family; therefore they do not have as many family members to care for them. Despite the trend toward indepen- dent living among older Americans, many of them are not able to live alone without assistance.
Marriage, Divorce, and Cohabitation Marriage, although still a popular American ideal, has assumed a forerunner: cohabitation. Cohabitation is a couple living
601CHAPTER 27 Working with Families in the Community for Healthy Outcomes
century, with occasional boosts, such as the baby boom after World War II in the late 1940s and early 1950s. In 2010 the fertility rate in the United States was 1.93, which is just below replacement factor (Martin et al, 2012). In response to this lower fertility rate, the United States typically responds by opening immigration into the country, as immigrant women tend to have higher fertility rates than native-born American women. In 2010, native-born women had on average 1.8 chil- dren, whereas foreign-born women had 2.2 children (U.S. Census Bureau, 2010a).
Fertility rates differ by race and ethnicity. Hispanic women have the highest fertility rates at 2.3, followed by African American women at 2.0, and Asian women have the lowest fertility rate at 1.8 (U.S. Census Bureau, 2010b). Not all cultures value limiting the number of children in a family, and nurses may be challenged to understand these values and provide ser- vices where the woman assumes the value of limiting the number of children while the husband does not. For example, a Hispanic woman comes to the public health clinic for family planning services. It is not uncommon for the husband to come in at the end of the week to pay for those services. If the wife is on birth control, such as Depo, but does not want her husband to know, itemizing services on the receipt would present a problem. The nurse needs to understand these changing values and facilitate the family planning services requested by the woman without violating her confidentiality.
One of the major changes in the births in the United States is the increase in the rise of children born to women outside of marriage. In 2010, 41% of all births in the United States were to unmarried women (Martin et al, 2012). As women are delay- ing marriage, so too are they older at the birth of their first child. In 2010, the average age at first birth was 25.4 (Martin et al, 2012). This means that nurses will likely have older mothers who are at risk of having more complications with pregnancy and birth. The birth rate for teenagers has decreased substan- tially, but the United States still has one of the highest rates of teenage pregnancies in the industrialized world. The U.S. teenage birth rate for women ages 15 to 19 was 34.3 births per 1,000 women in 2010, down from 52.2 in 1981 (Martin et al, 2012).
Parenting Even with the increase in divorce and cohabitation, postpone- ment of marriage, and decline in childbearing, most North American adults have children, and most children live with two parents. In 2011, 64% of families with children were two-parent, married families and an additional 5% were two-parent, unmar- ried families (U.S. Census Bureau, 2011e, 2011f; Casper et al, 2015). Blended family households are when two people marry and at least one of these individuals brings a child with them into the marriage. In 2009, 13.3% of households with children under 18 were blended family households, numbering 5.3 million (Kreider and Ellis, 2011a). Therefore, almost 16% of U.S. children (11.7 million) lived in blended families in 2009 (Kreider & Ellis, 2011a). Because the blended family comprises a significant proportion of families with children, nurses are likely to interact with parents and children whose roles and
education being associated with longer cohabitation (Goodwin et al, 2010).
As cohabitation increases, ensuring sexually transmitted disease (STD) reduction and family planning services becomes essential. The most frequently reported infectious disease in the United States is chlamydia (CDC, 2010). In 2008 more than 1.2 million cases of chlamydia were reported. Women between the ages of 15 and 19 years of age and minority women are at the highest risk (CDC, 2010). Untreated chlamydia can cause severe and costly reproductive health problems. A model col- laborative program is the Region X Infertility Prevention Project (2000), which aims to control chlamydia through collaborative efforts of STD and family planning providers and public health laboratories. A comprehensive approach to STD prevention that includes screening, treatment of infected partners, and behavioral interventions with a focus on reducing racial dis- parities is an important aspect of providing community health (CDC, 2010).
Effects of Cohabitation on Children Cohabitating couples in the United States live together for shorter periods of time than cohabiting couples in other coun- tries (Cherlin, 2010). Parental separation is five times greater for children born to cohabiting parents than to married parents (Brown, 2010). The unstable living arrangements for children born outside of marriage remains an important question rela- tive to the well-being of these children. The number of transi- tions is associated with negative child well-being (Osborne and McLanahan, 2007). Many of these children experience about three transition relationships from birth to 3 years of age (Osborne and McLanahan, 2007). The research shows that chil- dren in cohabitating relationships have more behavioral and cognitive problems (Ray, 2013).
DeLeire and Kalil (2005) found relatively high rates of poverty in cohabitating families with children compared with the national average (18.2% to 22.4%, compared with 12.1% overall and 5.3% among married couples). They also found that cohabitating-parent families spend a greater share of their budgets on alcohol and tobacco than do married, divorced, and never-married single-parent families (DeLeire and Kalil, 2005). Nurses must ensure that these families have access to health insurance such as the Medicaid S-CHIP program. Teaching cohabitating families with children about the implications of secondhand smoke becomes a priority because these children are at risk for health problems such as increased lower respira- tory tract infections and asthma. Because poverty rates are higher, assisting these families in gaining access to resources such as food stamps and budget management skills is the work of nurses in the community.
Births Replacement-level fertility refers to the required number of children each woman in the population would have to bear on average to replace herself and her partner, and it is con- ventionally set at 2.1 children per woman for countries with low mortality rates (Casper et al, 2015). The fertility rate in the United States has been in continual decline over the last
602 PART 5 Health Promotion with Target Populations Across the Life Span
13% of the total population (Grieco et al, 2012). Because immi- grants tend to arrive in the United States early in their working careers, they are younger, on average, than the overall U.S. pop- ulation and account for a larger share of young families (Casper et al, 2015). In 2010, for example, 20% of all births in the United States were to mothers born outside the country (U.S. Census Bureau, 2010b). This means that nurses need a solid under- standing of culture and health beliefs because they are essential components of practice with families. Half of adults 18 to 40 years old who speak Spanish at home reported that they could not speak English well (Shin and Kominski, 2010). In addition to a language issue, many of these immigrants are in the United States illegally and do not qualify for federal public benefits or health care.
Family Caregivers In 2010, 30% of adults were family caregivers with 55% of the caregivers being women and 45% being men (PEW, 2012). Most family caregivers (7 out of 10) provide care to someone 50 years of age or older, 14% take care of an adult age 18 to 49, while 14% take care of a child under the age of 18 (National Alliance for Family Caregiving, 2009). The most prevalent reasons for providing care are due to an aging family member who needs assistance with activities of daily living and some type of dementia (National Alliance for Family Caregiving, 2009). The 2012 National Health Survey states that about 40 million people (12% of the population) are limited in their activities of daily living due to one or more chronic health conditions. About 10 million people require the help of another person with their instrumental activities of daily living.
The majority (31%) of the family caregivers are over the age of 50 and 12% of them are over the age of 65 (Pew, 2012). On average the family caregivers reported providing 24 hours of assistance each week for an adult family member and parents reported providing care for 30 hours a week for a child with special health needs (National Alliance for Family Caregiving, 2009). Of these caregivers, 24% reported that they themselves have a disability (Pew, 2012). Of these caregivers, 47% work full time, 13% work part time, 14% are retired, and 18% do not work for pay (Pew, 2012).
An invisible trend that needs attention is the number of children under 19 years of age who are providing care for a family member. In the United States there are 1.3 to 1.4 million children, ranging in age from 10 to 20 years who provide care for sick or disabled relatives, with about a third caring for a grandparent (National Alliance for Family Caregiving, 2005). Three in ten child caregivers are ages 8 to 11 (31%), 38% are ages 12 to 15, and the remaining 31% are ages 16 to 18. Child caregivers are evenly balanced by gender (male 49%, female 51%). Caregivers tend to live in households with lower incomes than do noncaregivers, and they are less likely than noncaregiv- ers to have two-parent households (76% vs. 85%) (National Alliance for Family Caregiving, 2005, p. 5). In a large study conducted by Siskowski (2006) of 12,681 public school children in Palm Beach County, Florida, more than 1 in 2 middle and high school children (6,210) were providing care for a family member. Of these young caregivers 67% missed school or after
responsibilities are not well defined. Obtaining legal authoriza- tion can be challenging when legal obligations are unclear; therefore it is important that nurses identify which parent(s) have legal responsibility for medical decision making. It is also important for nurses to be aware that they may also need to notify nonresidential parents when their children require medical attention because these parents may share the legal right to make medical decisions.
Single mothers, never married, are particularly disadvan- taged; they are younger, less well educated, and less often employed than are divorced single mothers and married mothers (Casper et al, 2015). Mothers who never married (25%) are much less likely to get child support from the father than are mothers who are divorced or separated (43%) (Casper et al, 2015). Divorced mothers are substantially better educated and more often employed than are mothers who are separated or who never married. However, the average income of families headed by divorced mothers is less than half that of two-parent families (Casper et al, 2015). Approximately 12% of single mothers and their children live in the homes of their grandpar- ents and 5.2% have a grandparent living with them (U.S. Census Bureau, 2011f ).
Despite the fact that the majority of American single mothers are not poor, they are much more likely to be poorer than other parents. For example, a single mother with two children with an annual income of less than $18,123 in 2011 was below the federal poverty level (Casper et al, 2015). Overall, 20% of U.S. children lived in poverty in 2009 (Kreider and Ellis, 2011b). Children in two-parent families had the lowest rate of poverty at 13.3%, followed by children living in father-only families at 19.9%. Children in mother-only families had the highest poverty rate at 38.1% (Kreider & Ellis, 2011b).
The slow but steady increase in the number of single-father households is one changing aspect of family life in America. Between 1950 and 2011 the number of households with children that were maintained by an unmarried father increased from 229,000 to 2.2 million (U.S. Census Bureau, 2011g). Fathers who are divorced are more likely to share child custody than in the past; however, that does not mean that there are fewer obstacles in such complicated family arrangements (Carlson and McLa- nahan, 2010). In general, fathers are spending more time with their children than in the past (Casper et al, 2015).
Many children are raised by or receive regular care from their grandparents. These grandparents may or may not have legal responsibility for their grandchildren, but may seek medical care for them. In 2011, about 7.7 million children lived in a home with a grandparent (Desilver, 2013). Of these children 80% had at least one parent also living in the same household. However, 3 million of these children had their grandparent as their primary caregiver and provider (Desilver, 2013). Although there are many rewards for both the grandparent and grand- child, taking care of children at such an “off family” time creates stress and can be very difficult.
Immigration In 2010 the U.S. Census Bureau estimated that there were 40 million U.S. residents born outside the country, which is nearly
603CHAPTER 27 Working with Families in the Community for Healthy Outcomes
well as family stressors that are useful for nurses to include in their assessment (Kaakinen and Hanson, 2015a; Driver et al, 2003; Olson and Gorall, 2003). Box 27-2 shows characteristics of families who are healthy and functioning well in society.
The most recent concept described in the family literature pertains to ways families function across the family life cycle. Balanced families are those that have the ability to adapt to situ- ations; therefore, they demonstrate family flexibility in leader- ship, relationships, rules, control, discipline, negotiation, and role sharing (Kaakinen and Hanson, 2015a; Olson and Gorall, 2003). Balanced families have the ability to allow family members to be independent from the family yet remain con- nected to the family as a whole, which is termed family cohe- sion (Olson and Gorall, 2003).
FOUR APPROACHES TO FAMILY NURSING Central to the practice of family nursing is conceptualizing and approaching the family from four perspectives. All have legiti- mate implications for family nursing assessment and interven- tion (Figures 27-2 and 27-3). The approaches that nurses use are determined by many factors, including the issues for which the individuals or families as a whole are seeking help, the envi- ronment in which they coexist with other family members and the community, the interaction among all of these factors, and of course the nursing resources available to deal with all of these factors (Hanson, 2005).
Family As Context The family has a traditional focus that places the individual first and the family second. The family as context serves as either a strength or a stressor to individual health and illness issues. The nurse is most interested in the individual and realizes that the family influences the health of the individual. A nurse using this focus might ask an individual client the following questions: “Is your family available to help you get to your doctor appoint- ments?” “Can your wife help you with your insulin injections?”
school activities, did not complete their homework or were interrupted in their studying to provide care for a family member. Approximately 22% of high school dropouts leave school to provide care for a family member (Bridgeland, Dilulio and Morrison, 2006).
As family caregivers are the primary care providers, it is crucial that they be supported in all ways possible. Nurses can work with families who are providing care to their family member in the following ways (National Alliance for Family Caregiving, 2009): 1. Identify and help caregivers who are most at risk for deterio-
rating health, financial security, and quality of life so that they can continue to provide care while maintaining their own well-being.
2. Identify and advocate for programs that make a real differ- ence in caregivers’ well-being and in their ability to continue providing care.
3. Identify and promote the use of technologies that can facili- tate caregiving.
4. Extend the reach of caregiver programs to all caregivers regardless of the age of their care recipient.
5. Encourage families to plan proactively for aging and poten- tial health/disability issues.
FAMILY HEALTH The meaning of family health is not precise and lacks consensus, despite the increased focus on family health within the nursing profession. The term family health is often used interchange- ably with the concepts of family functioning, healthy families, and familial health. Hanson (2005, p. 7) defines family health as “a dynamic changing relative state of well-being which includes the biological, psychological, spiritual, sociological, and cultural factors of the family system.” This holistic approach refers to individual members as well as the family unit as a whole entity and in turn the family within the community context. An individual’s health (the wellness and illness con- tinuum) affects the functioning of the entire family, and in turn, the family’s functioning affects the health of individuals. Thus assessment of family health involves simultaneous assessment of individual family members, the family system as a whole, and the community in which the family is embedded.
Health professionals have tended to classify clients and their families into two groups: healthy families and nonhealthy fami- lies, or those in need of psychosocial evaluation and interven- tion. The term family health implies mental health rather than physical health. A popular term for nonhealthy families is dys- functional families, also called noncompliant, resistant, or unmotivated—phrases that label families who are not function- ing well with each other or in their communities.
Families are neither all good nor all bad; rather, all families have both strengths and difficulties. All families have seeds of resilience and strengths upon which the nurse should work with the family to build interventions and design plans of action.
Families with strengths, functional families, and balanced families are terms often used to refer to healthy families that are doing well. Studies have identified traits of healthy families as
From: Hanson SMH: Family health care nursing: an overview. In Hanson SMH, Gedaly-Duff V, Kaakinen JR, editors: Family health care nursing: theory, practice and research, ed 3, Philadelphia, 2005, FA Davis.
1. The family tends to communicate well and listen to all members. 2. The family affirms and supports all of its members. 3. Teaching respect for others is valued by the family. 4. The family members have a sense of trust. 5. The family plays together, and humor is present. 6. All members interact with each other, and a balance in the interactions
is noted among the members. 7. The family shares leisure time together. 8. The family has a shared sense of responsibility. 9. The family has traditions and rituals.
10. The family shares a religious core. 11. Privacy of members is honored by the family. 12. The family opens its boundaries to admit and seek help with problems.
BOX 27-2 Characteristics of Healthy Families
604 PART 5 Health Promotion with Target Populations Across the Life Span
FIG 27-2 Approaches to family nursing. (From Hanson SMH, Gedaly-Duff V, Kaakinen JR, editors: Family Health Care Nursing: Theory, Practice and Research, ed 3, Philadelphia, 2005, FA Davis.)
Family as Context
Individual as foreground Family as background
Family as Client
Family as foreground Individual as background
Family as System
Interactional family
Family as Component of Society
Legal
Education
Health
Social
Financial
Religion
Church
School
Bank
Medical center
Family home
Family
605CHAPTER 27 Working with Families in the Community for Healthy Outcomes
FIG 27-3 Four views of the family.
Component
Context
Client
System
FIG 27-4 Theory-based family nursing. (Modified from Hanson SMH, Kaakinen JR: Theoretical foundations for family nursing. In Hanson SMH, Gedaly-Duff V, Kaakinen JR, editors: Family Health Care Nursing: Theory, Practice and Research, Philadel- phia, 2005, FA Davis.)
Nursing models/theories
Family social science theories
Emerging Family
Nursing Theories
Family therapy theories
or “Perhaps your son could help you go up and down the stairs since your mother is so much smaller than you and your dad.”
Family As Client When the nurse views the family as client the family is the primary focus and individual family members are secondary. The family is seen as the sum of individual family members. The focus is concentrated on how the family as a whole is react- ing to the event when a family member experiences a health issue. In addition, the nurse looks to see how each family member is affected by the health event. From this perspective, a nurse might say the following to a family member who has recently become ill: “How is the family reacting to your moth- er’s recent diagnosis of liver cancer?” “How have you experi- enced your mother’s recent diagnosis of liver cancer?” “How has your diagnosis of insulin-dependent diabetes affected your family?” “Will your need for medication at night be a problem for your family?”
Family As a System The focus is on the family as client, and the family is viewed as an interactional system in which the whole is more than the sum of its parts. This approach focuses on individual members and the family as a whole at the same time. The interactions among family members become the target for nursing interven- tions (e.g., the interactions among both parents and children, and between the parental dyad). The systems approach to fami- lies always implies that when something happens to one family member, the other members of the family system also are affected, and vice versa. Questions nurses ask when approaching the family as a system are the following: “What has changed between you and your spouse since your child’s head injury?” “How do you feel about the fact that your son’s long-term rehabilitation will affect the ways members of your family are functioning and interact with one another?”
Family As a Component of Society The family as a component of society is seen as one of many institutions in society, along with health, education, and reli- gious and financial institutions. The family is a basic or primary
unit of society, as are all the other units, and they are all a part of the larger system of society. The family as a whole interacts with other institutions to receive, exchange, or give services. Nurses who work with families have derived many of their tenets of practice from this component of society, because they focus on the interface between families and community agen- cies. Nurses using this approach see families as a population. Questions the nurse might ask using this lens are, “How do we meet the needs of adolescent pregnant women?” or “What plan should we develop to increase the H1N1 immunization rates in the families living in the lower-income housing developments?” This is the approach used by public health nurses as they imple- ment population-centered strategies to improve the health of the overall community.
THEORIES FOR WORKING WITH FAMILIES IN THE COMMUNITY There is no single theory or conceptual framework that fully describes the relationships and dynamics and can be used to understand and intervene with families. Thus, an integrated theoretical approach is necessary because one theoretical per- spective does not provide nurses with enough knowledge to work effectively with families. Public health nurses must also blend family nursing theories with public health theories and frameworks to work both with individual families and popula- tions of families.
Family nursing theory is an evolving synthesis of the schol- arship from three different traditions: family social science, family therapy, and nursing (Figure 27-4). Of the three catego- ries of theory, the family social science theories are the most well-developed and informative with respect to how families function, the environment–family interchange, interactions within the family, how the family changes over time, and the family’s reaction to health and illness. Therefore, in this chapter, three family social science theories that blend well with public health nursing are reviewed. These social science theories are
606 PART 5 Health Promotion with Target Populations Across the Life Span
subsystems, boundaries, openness, inputs and outputs, family interactions, family processing, and adapting or changing abili- ties. Examples of assessment questions nurses could ask a family based on a family systems theory would include the following: • Who are the members of your family? • How has one member’s illness affected the family? • Who in the family is or will be affected the most? • What has helped your family in the past when you have had
a similar experience? • Who outside of your family do you see as being able to help? • How would your family react to having someone from
outside the family come to help? • How do you think the children, spouse, or parents are
meeting their needs? • What will help the family cope with the changes?
Interventions need to build on the strengths of the family to improve or support the functioning of the individual members and the whole family. Some nursing strategies based on a family systems theory include establishing a mechanism for providing families with information about their family members on a regular basis, helping the family maintain routines and rituals, and discussing ways to provide for everyday functioning when a family member becomes ill.
The major strength of the systems framework is that it views families from both a subsystem and a suprasystem approach. That is, it views the interactions within and between family subsystems as well as the interaction between families and the larger supersystems, such as the community and the world. The major weakness of the systems framework is that the focus is on the interaction of the family with other systems rather than on the individual, which is sometimes more important.
Family Developmental and Life Cycle Theory Family developmental and life cycle theory provides a frame- work for understanding normal predicted stresses that families experience as they change and transition over time. In the origi- nal theory of family development by Duvall and Miller (1985) they applied the principles of individual development to the family as a unit. The stages of family development are based on the age of the eldest child. Overall family tasks are identified that need to be accomplished for each stage of family develop- ment. Table 27-1 shows the stages of the family life cycle and some of the family developmental tasks. One developmental concept of this theory is that families as a system move to a different level of functioning, thus implying progress in a single direction. Family disequilibrium and conflicts occur during these expected transition periods from one stage of family development to another. The family begins as a married couple. Then the family becomes more complex with the addition of each new child until it becomes simpler and less complex as the younger generation begins to leave the home. Finally, the family comes full circle to the original husband–wife pair. Recognizing that families of today are different in structure, function, and processes, Carter and McGoldrick (2005) expanded the work of Duvall and Miller (1985) to have the family developmental and life cycle theory include different family structures such as divorced families and blended families.
the family systems theory, family developmental and life cycle theory, and the bioecological systems theory.
Family Systems Theory Families are social systems and much can be learned from the systems approach. A system is composed of a set of organized, complex, interacting elements. Nurses use family systems theory to understand how a family is an organized whole as well as composed of individuals (Kaakinen and Hanson, 2015b). The purpose of the family system is to maintain stability through adaptation to internal and external stresses that are created by change (Kaakinen and Hanson, 2015b; White and Klein, 2008). Assumptions of family systems theory include the following: • Family systems are greater than and different from the sum
of their parts. • There are many hierarchies within family systems and
logical relationships between subsystems (e.g., mother–child, family–community).
• Boundaries in the family system can be open, closed, or random.
• Family systems increase in complexity over time, evolving to allow greater adaptability, tolerance to change, and growth by differentiation.
• Family systems change constantly in response to stresses and strains from within and from outside environments.
• Change in one part of a family system affects the total system. • Family systems are an organized whole; therefore, individu-
als within the family are interdependent. • Family systems have homeostatic features to maintain stable
patterns that can be adaptive or maladaptive. An excellent way to understand family systems theory is to
visualize a mobile that consists of different members of a family suspended from each arm of the mobile; this represents the family as a whole. The parts of the mobile move about in response to changes in the balance. The amount of movement and length of time it takes to achieve a calm, balanced state depends on the severity of the imbalance. The family is a system similar to that of the mobile. When one member is affected by a health event, the whole family and each member of the family is affected differently by this change in balance. Imagine what would happen to the mobile if one of the parts was cut off as in the death of a family member, an additional part was added as in the birth or adoption of an infant, an arm of the mobile was extended such as a child moving out of the family home, or one part is yanked really hard and held down for an extended period of time and then suddenly released such as when a family member experiences a life-limiting illness and recovers or pro- ceeds to a chronic illness.
The family systems theory encourages nurses to view the individual clients as participating members of a whole family. The goal is for nurses to help families maintain balance and stability in the family system so that the family can maximize their ability to function and adapt (Kaakinen and Hanson, 2015a). Nurses using this theory determine the effects of illness or injury on the entire family system. Emphasis is on the whole rather than on individuals. Nursing assessment of family systems includes assessment of individual members,
607CHAPTER 27 Working with Families in the Community for Healthy Outcomes
considered “on time” or “off time.” For example, a couple in their late 20s having their first child would be considered “on time,” whereas a teenager having a child or a 30-year-old wife and mother dying from breast cancer would be considered “off-time” transitions. This theory assists nurses in anticipating stresses families
may experience based on the stage of the family life cycle and if the family is experiencing these changes “on time” or “off time.” Nurses can also use these predictable stresses to identify family strengths in adaptation to the changes. In conducting an assessment of families, the following are examples of the types of questions nurses can ask based on the family developmental and life cycle theory. • How has time that the family spends together been affected? • How has communication among and between the family
members been altered? • Has physical space in the home been changed to meet the
needs of the evolving family? • In what ways have the informal roles of the family been
changed? • What changes are being experienced in family meals, recre-
ation, spirituality, or sleep habits? • How are the family finances affected as the family members
age? • Who should be included in the family decision making?
Nursing intervention strategies that derive from the family developmental and life cycle theory help individuals and fami- lies understand the growth and development stages and manage the normal transition periods between developmental periods (e.g., tasks of the school-age family member versus tasks of the adolescent family member) with the least amount of stress pos- sible. Family nurses must recognize that in every family there are both individual and family developmental tasks that need to be accomplished for every stage of the individual or family life cycle that are unique to that particular family.
The major strength of this approach is that it provides a basis for forecasting normative stresses and issues that families will experience at any stage in the family life cycle. The major weak- ness of the model is that it was developed at a time when the traditional nuclear family was emphasized and that some theory development has been conducted on how family life cycles or stages are affected in divorced families, step-parent families, and domestic-partner relationships (Carter and McGoldrick, 2005).
Bioecological Systems Theory The bioecological systems theory was developed by Urie Bron- fenbrenner (1972, 1979, 1997) to describe how environments and systems outside of the family influence the development of a child over time. Even though this theory was designed around how both nature and nurture shape the development of a child, the same underlying principles can be applied when the client is the family. This theory is very useful for public health nurses since it helps identify the stresses and potential resources that can affect family adaptation. Figure 27-5 depicts the four systems in this theory at different levels of engagement that can affect family development and adaptation. The family as the client is at the center of the concentric circles. Each of the levels
Traditional Family Life Cycle Stages and Family Developmental Tasks Family developmental and life cycle theory explains and pre- dicts the changes that occur to families and its members over time. Achievement of family developmental tasks helps indi- vidual family members to accomplish their tasks. Two of the major assumptions of this theory are as follows: • Families change and develop over time based on the age of
the family members and the social norms of the society. Families have predictable stressors and changes based on changes in the family development and family structure. For example, when a family has their first child, there are predict- able stresses and goals to accomplish. Also, families who experience a divorce have some predictable stresses based on when in the life cycle of the family the divorce occurs.
• Families experience disequilibrium when they transition from one stage to another stage. These transitions are
Stages of Family Life Cycle Family Developmental Tasks
Married couple Establish relationship as a family unit, role development
Determine family routines and rituals Childbearing families
with infants Adjust to pregnancy and then birth of infant Learn new roles as mother and father Maintain couple time, intimacy, and relationship
as a unit Families with
preschool children Understand growth and development, including
discipline Cope with energy depletion Arrange for individual time, family time, and
couple time Families with
school-aged children
Learn to open family boundaries as child increases amount of time spent with others outside of the family
Manage time demands in supporting child’s interest and needs outside of the home
Establish rules, new disciplinary actions Maintain couple time
Families with adolescents
Adapt to changes in family communication, power structure, and decision making as teen increases autonomy
Help teen develop as individual and as a family member
Families launching young adults
As young adult moves in and out of the home allocate space, power, communication, roles
Maintain couple time, intimacy, and relationship Middle-aged parents Refocus on couple time, intimacy, and relationship
Maintain kinship ties Focus on retirement and the future
Aging parents Adjust to retirement, death of spouse, and living alone
Adjust to new roles (i.e., widow, single, grandparent)
Adjust to new living situations, changes in health
TABLE 27-1 Traditional Family Life Cycle Stages and Family Developmental Tasks
608 PART 5 Health Promotion with Target Populations Across the Life Span
strength of this model is that it provides a holistic view of inter- actions between the family and society. In working with the family, a critical intervention strategy is drawing a family ecomap that shows the systems with which the family interacts, including the flow of energy from that system into the family or out of the family. The family ecomap is explained in more detail later in the chapter. The weakness of this model is that it does not address how families cope or adapt to the interaction with these systems.
WORKING WITH FAMILIES FOR HEALTHY OUTCOMES Family nurses should transcend the traditional nursing approach as a service model and change their practice to a capacity building model (Kim-Godwin and Bomar, 2015; Bomar, 2004). In a capacity building model nurses assume the family has the most knowledge about how their health issues affect the family, supports family decision making, empowers the family to act, and facilitates actions for and with the family. The goal of family nursing is to focus care, interventions, and services to optimize the self-care capabilities of families and to achieve the best possible outcomes.
Nurses work with all types of family structures in a variety of settings. Each family is unique in how it responds to the stresses that evolve when a family member experiences a health event. Public health nurses are in a unique position to help families by providing direct care, removing barriers to needed services, and improving the capacity of the family to take care of its members (Kaakinen and Tabacco, 2015).
Pre-encounter Data Collection Using excellent communication skills, nurses help families determine the priority of issues they are confronting, identify their needs, and develop a plan of action. Family members are experts in their own health. They know the family health history, their health status, and their health-related concerns (Smith, 2009).
Nurses gather information about the family from a myriad of sources as well as directly from the family. Data collection begins when an actual or potential problem is identified by a source, which may be the family, the health care provider, a school nurse, or a caseworker. Several examples follow: 1. A family is referred to the home health agency because of the
birth of the newest family member. In that district, all births are automatically followed up with a home visit.
2. A family calls hospice to request assistance in providing care to a family member with a terminal illness.
3. A school nurse is asked to conduct a family assessment by a teacher who noticed that the student has frequent absences and has demonstrated significant behavior changes in the classroom.
4. A nurse practitioner requests a family assessment for a child who has failure to thrive.
5. An individual seeks health care in a primary care county clinic or a program-specific clinic such as family planning or an STD clinic.
contains roles, norms, and rules that influence the current situ- ation of the family.
Microsystems are composed of the systems and individuals that the family directly interacts with on a daily basis. These systems vary for each family, but could include their home, neighborhood, place of work, school systems, extended family, health care system, community/public health system, or close friends.
Mesosystems are the systems that the family interacts with frequently but not on a daily basis. These systems vary based on the situation in which the public health nurse is working with a family. Some ideas for systems at this level could be a home health aide who comes to the home twice a week, a hospice nurse who comes to the home once a week, a social worker, church members who come to deliver food to the family, the transportation system, the school system, specialty physicians, pharmacy, or extended family.
Exosystems are external environments that have an indirect influence on the family. For example, some of these systems could be the economic system, local and state political systems, religious system, the school board, community/health and welfare services, the social security office, or protective services.
Macrosystems are broad overarching social ideological and cultural values, attitudes, and beliefs that indirectly influence the family. Examples include a Jewish religious ethic, a cultural value of autonomy in decision making, or ethnicity.
Chronosystems refer to time-related contexts in which changes that have occurred over time may influence any or all of the other levels/systems. Examples include the death of a young parent, a divorce and remarriage, war, or natural disasters.
One assumption of this model is that what happens outside of the family is equally as important as what happens inside the family. The interaction between the family and the systems in which it interacts is bidirectional in that the family is affected by the outside systems and the family affects these systems. The
FIG 27-5 Bioecological family systems model: levels of systems.
Chronosystem
Macrosystem
Exosystem
Mesosystem
Microsystem
609CHAPTER 27 Working with Families in the Community for Healthy Outcomes
emphasizes that the whole family and not one family member is the client. This approach allows the whole family to partici- pate in the identification and resolution of the health problem. Conducting the interview in the home may increase the prob- ability of having more family members present. There are two important disadvantages of meeting in the family home: (1) the family home may be the only sanctuary or safe place for the family or its members to be away from the scrutiny of others, and (2) meeting with a family on their ground requires the nurse to be highly skilled in communication by setting limits and guiding the interaction.
Conducting the family appointment in the office or clinic allows easier access to other health care providers for consulta- tion. An advantage of using the clinic may be that the family situation is so intense that a more formal, less personal setting may be necessary for the family to begin discussion of emotion- ally charged issues. A disadvantage of not seeing the everyday family environment is that it may reinforce a possible culture gap between the family and the nurse.
Making an Appointment with the Family After the decision is made regarding where to meet the family, the nurse contacts the family. It is important to remember that the family gathers information about the nurse from this initial phone call to arrange a meeting, so the nurse should be confi- dent and organized. After the introduction, the nurse concisely states the reason for requesting the family visit and encourages all family members to attend the meeting. The How To Make an Appointment with the Family box reviews steps for making an appointment with the family. Determine if you need an interpreter with you or if you need to arrange to have one avail- able by phone during the visit. Several possible times for the appointment can be offered, including late afternoon or evening, which allows the family to select the most convenient time for all members to be present. It is important to remember that families ultimately retain control of the situation and they do not have to let the nurse enter their home (Smith, 2009).
The assessment process and data collection begin as soon as the referral occurs or the appointment is made. Sources of pre- encounter data the nurse gathers include the following: • Referral source. The information collected from the referral
source includes data that led to the identification of a problem for this family. Demographic information and sub- jective and objective information may be obtained from the referral source.
• Family. A family may identify a health care concern and seek help. During the initial intake or screening procedure, valu- able information can be collected from the family. Informa- tion is collected during phone interaction with the family member, even when calling to set up the initial appointment. This information might include family members’ views of the problem, surprise that the referral was made, reluctance to set up the meeting, avoidance in setting up the interview, or recognition that a referral was made or that a probable health care concern exists.
• Previous records. Previous records may be available for review before the first meeting between the nurse and the family. Often, a record release for information is necessary to obtain family or individual records. However, one challenge may be that many of the electronic health records are premade tem- plates that ignore family information.
Determine Where to Meet the Family Before contacting the family to arrange for the initial appoint- ment, the nurse decides the best place to meet with the family, which might be in the home, clinic, or office. The How To Plan for Family Assessment box identifies reflection questions nurses need to address before meeting the family. Often the decision about the place of the family meeting will be determined by the type of agency with which the nurse works (e.g., home health is conducted in the home, and mental health agencies meet the family in the clinic).
HOW TO Plan for Family Assessment Assessment of families requires an organized plan before you see the family. This plan is developed through the following questions: 1. Why are you seeing the family? 2. Are there any specific family concerns that have been identified
by other sources? 3. Is there a need for an interpreter? 4. Who will be present during the interview? 5. Where will you see the family and how will the space be
arranged? 6. What are you going to be assessing? 7. How are you going to collect the data? 8. What services do you anticipate the family will need? 9. What are the insurance sources for the family?
10. What cultural factors need to be considered in working with this family?
One major advantage to meeting in the family home is seeing the everyday family environment. Family members are likely to feel more relaxed in their home, thereby demonstrating typical family interactions. Meeting with a family in their home
HOW TO Make an Appointment with the Family Data collection starts immediately upon referral to the nurse. The following are suggestions that will make the process of arranging a meeting with the family easier: 1. Remember that the assessment is reciprocal and the family will
be making judgments about you when you call to make the appointment.
2. Introduce yourself and the purpose for the contact. 3. Do not apologize for contacting the family. Be clear, direct, and
specific about the need for an appointment. 4. Arrange a time that is convenient for all parties and allows the
most family members to be present. 5. If appropriate, ask if an interpreter will be needed during the
meeting. 6. Confirm place, time, date, and directions.
Planning for Your Own Safety It is critical to plan for your own safety when you make a home visit. Learn about the neighborhood you will be visiting,
610 PART 5 Health Promotion with Target Populations Across the Life Span
Box 27-3 lists a variety of additional interview questions that will help uncover the family story. Encourage several members of the family to provide input into the discussion. One strategy is to ask the same question of several different family members. It is critical for the nurse to not take sides in the family discus- sion and to focus on guiding them in their decision making. In addition to the family story, the nurse will likely need to ask specific assessment questions about the family member who is in need of services.
Family Assessment Instruments One quick way for nurses to gather information from a family is to use reliable and valid short assessment instruments that are specifically focused on the relevant family situation. Well over 1000 different family assessment instruments exist (Toulia- tos, Perlmutter, and Straus, 2001); therefore, it is critical that the following criteria be used to help determine the most appropri- ate assessment instrument (Kaakinen and Tabacco, 2015): • Written in uncomplicated language at a fifth-grade level • Only takes 10 to 15 minutes to complete • Relatively easy and quick to score • Offers valid data on which to base decisions • Sensitive to gender, race, social class, and ethnic background
Families should always be asked their permission to use an assessment instrument and be informed of how the
anticipate needs you may have, and determine if it is safe for you to make the home visit alone or if you need to arrange to have a security person with you during the visit. Always have your cell phone fully charged and readily available. In addition, the following strategies will help to ensure your own safety when you visit families in their homes (Smith, 2009, p. 316): 1. Leave a schedule at your office. 2. Plan the visit during safe times of day. 3. Dress appropriately, bringing little jewelry or money. 4. Avoid secluded places if you are by yourself. 5. Obtain an escort; take a coworker or neighborhood
volunteer. 6. Sit between the client and the exit. 7. If you feel unsafe, do not visit or leave immediately. 8. Check in with your work at the end of the day.
Interviewing the Family: Defining the Problem One of the underlying central tenets of family nursing is to build a trusting family–nurse relationship. Working with fami- lies requires nurses to use therapeutic communication effi- ciently and skillfully by moving between informal conversation and skilled interviewing strategies. Prepare your family ques- tions before your interview based on the best family theory given what is known about the family situation.
Although it seems commonplace, it is important for nurses to introduce themselves to the family and to initiate conversa- tion with each member present. Spending some initial time on informal conversation helps put the family at ease, allows them time to assess the person/nurse, and disperses some of the tension surrounding the visit (Tabacco, 2010). Involving each family member in the conversation, including children, elderly, or any disabled family member, demonstrates respect and caring and sends the message that the purpose of the visit is to help the whole family and not just the individual family member. Too much disclosure during the early contacts between the family and nurse may scare the family away. Slow down the process and take time to build trust.
Shifting the conversation into a more formal interview can be accomplished by asking the family to share their story about the current situation. If the nurse focuses only on the medical aspect or illness story, much valuable information and the pri- ority issue confronting the family may be missed in the data collection. The purpose of the interview is to gather informa- tion and help the family focus on their problem and determine solutions. The following specific therapeutic questions have been found to provide important family information (Leahey and Svavarsdottir, 2009, p. 449): • What is the greatest challenge facing your family now? • Who in the family do you think the illness has the most
impact on? • Who is suffering the most? • What has been most and least helpful to you in similar
situations? • If there is one question you could have answered now, what
would that be? • How can we best help you and your family? • What are your needs/wishes for assistance now?
• What do you believe is the most important or pressing issue right now? • What have you done to improve the situation? • Share with me your primary goal in the immediate situation. • What are the main problems you are having related to ____? • What is causing you the most stress? • How has this stress affected you and the members of your family? • How are the everyday needs of the family getting done (e.g., cooking,
shopping, cleaning, laundry, transportation, sleeping)? • How well is your family managing this stress? • What results or outcomes do you hope for? • What do you feel you need to help solve this situation? • What can your family do for you? • Who do we need to involve in this situation? • What information do you need to know? • Walk me through a typical 24-hour day in your home. • During times of need, where can you go for support and resources? • What do you think would help me better understand what you are
experiencing? • How does your family anticipate caring for ___? • How does this situation affect you financially? • Where, how, and from whom do you receive your support, inspiration, and
energy to maintain the responsibilities required of you? • What has been the biggest surprise to you about all of this? • How do you think your family roles and routines are going to change in this
situation? • How have you and your family prepared to provide care for ____? • What are your family plans for when you have to return to work? • What does your family do to feel relief or take a break? • What are some specific changes that you and your family members have
had to make? • What do you fear the most about ____?
BOX 27-3 Family Interview Questions
611CHAPTER 27 Working with Families in the Community for Healthy Outcomes
• Developing and evaluating tools for collecting family history • Evaluating whether family history-based strategies work • Promoting evidence-based applications of family history to
health professionals and the public The diagramming of the genogram must adhere to a specific
format to ensure that all parties understand the information. A form that can be used for developing genograms is depicted in Figure 27-6, and the symbols most often used in a genogram are shown in Figure 27-7.
An outline for gathering information during the genogram interview is presented in Box 27-4, and genogram interpretive categories are found in Box 27-5. The health history for all family members (morbidity, mortality, onset of illness) is important information for family nurses and can be the focus of analysis of the family genogram. The more information that
information will be used by the nurse in helping to plan their care. Nurses should review the results or interpretation of the information with the family.
Genograms and ecomaps are both assessment instruments that actively engage the family in their care. In addition, they both provide visual diagrams of the current family story and offer ideas about the plan of action, solutions, and resources (Kaakinen and Tabacco, 2015; Harrison and Neufeld, 2009). The genogram and ecomap are essential components of any family assessment, and they should be used concurrently with any other specific assessment instruments used in the interview.
Genogram The genogram displays pertinent family information in a family tree format that shows family members and their rela- tionships over at least three generations (McGoldrick, Gerson , and Petry, 2008). The genogram shows family history and pat- terns of health-related information, which is a rich source of information for planning interventions. The identified client and his or her family are highlighted on the genogram. Geno- grams enhance nurses’ abilities to make clinical judgments and connect them to family structure and history.
Nurses have various resources available to them to assist families with the collection of family history. In 2002, the Office of Public Health Genomics (OPHG) through the Centers for Disease and Prevention (CDC) started the Family History Public Health Initiative to increase awareness of family history as an important risk factor for common chronic diseases such as cancer, heart disease, and diabetes, and to promote its use in programs aimed at reducing the burden of these diseases in the U.S. population (CDC, 2013a). The initiative has four main activities (For more information check out their website: http:// www.cdc.gov/genomics/famhistory/famhist.htm): • Conducting research to define, measure, and assess family
history in populations and individuals
FIG 27-6 Genogram form. (Modified from McGoldrick M, Gerson R, Schellenburger S: Geno- grams: Assessment and Intervention, ed 2, New York, 1999, Norton.)
Date Completed by
Family Name
Generation 1
Generation 2
Generation 3
Modified from: McGoldrick M, Gerson R, Petry SS: Genograms: assessment and interventions, ed 3, New York, 2008, W.W. Norton.
For each person on the genogram, the nurse should determine which of the following pieces of information to include on the genogram. The information should be relevant to the issues the family is facing. • First name • Age • Date of birth • Occupation • Health problems • Cause of death • Dates of marriages, divorces, separations, commitments, cohabitations,
and remarriages • Education level • Ethnic or religious background
BOX 27-4 Outline For a Genogram Interview
612 PART 5 Health Promotion with Target Populations Across the Life Span
FIG 27-7 Genogram symbols. (Modified from McGoldrick M, Shellenberger S, Petry SS: Geno- grams: Assessment and Intervention, ed 3, New York, 2008, Norton.)
Symbols to describe basic family membership and structure.
Male: Female: Birth date
Gay Lesbian Pet
1943-1975 Death date
Death�X Index Person (IP):
Marriage (give date) (Husband on left, wife on right):
Members of current IP household (circle them):
Living together, relationship, or liaison:
Marital separation (give date): Divorce (give date):
Children: list in birth order, beginning with oldest on left:
Adopted or foster children:
Fraternal twins:
Identical twins:
Pregnancy:
Spontaneous abortion:
Induced abortion:
Stillbirth:
The following areas are important to note in the family genogram: • Family structure: nuclear, blended, single-parent household, gay/lesbian rela-
tionship, cohabitation, divorces, and separations • Sibling subsystem group: birth order, sex, distance between ages of
children
• Patterns of repetition: patterns across the generations related to family struc- ture, behaviors, health problems, relationships, violence, abuse, poverty
• Life events: repeated similar events across generations, such as transitions, traumas
BOX 27-5 Genogram Interpretive Categories
613CHAPTER 27 Working with Families in the Community for Healthy Outcomes
between the family members and the subsystems are shown by different connecting lines.
The ecomap serves as a tool to organize and present infor- mation, allowing the nurse and family to have a more holistic and integrated perception of the current situation. Not only does it portray the present situation, but it can also be used to set goals for the future by encouraging connection and exchange with individuals and agencies in the community. A more detailed discussion of ecomapping can be found in Kaakinen and Tabacco (2015) and McGoldrick et al (2008).
Family Health Literacy Family health literacy is necessary for the family or its members to be actively involved in their care. Family health literacy includes the ability to understand information in order to make appropriate health care decisions, accurately carry out plans of action, and successfully advocate for the family in the complex health care systems in which they receive care (Kaakinen and Tabacco, 2015). Those with poor health literacy skills have been strongly associated with lower health outcomes (Berkman et al, 2011; Wolff et al, 2009).
Functional health literacy includes the ability to read and understand numbers in order to use this health information to make informed decisions (DeWalt, Boone, and Pignone, 2007) and to understand the consequences when instructions or plans of action are not followed (Speros, 2005).
Nurses can assess for health literacy in conversations and when completing genograms and ecomaps. Rather than spend time determining the extent of the health literacy in a family, it is most important that nurses use the following techniques when writing out plans of care, listing directions, discussing medication management, or writing telephone numbers (Kaaki- nen and Tabacco, 2015; Peters et al, 2007). • Use black ink on white paper • Use short sentences • Use bullets no longer than seven items • Information should be written at the fifth-grade level • Remove all extra words • Print in upper- and lower-case letters • If using a computer, use 14-point font with high contrasting
Arial or sans serif print • Have plenty of white space
Families retain more information when nurses use a variety of communication methods (Bass, 2005), including both visual materials and visual language (Peters et al, 2007). Families need direct, clear information to assist in their decision making and carrying out the plans of action (Salmond, 2008).
Designing Family Interventions Nurses will be challenged to help families identify the primary problem confronting them and to step aside and accept the family priority as they work in partnership with the family to keep their interventions simple, specific, timely, and realistic. It is essential that the family participate in determining the primary need and in designing interventions.
It is important to view the family with an open approach, since the central issue identified by the referral source may not
can be added to the family genogram, the more the family and nurse understand the family situation. Most families are coop- erative and interested in completing the genogram, which does not have to be completed in one sitting. The genogram becomes a part of the ongoing health care record.
Ecomap The ecomap is a visual diagram of the family unit in relation to other units or subsystems in the community. The ecomap serves as a tool to organize and present factual information and thus allows the nurse to have a more holistic and integrated perception of the family situation. The ecomap shows the nature of the relationships among family members, and between family members and the community; it is an overview of the family, picturing both the important nurturing and the impor- tant stress-producing connections between the family and its environment. The nurse starts with a blank ecomap, which consists of a large circle with smaller circles around it (Figure 27-8). The identified client and his or her family are placed in the center of the large circle. The outer smaller circles around the family unit represent significant people, agencies, or orga- nizations in the family’s environment that interact with the family members (Kaakinen and Tabacco, 2015). The nature and quality of the relationships and the direction of energy flow
FIG 27-8 Ecomap form. (Modified from Kaakinen JR, Hanson SMH: Family nursing assessment and intervention. In Hanson SMH, Gedaly-Duff V, Kaakinen JR, editors: Family Health Care Nursing: Theory, Practice and Research, ed 3, Philadelphia, 2005, FA Davis.)
Church
School
Extended family
Key
Work
Friends
Strong Tenuous Stressful Energy flow
614 PART 5 Health Promotion with Target Populations Across the Life Span
the nurse worked with the family to help them identify that their major concern centered on nutritional management of hypoglycemia, which ultimately affects the administration of medication.
The major difference between the two scenarios presented here was the way in which the nurse framed questions while listening to the family story. In the first scenario the nurse asked questions that allowed for consideration of only one aspect of family health. This type of step-by-step nurse-lead linear problem-solving process is tedious and time consuming, and will likely cause errors in the identification of the most pressing family concern (Figure 27-9). In the second scenario, the nurse asked questions that allowed for critical thinking about the family view of their challenges (Figure 27-10). The nurse gath- ered information from the referral source, conducted an assess- ment of the impact of the new management plan on the whole family, and collaboratively the nurse and family identified the critical family issue that had a more far-reaching effect on the health of the whole family.
The nurse works with the family to help them design realistic steps or a plan of action based on their ability to successfully adapt to the health issue given the strengths of the family. Working with the family, the following action plan approach helps focus the family on things they can immediately do to help address the problem: 1. We need the following type of help. 2. We need the following information. 3. We need the following supplies. 4. We need to involve or tell the following people. 5. To make our family action plan happen we need to … (list
5 things in the order they need to have happen). Using knowledge and evidence-based practice, the nurse
guides the family in outlining ways to prevent a potential problem, minimize the problem, stabilize the problem, or help the family recognize it as a deteriorating problem. The following scenario shows how nurses work with families to
be the actual problem the family is experiencing. See the fol- lowing case study:
The Raggs family is referred to the home health clinic by a physician for medication management. Sam, the 73-year- old husband, has been a Type 2 diabetic for 13 years and now requires insulin to manage his condition. He is being discharged from the hospital. The potential area of concern that prompted the referral was the administration of insulin. After the initial meeting with the family, the primary problem the family uncovers is really not the administration of the medication, but managing his nutrition. The infer- ence of the referral source was that the family knew how to manage the dietary aspects of diabetes because Sam had Type 2 diabetes for 13 years.
If the primary family issue is not accurately identified, the family and the nurse will collect data, design interventions, and implement plans of care that do not meet the most pressing family needs. The importance of identifying the family issue of concern and accurately making the family nursing diagnosis is demonstrated by comparing the following two scenarios:
Scenario #1: The hypothesized central issue for the Raggs family was identified by the referral source: Is insulin being administered correctly? Based on this question from the referral source, the nurse asked only for information per- taining to this specific problem. The nurse asked questions that elicited information about (1) concerns of giving injec- tions, (2) difficulty drawing up the accurate amount of insulin, and (3) the storage of insulin. The nurse focused the interventions on (1) the psychomotor skills of family members necessary to give the insulin injection, (2) the correct amount of insulin to give according to blood glucose level, and (3) the correct storage and handling of the medi- cation and the equipment. By not looking at the whole family, the care was based on the nurse’s perception of the problem confronting the family.
Scenario #2: The central question asked by a nurse who knows how to integrate family theory into practice was, “What is the best way to ensure that the Raggs family understands how to manage his Type 2 diabetes?” By asking the family to share their story of the situation together, they determined that the primary issue was not medication administration but rather a lack of family knowledge related to health care management of a family member who now requires the addition of insulin to his management plan.
Asking broader-based questions uncovers the whole picture of the family dealing with this specific health concern and directs a more comprehensive holistic data-collection process. More evidence was collected in this case scenario because more options for possible interventions were considered concur- rently. Areas of data collection based on the whole family story were (1) administration of medication, (2) nutritional manage- ment, (3) blood glucose monitoring, (4) activity/exercise, (5) coping with a changed management plan, and (6) knowl- edge of pathophysiology of diabetes. Out of all these issues,
FIG 27-9 Scenario 1: Nurse-led linear problem-solving identifi- cation process.
Amount to give
Storage of medications
Giving injection
Technical procedures–glucose
testing
Who will give the injection?
Side effects of medicine
Insulin administration
615CHAPTER 27 Working with Families in the Community for Healthy Outcomes
her job to stay home to care for her mother, some members of the family were surprised by her statement as they did not realize she was so overwhelmed. The family worked with the nurse to find ways to minimize her role strain by spreading the caregiver role among the extended family members.
By understanding the family systems theory, the nurse knows that what affects one member of the family affects all members of the family. One of the strengths this family has is the shared belief that caring for the dying grandmother in their home is the “right” ethical choice for them. The nurse brings knowledge and evidence into this situation because he or she knows that the disruption to the family and their expected roles will be short term because the grandmother will probably not live for more than 4 months. However, experience with families also supports this nurse’s knowledge that Myra’s role conflict may likely increase as her caregiver role becomes more intense as her mother’s health declines. By conducting a family genogram, another strength of this family is uncovered: it has a strong internal and external support system. The family determines that the extended family is willing to be involved in the care of Bernice. The intervention is aimed at mobilizing resources to minimize Myra’s role conflict. Using the simple action plan outlined previously, the family determined the following: 1. We need the following type of help:
• Other family members to come every day to relieve Myra • Every other weekend, one of Bernice’s other daughters
will provide care through the night to relieve Myra • Jobs in the family will be shared to relieve Myra. Dylan
will do the shopping, William will clear the table and put dishes in the dishwasher, and Jessica will help fold the clothes and put them away. William and Jessica agreed to help by spending some time each evening with Bernice, such as reading to her or watching TV with her.
determine their strengths, identify the problem, and design interventions.
Scenario #3: The home hospice nurse has been working with the Brush family for 3 weeks. The Brush family consists of the members outlined in Figure 27-11.
Family story: Beatrice was diagnosed with terminal liver cancer 4 weeks ago. The Brush family—Bernice, Dylan, Myra, William and Jessica—agreed that Bernice should live with them and be cared for until her death in their home. Bernice has other children who live in the same city. The hospice nurse in collaboration with the Brush family identified that the primary problem is that Myra is experi- encing role stress, strain, and overload in her new role as the family caregiver. Myra showed her role conflict by stating, “Sometimes I do not know who I am—daughter, nurse, mother, or wife.” As Myra took a family leave from
FIG 27-10 Scenario 2: An example of complex relationships between issues affecting the whole family because of the new diagnosis.
Nutrition Retired, low
income
Activity/ excercise
Health-related behaviors
Technical procedures
Stress and coping, disease progressing
Prescribed medication regimen
Newly Dx insulin- dependent diabetes
FIG 27-11 The Brush family genogram.
Tom Deceased
MyraDylan
William 10 yr old
Jessica 7 yr old
Sally Peggy
Bernice 77 yr old Terminal liver cancer
616 PART 5 Health Promotion with Target Populations Across the Life Span
nurse, extending invitations to the family for follow-up, and making referrals when appropriate. The termination should include a summative evaluation meeting, in which the nurse and family put a formal closure to their relationship.
When termination with a family occurs suddenly, it is impor- tant for the nurse to determine the forces bringing about the closure. The family may be initiating the termination prema- turely, which requires a renegotiating process. The insurance or agency requirements may be placing a financial constraint on the amount of time the nurse can work with a family. Regardless of how termination comes about, it is important to recognize the transition from depending on the family nurse on some level to having no dependence. Strategies that help with the termination are to (1) increase time between the nurse’s visits, (2) develop a plan for the transition, (3) assess the family support systems, (4) make referrals to other resources, and (5) provide a written summary to the family.
SOCIAL AND FAMILY POLICY CHALLENGES National, state, and local social and family policies provide various challenges to nurses’ practices. As professionals, public health nurses are accountable for participating in the three core public health functions: assessment, policy development, and assurance.
National family policy is government actions that have a direct or indirect effect on families. The range of social policy decisions that affect families is vast, such as health care access and coverage, low-income housing, social security, welfare, food stamps, pension plans, affirmative action, and education. Although all government polices affect families in both negative and positive ways, the United States has little overall explicit family policy (Gebbie and Gebbie, 2005). Most government policy indirectly affects families. The Family Medical Leave leg- islation passed in 1993 by the U.S. Congress is an example of a type of family policy that has been positive for families. A family member may take a defined amount of leave for family events (e.g., births, deaths) without fear of losing his or her job. The Affordable Health Care Act (ACA) of 2010 is an example of a national policy that has effects on family policy.
Nurses must become familiar with some of the key features of the ACA reforms affecting individuals and their families, which include the following (check out: www.HHS.gov/ healthcare): • Health plans can no longer limit or deny benefits to children
under the age of 19 due to a pre-existing condition. • Young adults under the age of 26 may be eligible to be
covered under their parent’s health plan. • Insurance companies can no longer arbitrarily cancel a per-
son’s health insurance coverage. • An individual’s right to appeal is guaranteed. • Health plans are prohibited from putting a lifetime dollar
limit on most benefits individuals receive. • Insurance companies must now publicly justify any unrea-
sonable rate hikes. • Requires insurance companies to spend premium dollars
primarily on health care. It does this by enforcing a policy
2. We need the following information: • How to call the hospice nurse when Bernice gets worse or
they need immediate help • A list of who to call when an emergency occurs • A list and numbers of Bernice’s health care team
3. We need the following supplies: None at this time 4. We need to involve or tell the following people: Sally and
Peggy 5. To make our family action plan happen we need to … (list
5 things in the order they need to happen): • Invite Sally and Peggy over for a family meeting, and
include the home hospice nurse. • Make a list of what weekends Sally and Peggy will help
with Bernice. • Make a calendar with whose turn it is to spend time
with Bernice every evening, which will relieve Myra of the care.
Based on the family story just described, as viewed through the frame of family systems theory, the following interventions were implemented: (1) assisting the family in the role negotia- tion of tasks and who performs them, (2) educating family members so they can safely care for Bernice now and when she enters the stage of active dying, and (3) determining what addi- tional resources the family needs. After a plan is put into place, it needs to be evaluated periodically.
Evaluation of the Plan In evaluating the outcome, nurses engage in critical thinking to determine if the plan is working, if it is working fast enough to address the problem, if it is addressing only part of the problem, or if the plan needs to be revised based on changes. When the plan is not working, the nurse and the family work together to determine the barriers interfering with the plan or figure out if something changed in the family story. Family apathy and indecision are known to be barriers in family nursing (Friedman, Bowden, and Jones, 2003). Friedman et al (2003) also identified the following nurse-related barriers that can affect achievement of the outcome: (1) nurse-imposed ideas, (2) negative labeling, (3) overlooking family strengths, and (4) neglecting cultural or gender implications. Family apathy may occur because of value differences between the nurse and the family, because the family is overcome with a sense of hopeless- ness, because the family views the problems as too overwhelm- ing, or because family members have a fear of failure. Additional factors to be considered are that the family may be indecisive because they cannot determine which course of action is better (because they have an unexpressed fear or concern) or because they have a pattern of making decisions only when faced with a crisis.
An important part of the evaluation step in working with families is the decision to terminate the relationship between the nurse and the family. Termination is phasing out the nurse from family involvement. When termination is built into the interventions the family benefits from a smooth transition process. The family is given credit for the outcomes of the interventions that they helped design. Strategies often used in the termination component are decreasing contact with the
617CHAPTER 27 Working with Families in the Community for Healthy Outcomes
the elderly has proven to be beneficial, yet is fraught with numerous problems. Both living wills and durable power of attorney for health care, legal contracts that designate a person to make health care decisions when the individual is incapacitated, are more commonplace today than in the past. However, without these legal instruments, families are faced with making end-of-life decisions for their loved ones. Although Medicare and Medicaid provide health care to many, a significant population is still uninsured. Emergency depart- ments continue to be the only access to health care for the uninsured and a convenient and accessible source of health care for many without access to a health care provider (Marco et al, 2012)
The H1N1 pandemic was an excellent example of mobilizing community partnerships to solve health problems. In one county health department, space for storing vaccines was insuf- ficient in the county health clinics, so arrangements were made with the law enforcement departments to store vaccines in their secure evidence refrigerators. Other examples of partnering included collaboration with Health and Human Services departments and homeless programs to get at-risk populations and the homeless vaccinated. County health departments and pediatricians worked together to get members of families who had infants under 6 months of age vaccinated, since these infants were too young to receive the H1N1 vaccine.
These are only a few examples of social and family policy in which nurses are involved. Population-focused nurses need to be involved in making policy at the local, state, and national level that affects families. Using the core public health functions as a framework allows the population-focused nurse to view the broad spectrum of activities that improve the lives of communi- ties, families, and the individuals within those families.
called the “80/20 rule” to hold insurance companies accountable.
• Insurance companies are required to cover certain preventive services at no cost to the individual. There are specific covered preventive services for adults, women, and children.
• Ensures that individuals can seek emergency care at a hos- pital outside their plan’s network without prior approval from their health plan. The Congressional Budget Office (2010) estimates that by
2016, some 24 million people will get insurance through the insurance exchanges set up by states, while another 12 million will continue to get individual coverage outside of them.
Many programs that do exist for families, such as Social Security and Temporary Assistance to Needy Families, are not available to all families. State assistance for families varies by state.
The challenges of social policy for families are numerous. Given the ongoing debate as to what constitutes a family, social policies may specify a definition that is not consistent with the family’s own definition. Examples include same-sex partner- ships and/or marriage, legal definition of parents, reproductive and fertility issues (e.g., a surrogate mother decides she wants to keep the baby), or issues involving care of older adults (e.g., a niece wants to institutionalize an older aunt with dementia because her children are not available). Besides how families define themselves, governments define health care services that affect families.
Teen pregnancy prevention is a monitored health status throughout the United States and a good example of the chal- lenges of family health policy. In some states, any child who is sexually active may have access to reproductive health services. This is a family policy to which some families object, yet the sexually active teenager is protected by a number of laws, both state and federal. The teenager who requests confidential ser- vices is protected by Title X and HIPAA federal regulations given the state law allowing access to services. Providers can encourage the teen to talk with his or her parents, but ultimately it is the teen’s decision. Nurses need to be knowledgeable about these policies since they participate in carrying out family policy and have a responsibility to inform state policy regarding the services they provide.
Nurses participate in enforcing laws and regulations that affect the family such as state immunization laws. Most states have some school immunization laws that exclude children from school who are not vaccinated. If the child does not have that state’s particular set of immunizations and the parents do not want the child vaccinated, two sets of laws are in conflict: the immunization laws and the school attendance laws. The state could provide a mechanism for a waiver, or the child could be excluded from school, thus making home schooling the only option.
Health care insurance is a social and family policy issue. Medicare and Medicaid, enacted in 1965, provide some health care for the elderly and low-income families. Today Medicare covers nearly 42 million beneficiaries, or one in seven U.S. citi- zens (National Bureau of Economic Research, 2013). Insuring
Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency: Client-Centered Care Recognize the client or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for client’s preferences, values, and needs.
Important aspects of client-centered care include: • Knowledge: Describe strategies to empower clients or families in all
aspects of the health care process • Skills: Assess level of client’s decisional conflict and provide access to
resources • Attitudes: Value active partnership with clients or designated surrogates
in planning, implementation, and evaluation of care
Client-Centered Care Question Describe how a family assessment is different from an individual client assessment. Beyond immediate family members, who might be included in a client’s “family”? Think about the difference between being an advocate for an individual (the client) and an advocate for a family. What different skills are needed?
618 PART 5 Health Promotion with Target Populations Across the Life Span
P R A C T I C E A P P L I C A T I O N One of the most notable changes in the twenty-first century is women and mothers working outside of the home. The differ- ence can be seen in the following statistic: In 1960 only 19% of married mothers with children under 6 years of age worked outside the home (U.S. Census Bureau, 2008) compared with 64.8% in 2012 (Bureau of Labor Statistics, 2013).
A. In what ways does this influence family socialization and affective functions?
B. In what ways does this situation affect the family health care function?
C. How does this impact family nursing? Answers can be found on the Evolve site.
K E Y P O I N T S • Families are the context within which health care decisions
are made. • Nurses are responsible for assisting families in meeting
health care needs. • Family nursing is practiced in all settings. • Family nursing is a specialty area that has a strong theoretical
base and is more than just common sense. • Community health nurses must integrate both family theory
and public health theory in their practice. • There are a variety of family definitions, such as a group of
two or more, a unique social group, and two or more persons joined together by emotional bonds.
• The five functions performed by families are economic, reproduction, socialization, affective, and health care.
• Family structure refers to the characteristics, sex, age, and number of the individual members who make up the family unit.
• Family demographics is the study of structures of families and households as well as events that alter the family, such as marriage, divorce, births, and cohabitation. Demographic trends affect the family.
• Family health is difficult to define, but it includes the biologi- cal, psychological, sociological, cultural, and spiritual factors of the family system.
• There are four approaches to viewing families: family as context, family as client, family as a system, and family as a component of society.
• Systems theory describes families as a unit of the whole composed of members whose interactional patterns are the
focus of attention, in that what affects one member affects all members.
• Family developmental and life cycle theory emphasizes how families change over time and focuses on interactions and relationships among family members.
• Bioecological family theory helps community/public health nurses identify the stressors and potential resources that can affect family adaptation.
• One of the underlying central tenets of family nursing is to build a trusting family–nurse relationship.
• Working with families requires nurses to use therapeutic communication efficiently and skillfully by moving between informal conversation and skilled interviewing strategies.
• Nurses should ask clients whom they consider to be their family and then include those members in the health care plan. Genograms and ecomaps are essential components of any family assessment.
• Families want to be involved in identifying their major problem and designing solutions that are family focused.
• It is important for the nurse to recognize that the family has the right to make its own health decisions.
• The goal of family nursing is to focus care, interventions, and services to optimize the self-care capabilities of families and to achieve the best possible outcomes.
• Nurses working with families must understand the effects of health care reforms at the local, state, and federal levels as all government actions affect the family.
C L I N I C A L D E C I S I O N M A K I N G A C T I V I T I E S 1. Select six or more health professionals and ask them to
define family. Analyze the responses for common points and differences. Write your own definition of family.
2. Characterize the different family structures and household arrangements represented in your community. This infor- mation may be available from various sources, such as the health department, schools, other social and welfare agen- cies, and census data. Be specific.
3. Draw your own family genogram and ecomap. Discuss how they are used in family nursing.
4. Discuss the role of nursing related to family policy. Be spe- cific about issues related to family culture.
5. Break into small groups and have students discuss the Brush family presented in the chapter in terms of the three family social science theories. What questions would they ask the
family from the different theoretical perspectives? Examine different situations when one theory might be more appro- priate to use than another.
6. How might you go about obtaining services for a Hispanic woman who tests positive for diabetes who is uninsured or underinsured?
7. Break into small groups to discuss how you have found judging or reacting to family structure situations that are different from those you personally bring to practice. What helps you try to reframe this situation in order to practice family nursing?
8. You are working with a lesbian family with three children. What barriers or problems do you anticipate with social policies while trying to access resources?
619CHAPTER 27 Working with Families in the Community for Healthy Outcomes
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621CHAPTER 27 Working with Families in the Community for Healthy Outcomes
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28
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Evaluate the various approaches to defining and
conceptualizing family health. 2. Analyze the major risks to family health. 3. Analyze the interrelationships among individual health,
family health, and community health. 4. Explain the relevance of knowledge about family
structures, roles, and functions for family-focused nursing in the community.
5. Discuss the implications of policy and policy decisions, at all governmental levels, on families.
6. Explain the application of the nursing process (assessment, planning, implementation, evaluation) to reducing family health risks and promoting family health.
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • Quiz • Case Studies • WebLinks • Glossary • Answers to Practice Application • Resource Tools
• Resource Tool 5.A: Schedule of Clinical Preventive Services
• Resource Tool 27.A: Family Systems Stressor-Strength Inventory
• Resource Tool 27.B: Case Example of Family Assessment
Appendix • Appendix E: Friedman Family Assessment Model
(Short Form)
Debra Gay Anderson, PhD, PHCNS-BC Dr. Debra Gay Anderson is a faculty member at the University of Kentucky’s College of Nursing. She is certified as a clinical specialist in public/ community health nursing and has provided health care for the homeless and other vulnerable populations. Dr. Anderson has taught public health, epidemiology, leadership, and research courses at both the graduate and undergraduate levels. The focus of her program of research, publications, and presentations is vulnerable populations, primarily women who have experienced homelessness, domestic violence or workplace violence. Dr. Anderson completed her doctoral studies and a family nursing postdoctoral fellowship at Oregon Health Sciences University in Portland, Oregon. Dr. Anderson is an active member of the American Public Health Association (APHA) and has served in various leadership capacities, including Chair of the Public Health Nursing Section of APHA.
Hartley Feld received her Masters of Science in Nursing, Community and Public Health nursing specialty, in 2006 from the University of Kentucky. She is board certified as a Public Health Clinical Nurse Specialist. Ms. Feld is a lecturer and clinical instructor in Community and Public Health Nursing. Her clinical interests include global health, health care economics, determinants of health, and vulnerable populations.
Dr. Mollie E. Aleshire is a faculty member at the University of Kentucky College of Nursing and is certified as a family nurse practitioner and pediatric primary care nurse practitioner. Dr. Aleshire has taught interprofessional health systems, health promotion, and primary care prevention in both undergraduate and graduate courses. She received a Master of Science in Nursing and a Doctor of Nursing Practice from the University of Kentucky. Dr. Aleshire’s clinical and scholarship interests include prevention strategies in primary care settings and health issues of young women and female adolescents.
Hartley Feld, RN, MSN, PHCNS-BC
Mollie Aleshire, DNP, FNP-BC, PPCNP-BC
623CHAPTER 28 Family Health Risks
K E Y T E R M S Affordable Care Act, p. 624 behavioral risk, p. 633 biological risk, p. 628 contracting, p. 637 economic risk, p. 631 empowerment, p. 638 family crisis, p. 627 family health, p. 624 health risk appraisal, p. 627 health risk reduction, p. 627 health risks, p. 626 home visits, p. 634
in-home phase, p. 636 initiation phase, p. 634 life-event risk, p. 628 policy, p. 624 post-visit phase, p. 637 pre-visit phase, p. 635 risk, p. 625 social risks, p. 631 telehomecare, p. 639 termination phase, p. 636 transitions, p. 628 —See Glossary for definitions
C H A P T E R O U T L I N E Early Approaches to Family Health Risks
Health of Families Health of the Nation
Concepts in Family Health Risk Family Health Health Risk Health Risk Appraisal Health Risk Reduction Family Crisis
Major Family Health Risks and Nursing Interventions Family Health Risk Appraisal
Nursing Approaches to Family Health Risk Reduction Home Visits Contracting With Families Empowering Families
Community Resources Telehomecare Family Policy Vulnerable Populations: LGBTQ Families at Risk
What is a “family?” Is there one definition that fits all families? Is there a new normal? Was there ever a true “normal” family? In 2011, Lisa Belkin wrote an opinion piece for The New York Times, “A ‘Normal’ Family.” In her article, she discussed seven trends identified by the Pew Research Center. The trends were “more unmarried couples raising children; more gay and lesbian couples raising children; more single women having children without a male partner to help raise them; more people living together without getting married; more mothers of young chil- dren working outside the home; more people of different races marrying each other; and more women not ever having chil- dren” (Belkin, 2011).
Although Belkin is referring to current family incarnations, history demonstrates that the makeup of families is in constant flux, depending on the current socioeconomic pragmatism. We are reminded of Abraham Lincoln’s father leaving his two chil- dren following the death of their mother for the purpose of bringing back a new mother. Was that a “normal” family? Sarah Bush Johnston Lincoln, with three children, married Thomas Lincoln, following the deaths of both of their spouses and, in addition to their combined five children, raised a cousin of Nancy Hank Lincoln. Today, we might call that a “blended” family. We refer to Lincoln’s family simply to demonstrate that the “traditional” family was never the “normal” family. As family
makeup transitions, those families are often the ones that are the most vulnerable because they do not conform to traditional societal expectations.
Regardless of makeup, the family as a client unit is basic to the practice of population-centered nursing, and nurses are responsible for promoting healthy families in society. As such, families are described as a unique population in public health. The purpose of this chapter is to make the reader aware of influences, both individual and societal, that place families at risk for poor health outcomes, and to discuss how positive outcomes for diverse families can be accomplished through appropriate nursing interventions.
The expanding definition of the family unit presents today’s nurse with an array of challenges and opportunities to address the health needs of families. First, it is essential to place the family in the context of the twenty-first century. Many Ameri- cans tend to idealize family and wish for a return to family values of the past and a golden time for families. However, historical demographic statistics reveal that this prevalence of the idealized family that has often been portrayed in the media never actually existed. Rather than arguing for a return to the “traditional family” (male breadwinner and woman at home), serious discussions are needed about how to help today’s diverse families succeed. A focus on all family structures is a moral and
624 PART 5 Health Promotion with Target Populations Across the Life Span
help families to maintain their health in times of disaster, eco- nomic downturns, unemployment, health crises, and other situ- ations. An effective family health policy may consider as its foundational element an infrastructure of programs designed to provide access to primary and preventive health care. The building of this foundation requires a multiprofessional process in which nurses can be actively involved. Nurses are educated in community assessment, planning, development, and evalua- tion activities that emphasize and address issues crucial to pro- moting and sustaining primary family health. Nurses looking to positively influence family health will want to be aware of and actively participate in the ongoing national debate and dialogue on family health policy that embraces their role as principal constituents in building healthy families.
In establishing health objectives for the nation, an emphasis has been placed on both health promotion and risk reduction. Reducing the risks to segments of the population is a direct way to improve the health of the general population. Specific objectives have been identified related to specific health risks for families. The family is an important environmental factor that affects the health of individuals as well as a social unit whose health is basic to that of the community and the larger population. It is within the family that health values, health habits, and health risk perceptions are developed, orga- nized, and carried out. Individuals’ health behaviors are affected by and acted out within the family environment, the larger community, and society.
Family health habits are developed in the same manner in the context of community norms and values, and on the basis of availability and accessibility. For example, in a television commercial for an over-the-counter stimulant, a man is fea- tured who is able to coach his child’s basketball team, work at a rehabilitation center, and work as a borough inspector for the city, all while pursuing a college degree at night. The commer- cial credits the drug for providing the man with the energy needed to be successful in all of these areas. The message is clear: you can, and must, do it all, and taking drugs to succeed is a viable option. The health risks to individual and family health are affected by the societal norms—in this example, the norm is increasing productivity through drugs.
To intervene effectively and appropriately with families to reduce their health risk and thereby promote their health, nurses need to understand not only family structure and func- tioning, but also family theory, nursing theory, and models of health risk (see Chapters 9, 17, and 27). In addition, the effective nurse needs to look beyond the individual and the family in order to understand the complex environment in which the family exists. Increasing evidence of the effects of social, biological, economic, and life events on health requires a broader approach to addressing health risks for families. Nurses and the communities they serve have a vital interest in exploring new and appropriate options for structuring nursing interventions with families to decrease health risks and to promote health and well-being for all families. It is important for the nurse to focus on families who share similar health risks as a population. Working and planning interventions to reduce health risks in family populations provides a mechanism for
ethical imperative in the promotion of the health of individuals as well as the health of the community (Nightingale et al, 1978; Wright and Leahey, 2013).
The varying family structures of today need to be recognized and examined to better understand both the strengths and weaknesses associated with each. Only by doing this will we be able to help all families live healthy and productive lives. Nurses can play an active role in leading and facilitating this learning process. This facilitation can enable better-informed health care policy decisions that have a positive effect on single-parent families, remarried and stepfamilies, gay and lesbian families, grandparent-headed families, and ethnically diverse families, as well as “traditional” families.
A nation’s family health care policy is a primary determinant of family health. Family policy means anything that is done by the government that directly or indirectly affects families. Family health policy and its relative effectiveness demonstrates a government’s understanding of families and its role in pro- moting their health, with an important desired outcome being that families derive a sense of empowerment and are able to take responsibility for their own health (Chinn, 2012). The responsibility for family health programs is shared by the federal government with state and local governments. Each state, as well as regions within states, has programs and laws related to family services. The United States is one of the richest and most technologically advanced countries in the world today and yet, despite the profusion of technological advances and the con- tinually growing proportion of the national budget spent on health care, the disparities in health status between different populations of families has continued to grow (FAMILIES USA, 2014). These disparities have resulted, at least in part, from previous attempts to develop and implement “family policies” that either directly or indirectly affect specific issues related to family health but which have failed to take a comprehensive system-wide approach.
Although many disparities and inequities continue in the United States, the health care disparities related to insurance coverage should begin to change as the Affordable Care Act (ACA) expands. At the 2014 Health Action Conference, FAMI- LIES USA, Vice President Joe Biden spoke of the importance of the Affordable Care Act (discussed throughout this text) and the importance of the ACA for families in the United States. The specific benefits he highlighted were the coverage of pre-existing conditions, mental health coverage, the disparity in the cost of insurance for women and men, the more than three million young adults on their parents’ insurance policies, and not receiving medical care simply because one does not have insur- ance (Biden, 2014). Nursing has a rich history in social activism and social justice which should be continued, emphasizing advocacy and policy work to help families and communities become healthier for all populations.
Evidence to date suggests that the United States could benefit from a cohesive family policy designed to enhance the well- being of all families. Such a policy would go a long way toward preventing future crises in vulnerable family populations, such as those in or on the verge of poverty or families overwhelmed with abuse and neglect, by providing a structural safety net to
625CHAPTER 28 Family Health Risks
to read The Blue Zones: 9 Lessons for Living Longer for in-depth case studies. The nine lessons include the following: 1. Move naturally: Be active without thinking about it; 2. Hara Hachi Bu: Painlessly cut calories by 20 percent; 3. Plant slant: Avoid meat and processed foods; 4. Grapes of life: Drink red wine in moderation; 5. Purpose now: Take time to see the big picture; 6. Downshift: Take time to relieve stress; 7. Belong: Participate in a spiritual community; 8. Loved ones first: Make family a priority; and 9. Right tribe: Be surrounded by those who share Blue Zone
values. A growing body of literature supports the notion that life-
style and the environment interact with heredity to cause disease. In response to these findings and to the limited effect of medical interventions on the growing incidence and preva- lence of injuries and chronic disease, the government launched a major effort to address the health status of the population. Part of this effort was a report by the Division of Health Promo- tion and Disease Prevention of the Institute of Medicine that examined the critical components of the physical, socioeco- nomic, and family environments related to decreasing risk and promoting health (Nightingale et al, 1978). The Surgeon Gen- eral’s Report on Health Promotion and Disease Prevention (Cali- fano, 1979) described the risks to good health in the United States at that time. As a result of these reports, health objectives for the nation were established and then evaluated and restated for the year 2000 and again for 2010 (USDHHS, 2000). The Healthy People 2020 objectives extend the work of the three past documents. An innovative part of this latest Healthy People (USDHHS, 2010) update has been a move to become more creative and inclusive. The focus challenges health care provid- ers with a national goal of improving health and will provide the necessary background for future policy initiatives to reduce risk in all populations. Of the four goals, three are particularly important to families: • Achieve health equity, eliminate disparities, and improve the
health of all groups. • Create social and physical environments that promote good
health for all. • Promote quality of life, healthy development, and healthy
behaviors across all life stages. With the notion of risk, any factor resulting in a predisposi-
tion toward or an increased likelihood of ill health takes on increased importance. Specific attention is being paid to those environmental and behavioral factors that lead to ill health with or without the influence of heredity. Reducing health risks is a major step toward improving the health of the nation. Although the family is considered an important environment related to achieving important health objectives, limited attention and research have been directed at family health risks and the role of society in promoting healthy families.
CONCEPTS IN FAMILY HEALTH RISK Pender’s Health Promotion Model (2010), described in the latest edition of her textbook, continues to be useful in research
shared communication and support among families as well as efficient and effective health care interventions that will not only make the families, but the community as a whole, healthier.
EARLY APPROACHES TO FAMILY HEALTH RISKS Health of Families Historically, the study of the family relative to health and illness focused on three major areas: (1) the effect of illness on families, (2) the role of the family in the cause of disease, and (3) the role of the family in its use of services. In his classic review of the family as an important unit, Litman (1974) pointed out the important role that the family (as a primary unit of health care) plays in health and illness and emphasized that the rela- tionship between health, health behavior, and family “is a highly dynamic one in which each may have a dramatic effect on the other” (p. 495). At about this same time, Mauksch (1974) pro- posed the idea of distinguishing between family health and individual health. Pratt’s (1976) examination of the role of the family in health and illness included the role of family health in the promotion of healthy or unhealthy behavior. Pratt pro- posed and described the energized family as being an ideal family type that was most effective in meeting health needs. The energized family is characterized as promoting freedom and change, active contact with a variety of other groups and orga- nizations, flexible role relationships, equal power structure, and a high degree of autonomy in family members. Doherty and McCubbin (1985) proposed a family health and illness cycle consisting of six phases, beginning with family health promo- tion and risk reduction and continuing through the family’s vulnerability to illness, their illness response, their interaction with the health care system, and finally their ways of adapting to illness.
Health of the Nation In recent years, increased attention has been given to improv- ing the health of everyone in the United States. As a result of major public health and scientific advances, the leading causes of morbidity and mortality have shifted from infec- tious diseases to chronic diseases, accidents, and violence, all of which have strong lifestyle and environmental components. A classic population-focused study in Alameda County, Cali- fornia (Belloc and Breslow, 1972) demonstrated the relation- ships between seven lifestyle habits and decreased morbidity and mortality. These habits were (1) sleeping 7 to 8 hours daily, (2) eating breakfast almost every day, (3) never or rarely eating between meals, (4) being at or near recommended height- adjusted weight, (5) never smoking cigarettes, (6) moderate or no use of alcohol, and (7) regular physical activity. These same lifestyle health habits are still important for improved health in the twenty-first century.
The Alameda study has been supported by Dan Buettner’s (2009) work with The National Geographic Society and their examination of communities around the world who have not only longevity, but quality of life. Public health nurses will want
626 PART 5 Health Promotion with Target Populations Across the Life Span
the Neuman Systems Model proposes that families have a flex- ible external line of defense, a normal line of defense, and an internal line of resistance. When a life event is big enough to contract the flexible line of defense (a protective mechanism) and breaks through the normal line of defense, the family feels stress. The degree of wellness is determined by the amount of energy it takes for the system to become and remain stable. When more energy is available than is being used, the system remains stable.
Examples of energy-building characteristics in this system are social support, resources, and prevention (or avoidance) of stressors. Nurses can use preventive health care both to reduce the possibility that a family encounters a stressor and to help strengthen the family’s flexible line of defense. The following clinical example applies the Neuman Systems Model to one family’s situation:
The Harris family consists of Ms. Harris (Gloria), 12-year- old Kevin, 8-year-old Leisha, and Ms. Harris’s mother, 75-year-old Betty. Kevin was recently diagnosed with insulin-dependent diabetes mellitus, and the family was referred by the endocrinology clinic to the nursing service at the local health department to work with the family in adjusting to the diagnosis.
The focus of the Neuman Systems Model would be to assess the family’s ability to adapt to this stressful change and then focus on their strengths in the stabilizing process. The five inter- acting variables would compose an important component of the assessment: • Physiological: Is the Harris family physically able to deal with
Kevin’s illness? Is everyone else in the family currently healthy? Are there current health stressors?
• Psychological: How well will the family be able to deal with the illness psychologically? Are their relationships stable and healthy? Are there any memories of other family members with diabetes?
• Sociocultural: How will the sociocultural variable come into play in Kevin’s illness? Does the family have social support? Are the treatment and diagnosis culturally sensitive? Can family members support each other?
• Developmental: How will Kevin’s development as a preado- lescent be affected by diabetes? How will the family’s devel- opment change? How will Kevin’s diagnosis affect Leisha?
• Spiritual: How will the family’s spiritual beliefs be affected by the diagnosis? What effect will they have on his treatment and willingness to adhere to therapy?
Health Risk Several factors contribute to the development of healthy or unhealthy outcomes. Clearly, not everyone exposed to the same event will have the same outcome. The factors that determine or influence whether disease or other unhealthy results occur are called health risks. Control of health risks is done through disease prevention and health promotion efforts. Health risks can be classified into three general categories: (1) inherited biological risks (including age-related risks), (2) environmental risks (comprised of both social, such as economic, and physical
that is done with families. This health promotion model states there are two factors that motivate individuals to participate in positive health behaviors. One is a desire to promote one’s own health, using behaviors that have been determined to increase the individual, family, community, and society’s well-being, and in the process, actually moving toward not only individual self- actualization, but a society actualization as well. The second factor is a desire to protect health, using those same behaviors in an effort to decrease the probability of ill health and provide active protection against illness and dysfunction in families (Pender, 2010). Understanding family health risk requires an examination of several related concepts: family health, family health risk, risk appraisal, risk reduction, life events, lifestyle, and family crisis. These concepts will be defined and discussed here. It is important to remember that health can be defined in a number of ways, and it is defined by individuals and families within their own culture and value system.
Family Health Family theorists refer to healthy families but generally do not define family health (White and Klein, 2009). Based on the variety of perspectives on family (see Chapters 9, 17, and 27), definitions of healthy families can be derived within the guide- lines of the framework associated with that perspective. For example, within the perspective of the developmental frame- work, family health can be defined as possessing the abilities and resources to accomplish family developmental tasks. Thus, the accomplishment of stage-specific tasks is one indicator of family health.
Because the family unit is a part of many societal systems, the systems perspective will be discussed in more detail. Using the Neuman Systems Model (Nursing Theory Network, 2005; Neumann University, 2010), family health is defined in terms of system stability as characterized by five interacting sets of factors: physiological, psychological, sociocultural, develop- mental, and spiritual. The client family is seen as a whole system with the five interacting factors. The Neuman Systems Model is a wellness-oriented model in which the nurse uses the strengths and resources of the family to keep the system stable while adjusting to stress reactions that lead to health change and well- ness. In other words, this model focuses on family wellness in the face of change. Because change is inevitable in every family,
From U.S. Department of Health and Human Services: Healthy People 2020, Washington, DC, 2010, U.S. Government Printing Office.
HEALTHY PEOPLE 2020
• EH-18: Decrease the number of U.S. homes that are found to have lead- based paint or related hazards.
• MICH-11: Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women.
• NWS-12: Eliminate very low food security among children in U.S. households.
• TU-14: Increase the proportion of smoke-free homes.
Objectives Related to Family and Home Health
627CHAPTER 28 Family Health Risks
of it. Pender (2010) provides examples of different kinds of risks: • Voluntarily assumed risks are better tolerated than those
imposed by others. • Risks over which scientists debate and as a result have some
level of uncertainty as to their magnitude are more feared than risks on which scientists agree.
• Risks of natural origin are often considered less threatening than those created by humans.
• Thus, risk reduction is a complex process that requires knowledge of the specific risk and the family’s perceptions of the nature of the risk.
Family Crisis A family crisis occurs when the family is not able to cope with an event or multiple events and becomes disorganized or dys- functional. When the demands of the situation exceed the resources of the family, a family crisis exists. When families experience a crisis or a crisis-producing event, they attempt to gather their resources to deal with the demands created by the situation. Price, Price, and McKenry (2010) differentiate between family resources and family coping strategies. The former are the resources, such as money and extended family, that a family has available to them. The latter are the family’s efforts to manage, adapt, or deal with the stressful event in order to achieve balance in the family system (Price, Price, and McKenry, 2010). Thus, if a family were to experience an unex- pected illness of the primary wage earner, family resources might include financial assistance from relatives or emotional support. Family coping strategies, in contrast, would include whether the family was able to ask a relative to loan them emer- gency funds or was able to talk with relatives about the worries they were experiencing. On the basis of the existing literature, Friedman et al (2003) developed a system of coping strategies (Table 28-1).
It is important to note that the amount of support available to families in times of crisis from government and nongovern- ment agencies varies in different regions, states, and locales. In addition, the rules and conditions of support often differ and may inhibit families from seeking support, particularly if the conditions are demeaning. Nurses must be aware and sensitive to these differences in assessing the accessibility of support resources to families.
MAJOR FAMILY HEALTH RISKS AND NURSING INTERVENTIONS As mentioned earlier, risks to a family’s health arise in three major areas: biological, environmental, and behavioral. In most instances, a risk in one of these areas may not be enough to threaten family health, but a combination of risks from two or more categories could threaten health. For example, a family history of cardiovascular disease by itself may not indicate an increased risk, but the health risk is often increased by an unhealthy lifestyle. An understanding of each of these categories provides the basis for a comprehensive perspective on family health risk assessment and intervention.
aspects), and (3) behavioral risks (USDHHS, 2000). These three categories of risk are discussed later in terms of family health risk, under Major Family Health Risks and Nursing Interven- tions (USDHHS, 2010).
Although single risk factors can influence outcomes, the combined effect of accumulated risks is often greater than the sum of the individual effects. For example, a family history of cardiovascular disease is a single biological risk factor that is exacerbated by smoking (a behavioral risk that is more likely to occur if other family members also smoke). This risk factor can also be affected either positively or negatively by diet and exer- cise. Diet and exercise are influenced both by family and soci- ety’s norms. Although the demographics may be changing, residents of the Northwest and West have historically been more likely to eat heart-healthy diets and to exercise compared with people who live in the Midwest and South; thus, communities in the Northwest and West are often more supportive of exercise programs, bicycle paths, and diets lower in fat than communi- ties in other parts of the United States. This illustrative example of how the combined effect of a family history, family behav- ioral risks, and society’s influences is more than just the sum of the three individual behavioral risk factors (smoking, diet, and exercise) and demonstrates how a nurse working with popula- tions of families and intervening within a community is more likely to reduce the effects of the health risks overall and produce a healthier community as well as a healthier family unit.
Health Risk Appraisal Health risk appraisal refers to the process of assessing for the presence of specific factors in each of the categories that have been identified as being associated with an increased likelihood of an illness, such as cancer, or an unhealthy event, such as an automobile accident. Several techniques have been developed to accomplish health risk appraisal, including computer soft- ware programs and paper-and-pencil instruments. One tech- nique is the Youth Behavioral Health Risk Appraisal instrument of the Centers for Disease Control and Prevention (CDC, 2014). The general approach is to determine whether and to what degree a risk factor is present. On the basis of scientific evi- dence, each factor is weighted, and a total score is derived. This appraisal method provides an individual score that can be examined as a whole within the family being assessed, thus appraising the health risks that are likely to be experienced by other members of the family. Additional research is needed to determine if the individual appraisals can be used to determine family risk.
Health Risk Reduction Health risk reduction is based on the assumption that decreas- ing the number of risks or the magnitude of risk will result in a lower probability of an undesired event occurring. For example, to decrease the likelihood of adolescent substance abuse, family behaviors such as parents not drinking, alcohol not available in the home, and family contracts related to alcohol and drug use may be useful. Health risks can be reduced through a variety of approaches, such as those just described. It is important to note the specific risk and the family’s tolerance
628 PART 5 Health Promotion with Target Populations Across the Life Span
environmental risk, and behavioral risk. Box 28-1 provides some definitions related to family health.
Biological and Age-Related Risk The family plays an important role in both the development and the management of a disease or condition. Several illnesses have a family component that can be accounted for by either genetics or lifestyle patterns. These factors contribute to the biological risk for certain conditions. Patterns of cardiovascular disease, for example, can often be traced through several generations of a family. Such families are said to be at risk for cardiovascular disease. How or whether cardiovascular disease is found in a family is often influenced by the lifestyle of the family. Research evidence consistently supports the positive effects of diet, exer- cise, and stress management on preventing or delaying cardio- vascular disease. The development of hypertension can be managed by following a low-sodium diet, maintaining a normal weight, exercising regularly, and using effective stress manage- ment techniques, such as meditation (Brill, 2011). Diabetes mel- litus is another disease with a strong genetic pattern, and the family plays a major role in the management of the condition. Family patterns of obesity increase the risk in individuals for a number of conditions, including heart disease, hypertension, dia- betes, some types of cancer, and gallbladder disease (USDHHS, 2010). The role of genetics is becoming increasingly important in health care and is discussed in Chapter 11. It is often difficult to separate biological risks from individual lifestyle factors.
Transitions (movement from one stage or condition to another) are times of potential risk for families. Age-related or life-event risks often occur during transitions from one devel- opmental stage to another. Transitions present new situations and demands for families. These experiences often require that families change behaviors, schedules, and patterns of commu- nication; make new decisions; reallocate family roles; learn new skills; and identify and learn to use new resources. The demands that transitions place on families have implications for the health of the family unit and individual family members and can be considered as life-event risks. How well prepared families are to deal with a transition depends on the nature of the event. If the event is normative, or anticipated, then it is possible for families to identify needed resources, make plans, learn new skills, or otherwise prepare for the event and its consequences. This kind of anticipatory preparation can increase the family’s coping ability and lessen stress and negative outcomes. If, on the other hand, the event is non-normative, or unexpected,
Healthy People 2020 targets areas in health promotion, health protection, preventive services, and surveillance and data systems to describe age-related objectives (USDHHS, 2010). Included in the area of health promotion are physical activity and fitness, nutrition, tobacco use, use of alcohol and other drugs, family planning, mental health and mental disorders, and violent and abusive behavior. Health protection activities include issues related to unintentional injuries, occupational safety and health, environmental health, food and drug safety, and oral health. Preventive services, designed to reduce risks of illness, include maternal and infant health, heart disease and stroke, cancer, diabetes and other chronic disabling conditions, human immunodeficiency virus (HIV) infection, sexually transmitted diseases, immunization for infectious diseases, and clinical preventive services. The interrelationships among the various groups of risk are clear when the objectives for the nation are considered. Most of the national health objectives are based on risk factors of groups or populations in a variety of categories like age, gender, and health problems. However, it is important to recognize that some of these factors also relate to and have potential effects on the individuals’ families, work, school, and communities.
Family Health Risk Appraisal Assessment of family health risk requires many approaches. As in any assessment, the first and most important task is to get to know the family, their strengths, and their needs (see Chapter 27). This section focuses on appraisal of family health risks in the areas of biological and age-related risk, social and physical
From Friedman M, Bowden V, Jones E: Family nursing: research, theory & practice, ed 5, Upper Saddle River, NJ, 2003, Prentice Hall.
Internal Strategies (From Within Family) Processes for Coping
1. Cognitive 1. Be accepting of the situation and others.
2. Gain useful knowledge. Use of Internet helpful.
3. Collaborate in problem solving (reframe the situation).
2. Relationships 4. Increase cohesion (togetherness). 5. Increase flexibility. 6. Share feelings and thoughts. 7. Increase family structure.
3. Communication 8. Be open and honest. 9. Listen to one another.
10. Be sensitive to nonverbal communication.
11. Use humor when appropriate.
External Strategies Processes for Coping
4. Community links 12. Maintain links in organizations. 5. Spiritual 13. Be more involved in religious activities.
14. Increase faith or seek help from God. 6. Social support 15. Seek help and support from others.
TABLE 28-1 Framework of Coping Strategies
Determinants of health: An individual’s biological makeup influences health through interaction with social and physical environments as well as behavior.
Behaviors: These may be learned from other family members. Social environment: This includes the family, and it is where culture, language,
and personal and spiritual beliefs are learned. Physical environment: Hazards in the home may affect health negatively, and
a clean and safe home has a positive influence on health.
BOX 28-1 Definitions Related to Family Health
629CHAPTER 28 Family Health Risks
Both normative and non-normative life events pose poten- tial risks to the health of families. Even events that are generally viewed as being positive require changes and can place stress on a family. The normative event of the birth of a child, for example, requires considerable changes in family structures and roles. Furthermore, family functions are expanded from previous levels, requiring families to add new skills and establish addi- tional resources. These changes can in turn result in strain and, if adequate resources are not available, stress. Therefore, to adequately assess life risks, both normative and non-normative events occurring in the family need to be considered. Regardless of whether a life event is normative or non-normative, it is often a source of stress for families. Several theoretical frameworks have been developed to examine the processes of family stress and coping. Perhaps the most widely used is the ABC-X model. The model was originally developed by Hill (1949) and was based on work with families separated by war. In the model, crisis (X) was proposed to be a product of the nature of the event (A), the family’s definition of the event (B), and the resources available to the family (C). Doherty and McCubbin (1985) extended the model to the Double ABC-X model to encompass the period after the initial crisis and introduced the idea of a pile-up of stressors. Adaptation or maladaptation by the family is proposed to be determined by the pile-up of stress- ors (Aa), the family’s perception of the crisis (Bb), and new resources and coping strategies (Cc).
families have little or no time to prepare and the outcome can be increased stress, crisis, or even dysfunction. Table 28-2 lists family stages and the developmental tasks associated with each stage (Friedman et al, 2003).
Several normative events have been identified for families. The developmental model organizes these events into stages and identifies important transition points. It provides a useful framework for identifying normative events and preparing families to cope successfully with related demands. The devel- opmental tasks associated with each stage identify the types of skills families need. The kinds of normative events families experience are usually related to the addition or loss of a family member, such as the birth or adoption of a child, the death of a grandparent, a child moving out of the home to go to school or take a job, or the marriage of a child. There are health-related responsibilities associated with each of these tasks. For example, the birth or adoption of a child requires that families learn about human growth and development, parenting, immuniza- tions, management of childhood illnesses, normal childhood nutrition, and safety issues.
Non-normative events present different kinds of issues for families. Unexpected events can be either positive or negative. Getting a job promotion or inheriting a substantial sum of money may be unexpected but are usually positive events. More often, non-normative events are unpleasant, such as a major illness, divorce, death of a child, or loss of the main family income.
From: DeFrain J: Getting Connected, Staying Connected: Loving One Another, Day by Day, (June 20, 2012), iUniverse, Board of Regents of the University of Nebraska. (Table 2-1)
Stages of the Family Life Cycle Positions in the Family Family Developmental Tasks
Stage 1. The married couple Wife/Husband Establishing a mutually satisfying marriage. Adjusting to pregnancy Fitting into the kin network
Stage 2. Childbearing Wife/mother Husband/father Infant(s)
Having and adjusting to an infant Establishing a satisfying home for patents
Stage 3. Preschool-aged children Wife/mother Husband/father Daughter/sister Son/brother
Adapting to the needs of preschool children Coping with energy depletion and lack of privacy as parents
Stage 4. School-aged children Wife/mother Husband/father Daughter/sister Son/brother
Fitting into the community Encouraging children’s educational achievements
Stage 5. Teenage children Wife/mother Husband/father Daughter/sister Son/brother
Balancing freedom with responsibility Establishing post-parental interests
Stage 6. Launching the children Wife/mother/ grandmother Husband/father/grandfather
Launching youth into adulthood Maintaining a supportive home base
Stage 7. Middle-aged parents Wife/mother/ grandmother Husband/father/grandfather
Refocusing on the marriage relationship Maintaining kin ties with older and younger generations
Stage 8. Aging family members Widow/widower Wife/mother/ grandmother Husband/father/grandfather
Coping with death and living alone Selling the family home Adjusting to retirement
TABLE 28-2 Eight Major Stages and Eight Family Development Tasks in the Family Life Cycle
630 PART 5 Health Promotion with Target Populations Across the Life Span
his colleagues is extensive and continues to be used in research and practice (The Family Transitions Project, 2012).
Biological Health Risk Assessment One of the most effective techniques for assessing the patterns of health and illness in families is the genogram (see Chapter 27 for further discussion and an example). Briefly, a genogram is a drawing that shows the family unit of immediate interest and includes several generations using a series of circles, squares, and connecting lines. Basic information about the family, rela- tionships in the family, and patterns of health and illness can be obtained by completing the genogram with the family. Dates of birth, marriage, death, and other important events can be indicated where appropriate. Major illness or conditions can be listed for each family member. Patterns can be quickly assessed and provide a guide for the health interviewer about health areas that need further exploring.
A more intensive and quantitative assessment of a family’s biological risk can be achieved through the use of a standard family risk assessment. Because such assessments involve other areas in addition to biological risk, one will be described later, after the description of assessment of other types of risk.
Community-level support groups (e.g., Families Anony- mous, Bereaved Parents, Parents and Friends of Lesbian and Gay Persons, Single Parents) have been successful in assisting
Lorenz, Wickrama, and Conger (2004) challenged this step- by-step view of families and stress and coping. They advocated a more systems-oriented concept of family stress. They pointed out that families develop a series of processes to manage or transform inputs to the system (e.g., energy, time) to outputs (e.g., cohesion, growth, love) known as rules of transformation. Over time, families develop these patterns in enough quantity and variety to handle most changes and challenges; this is referred to as requisite variety of rules of transformation. However, when families do not have an adequate variety of rules to allow them to respond to an event, the event becomes stressful. Rather than being able to deal with the situation, they fall into a pattern of trying to figure out what it is they need to do, and the usual tasks of the family are not adequately addressed. Rules that were implicit in the family are now reconsidered and redefined.
Furthermore, the family stress theory of Lorenz et al (2004) proposed three levels of stress: level I is change “in the fairly specific patterns of behavior and transforming processes” (e.g., change in who does which household chores); level II is change “in processes that are at a higher level of abstraction” (e.g., change in what are defined as family chores); and level III is change in highly abstract processes (e.g., family values) (Lorenz et al, 2004). Coping strategies can be identified to address each level of stress that families go through in sequence, if necessary (see the Evidence-Based Practice box). The work of Lorenz and
Building the evidence-based case for the effectiveness of a nursing intervention program is not a goal that can be accomplished quickly. Rather, such a case requires many years of testing and refining interventions, as well as the ongoing and arduous task of obtaining funding from federal and state entities. It is also dependent on the intense advocacy involved in influencing legislators to achieve health and social policy reform necessary to enable lasting change. The Nurse Family Partnership (NFP) is one such program that was begun in the late 1970s by a social and behavioral sciences major who focused on psychology, specifi- cally with early infant attachment (Goodman, 2006). Dr. David Olds would later complete his doctoral studies under the mentoring of Dr. Urie Bronfenbrenner, a professor at Cornell University, and continued his research with the goal of improving the lives of children. Using nurses only for the intervention study, Olds set out to study the impact that home visitation to new mothers by nurses would have on social and health outcomes of both mother and baby. The home visita- tion began during pregnancy. Olds conducted randomized control studies in diverse locations and diverse populations. He also completed a study that com- pared the use of nurses with the use of paraprofessionals and determined that the use of nurses had more positive outcomes than did the use of paraprofessionals.
Outcomes of these studies have demonstrated that new mothers receiving nurse home visits, beginning during pregnancy and continuing for 2 years, exhibit improvements to maternal health, decrease in childhood injuries, lower rates of child abuse, and greater spacing of subsequent pregnancies when compared with new mothers not receiving nurse home visits. The results have also shown that these mothers are more likely to enter the workforce, and longitudinal data have demonstrated that the nurse-visited families are more economically self- sufficient and that criminal behavior has been less in both mothers and children. The Olds model in 2004 became the Nurse Family Partnership (NFP), a nonprofit organization, in an effort to make it more accessible as well as to ensure quality control, educate nurses, and monitor existing programs. NFP is currently operat- ing in 32 states. Criteria have been established to keep the program true to Olds’
fundamental principles outlined here to ensure consistent quality and positive outcomes.
Of his model, Olds says, “It reduces injuries to children. It helps families plan future pregnancies and create better spacing between the birth of the first and second children. It helps women find employment. It helps improve prenatal health. It improves children’s school readiness.”
Nurse Use The NFP developed by Dr. Olds and his team provides the ultimate example of the effects of nursing on the individual, family, and community. From care of the pregnant woman, to the care of her newborn and family, to the policy implica- tions that provide for healthier families and healthier communities, the NFP makes a difference in outcomes. The NFP is nursing at its very best—it provides evidence-based early nursing interventions that result in the positive outcomes listed above rather than the poor societal outcomes often described with teen pregnancies and single parenting. The evidence-based NFP model should con- tinue to be tested in other populations and environments, such as in foster and adoptive homes early in the foster or adoption process, thus allowing the ben- efits of the program to have an even broader reach.
References Eckenrode J, Campa M, Luckey DW, et al: Long-term effects of prenatal and infancy nurse
home visitation on the life course of youths: 19-year follow-up of a randomized trial. Archiv Pediatr Adolesc Med 164(1):9–15, 2010.
Goodman A: The Story of David Olds and the Nurse Home Visiting Program. Princeton, NJ, 2006, Robert Wood Johnson Foundation.
Olds DL, Henderson CR, Tatelbaum R, et al: Improving the delivery of prenatal care and outcomes of pregnancy: a randomized trial of nursing home visitation. Pediatrics 77:16– 28, 1986.
Olds DL, Robinson J, Pettitt LM, et al: Effects of home visits by paraprofessionals and by nurses: age four follow-up results of a randomized trial. Pediatrics 114(6):1560–1568, 2004.
EVIDENCE-BASED PRACTICE
631CHAPTER 28 Family Health Risks
both preventive and curative care more often than children not participating in WIC (Devaney, 2007). WIC continues to be touted as one of the most effective federally funded nutrition programs in the United States (USDA, 2013).
Environmental Risk Assessment Assessment of environmental health risk is less well-defined and developed. While the genogram portrays the family relation- ships, details on the relationships that the family has with others (e.g., relatives and neighbors), their connections with other social units (e.g., church, school, work, clubs, and organiza- tions), and the flow of energy (positive or negative) can be assessed through the use of an ecomap (Holtslander, Solar, and Smith, 2014). An ecomap represents the family’s interactions with other groups and organizations, accomplished using a series of circles and lines. The family of interest (the Graham family in Figure 28-1) is represented by a circle in the middle of the page; other groups and organizations are then indicated by other circles. Lines, representing the flow of energy, are drawn between the family circle and the circles representing other groups and organizations. An arrowhead at the end of each line indicates the direction of the flow of energy (into or out of the family), and the darkness of the line indicates the intensity of the energy. The Graham family ecomap indicates that much of the family energy goes into work (also a source of stress for the parents). Major sources of energy for the Grahams are their immediate and extended families and friends. (See Chapter 27 for additional discussion of the ecomap.)
In addition to the support network shown by the ecomap, other aspects of social risk include characteristics of the neigh- borhood and community where the family lives. A nurse who has worked in the general geographic area may already have performed a community assessment (see Chapter 18) and have a working knowledge of the neighborhood and community. It is important, however, for the nurse to obtain information from the family to understand their perceptions of the community.
Information about the origins of the family is useful to understand other social resources and stressors. Information about how long the family has lived in their current location and the immigration patterns of the family and their ancestors provides insight into the pressures they experience.
Economic risk is one of the foremost predictors of health. Families often consider financial information private, and both the nurse and the family may be uncomfortable when discuss- ing finances. It is not necessary to know actual family income except in certain instances when it is necessary to determine whether families are eligible for programs or benefits. It is useful to know whether the family’s resources are adequate to meet their needs, and it is important to understand that the family may be quite comfortable with their finances and standard of living, which may be different from those of the health care provider. The provider should not try to push financial values onto the family. In terms of health risk, it is important to under- stand the resources that families have to obtain health/illness care; adequate shelter, clothing, and food; and access to recre- ation. Families with limited resources may qualify for programs such as Medicaid, WIC, or Maternal Support Systems/Infant
families in dealing with a variety of stressful situations and crises that arise from both life events and age-related events. Nurses have been instrumental in developing and moderating such groups. These are examples of intervening with families as a specific population.
Environmental Risk The importance of social risks to family health is gaining increased recognition (see Chapters 7 and 18). Living in high- crime neighborhoods, in communities without adequate recre- ation or health resources, in communities that have major noise pollution or chemical pollution, or in other high-stress environ- ments increases a family’s health risk. One social stress is dis- crimination, whether racial, cultural, or other. The psychological burden resulting from discrimination is itself a stressor, and it adds to the effects of other stressors. The implication of these examples of risky social situations is that they contribute to the stressors experienced by the families. If adequate resources and coping processes are not available, breakdowns in health can occur.
The poor are at greater risk for health problems (see Chapter 33). Economic risk, which is related to social risk, is determined by the relationship between family financial resources and the demands on those resources. Having adequate financial resources means that a family is able to purchase the necessary commodities related to health. These include adequate housing, clothing, food, education, and health or illness care. The amount of money that a family has available is relative to situational, cultural, and social factors. A family may have an income well above the poverty level, but because of a devastating illness in a family member, they may not be able to meet financial demands. Likewise, families from ethnic populations or families with same-sex parents frequently experience discrimination in finding housing. Even if they find housing, they may not be welcome and may be harassed, resulting in increased stress.
Unfortunately, not all families have access to health care insurance. For families at the poverty level, programs such as Medicaid are available to pay for health and illness care. Fami- lies in the upper-income brackets usually have health insurance through an employer, or they can afford to either purchase health insurance or pay for health care out of pocket. An increasing number of middle-income families have major wage earners in jobs that do not have health benefits. These people often do not have enough income to purchase health care but earn too much money to qualify for public assistance programs. Consequently, many families have financial resources that allow them to maintain a subsistence level but that limit the quality of their purchasing power. Illness care may be available, but preventive care may not; food high in fat and calories may be affordable, whereas fresh fruit and vegetables are not. Nutritious diets are important in preventing illness and promoting health. Devaney (2007) presents an analysis of the first 35 years of the Women, Infants, and Children (WIC) program and the rela- tionship of participation in WIC to Medicaid costs and use of health care services and found that children who participated in WIC were more linked to the health care system than chil- dren who were not. Children in WIC were more likely to receive
632 PART 5 Health Promotion with Target Populations Across the Life Span
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633CHAPTER 28 Family Health Risks
morbidity and mortality. When caring for families with a smoking member, nurses can consider not only smoking cessa- tion, but also education regarding second-hand smoke. Passive smoking has been associated with several types of cancer, heart disease, chronic obstructive pulmonary disease, low birth weight, premature births, and sudden infant death syndrome (USDHHS, 2010).
Although violence and abusive behavior are well known health risks for individuals, the extent of their prevalence within families is not well understood. The amount of intrafamilial violence is thought to be underestimated. It is difficult to collect data and obtain accurate statistics on family violence because the issue is so sensitive for families. There is evidence, however, to support the intergenerational nature of violence and abuse— that is, abusers were often abused as children (USDHHS, 2013).
Behavioral (Lifestyle) Health Risk Assessment Families are the major source of factors that can promote or inhibit positive lifestyles. They regulate time and energy and the boundaries of the system. A number of tools exist for assessing individuals’ lifestyle risks, but few are available for assessing family lifestyle patterns. Although assessment of individual life- style contributes to determining the lifestyle risk of a family, it is important to look at risks for the family as a unit. One approach is to identify family patterns for each of the lifestyle components included in Healthy People 2020. In the areas of health promotion, health protection, and preventive services, lifestyle can be assessed in several dimensions. From the litera- ture on health behavior research (Healthy People 2020, 2010), the critical dimensions include the following: value placed on the behavior; knowledge of the behavior and its consequences; effect of the behavior on the family; effect of the behavior on the individual; barriers to performing the behavior; and bene- fits of the behavior.
It is important to assess the frequency, intensity, and regular- ity of specific behaviors. It also is important to evaluate the resources available to the family for implementing the behav- iors. Thus, items for assessment of physical activity include the value that a family places on physical activity, the hours that a family spends in exercise, the kinds of exercise in which the family participates, and resources available for exercise.
NURSING APPROACHES TO FAMILY HEALTH RISK REDUCTION Home Visits Home visits have been effective and have been used since the early days of nursing. Most notable are the Visiting Nurse Ser- vices of New York (VNSNY, 2014), founded by Lillian Wald in the late 1800s and the Frontier Nursing Service (FNS, 2014) of Kentucky, founded by Mary Breckinridge in 1925. Both visiting nurse services were developed to work with extremely vulner- able populations, particularly pregnant women and young chil- dren. Today’s home visitation programs often build on the values of the VNSNY and the FNS, working with young families to help the families learn principles of parenting as well as develop life skills, including resources for employment,
Support Systems. Families with wage earners with medical ben- efits and those with enough income are usually able to afford adequate health care. Unfortunately, in a growing number of families, the main wage earner is employed but receives no medical benefits and the salary is not sufficient for health pro- motion or illness care. This is a policy issue for which nurses are very capable of drafting legislation and providing testimony related to the stories of families in their caseloads. (See Chapter 8 for a discussion of policy involvement by nurses.)
Behavioral (Lifestyle) Risk Personal health habits continue to contribute to the major causes of morbidity and mortality in the United States (see Chapter 17). The pattern of personal health habits and behav- ioral risk defines individual and family lifestyle risk. The family is the basic unit within which health behavior—including health values, health habits, and health risk perceptions—is developed, organized, and performed. Families maintain major responsibility for determining what food is purchased and pre- pared, setting sleep patterns, planning family activities, setting and monitoring norms about health and health risk behaviors, determining when a family member is ill, determining when health care should be obtained, and carrying out treatment regimens. In 2010 more than half of all deaths in the United States were attributed to heart disease or cancer, both of which identify diet as a causative factor (Minino & Murphy, 2012; NCHS, 2010). General guidelines from the U.S. Department of Health and Human Services and the U.S. Department of Agri- culture include eating a variety of foods; maintaining healthy weight; choosing a diet low in fat and cholesterol, including plenty of vegetables, fruits, and grain products; limiting use of sugars, salt, and sodium; and consuming alcohol only in mod- eration (USDA, 2013).
Multiple health benefits of regular physical activity have been identified; regular physical exercise is effective in promot- ing and maintaining health and preventing disease. Physical activity can help to prevent obesity, diabetes, heart disease, cancer, osteoporosis, and depression (Mayo Clinic, 2010).
Among the benefits of regular physical activity are increased muscle strength, endurance, and flexibility; management of weight; prevention of colon cancer, stroke, and back injury; and prevention and management of coronary heart disease, hyper- tension, diabetes, osteoporosis, and depression (USDHHS, 2010). Families can structure time and activities for family members. It is helpful when the community in which they live promotes exercise by having accessible parks and walking or biking paths that help families select activities that provide moderate, regular physical exercise, rather than sedentary activ- ities in the home setting.
Substance use and abuse, such as the use of drugs, alcohol, or tobacco, is a major contributor to morbidity and mortality in the United States. Drug use is a major social and health problem. Drug use is associated with transmission of human immunodeficiency virus (HIV), fetal alcohol syndrome, liver disease, unwanted pregnancy, delinquency, school failure, vio- lence, and crime (NIDA, 2014). Drunk driving is also a public health hazard. It is well known that tobacco use increases
634 PART 5 Health Promotion with Target Populations Across the Life Span
health outcomes using home visitation rather than visits to the health department or clinic.
Process The components of a home visit are summarized in Table 28-3. The phases include the initiation phase, the pre-visit phase, the in-home phase, the termination phase, and the post-visit phase. Building a trusting relationship with the family client is the cornerstone of successful home visits. Five skills are fundamen- tal to effective home visits: observing, listening, questioning, probing, and prompting. The need for these skills is evident in all phases of the home visit process. Cultural competency cannot be over-stressed when discussing home visits. The PHN is a visitor in the client (or community) setting and every effort should be made to understand our clients’ cultures in order to provide the best and most effective interventions for each one. Fadiman’s (1997) book, The Spirit Catches You and You Fall Down, offers incredible insight into the negative impacts that occur when health care providers and systems do not make the effort to understand a culture other than their own. It is recom- mended (required) that this book be read by all public health and research students to demonstrate the outcomes based on lack of communication and understanding by health care pro- viders, even those with “good intentions.”
Initiation Phase. Usually, a home visit is initiated as the result of a referral from a health or social agency. However, a family may request services, or the nurse may initiate the home visit as a result of case-finding activities. The initiation phase is the first contact between the nurse and the family. It provides the foundation for an effective therapeutic relation- ship. Subsequent home visits should be based on need and
education, and housing. Although nurses work with families in a variety of settings, including clinics, schools, support groups, and offices, the home setting remains an important aspect of the nurse’s role in reducing health risks and promoting the health of populations.
Purpose Home visits, as compared with clinical visits, give a more accu- rate assessment of the family structure, the natural or home environment, and behavior in that environment. Home visits also provide opportunities to identify both barriers and sup- ports for reaching family health promotion goals. The nurse can work with the client directly to adapt interventions to match resources. Visiting the family in their home may also contribute to the family’s sense of control and active participation in meeting their health needs. The majority of historical studies evaluating home visits have focused on the maternal–child population (Fraser et al, 2000; Hammond-Ratzlaff and Fulton, 2001; Wagner et al, 2004). Studies of home visits are often con- ducted for maternal–child health (Nurse Family Partnership, 2010; Olds et al, 2007). The Health Access Nurturing Develop- ment Services (HANDS) program is a voluntary home visita- tion program offered to new parents in the Commonwealth of Kentucky (KCHFS, 2014). The purpose of HANDS is to provide a positive beginning for families, building on the family’s strengths, and improving the well-being of the family.
Home visiting programs have been receiving increased attention and provide a broad range of services to achieve a variety of health-related goals. Long-term effects of home visits are positive and are shown to be cost effective for society. As a result, several states have reinstituted home visits for high-risk families. If the home visit is to be a valuable and effective inter- vention, careful and systematic planning must occur (Pew Center, 2010).
Advantages and Disadvantages The effectiveness of health promotion services in the home has been critically reexamined by agencies such as health depart- ments and visiting nurses associations. Advantages include client convenience, client control of the setting, availability of an option for those clients unwilling or unable to travel, the ability to individualize services, and a natural, relaxed environ- ment for the discussion of concerns and needs. Costs are a major disadvantage; the cost of pre-visit preparation, travel to and from the home, time spent with one client, and post-visit preparation is high. Many agencies have actively explored alter- native modes of providing service to families, particularly group interventions. The important issue is determining which fami- lies would benefit the most and how home visits can most effectively be structured and scheduled. With increasing demands for home health care, the home visit is again becoming a prominent mode for delivery of nursing services. When looking at cost versus effectiveness, it is not always the least costly service that is the most effective (Sewell & Marczak, 2014), rather the social value produced may be more compel- ling. An example is that of home visits. Although more costly in the short term, some services are more effective in family
From Whitley DM, Kelley SJ, Sipe TA: Grandmothers raising grandchildren: are they at increased risk of health problems? Health Soc Work 26:105-114, 2001.
Phase Activity
I. Initiation phase Clarify source of referral for visit. Clarify purpose for home visit. Share information on reason and purpose of
home visit with family. II. Pre-visit phase Initiate contact with family.
Establish shared perceptions of purpose with family.
Determine family’s willingness for home visit. Schedule home visit. Review referral and/or family record.
III. In-home phase Introduce self and professional identity. Interact socially to establish rapport. Establish nurse–client relationship. Implement nursing process.
IV. Termination phase Review visit with family. Plan for future visits.
V. Post-visit phase Record visit. Plan for next visit.
TABLE 28-3 Phases and Activities of a Home Visit
635CHAPTER 28 Family Health Risks
The possibility exists that the family may refuse a home visit. Less-experienced nurses or students may mistakenly interpret this as a personal rejection. Families make decisions about when and which outsiders are allowed entry into their homes. The nurse needs to explore the reasons for the refusal; there may be a misunderstanding about the reason for a visit, or there may be a lack of information about services. The contact may be terminated as requested if the nurse determines either that the situation has been resolved or that services have been obtained from another source, and if the family understands that services are available and how to contact the agency if desired. There are instances when the nurse will be mandated to persist in request- ing a home visit because of legal obligations, such as follow-up of certain communicable diseases. This has become more obvious in this era of increasing contagious and infectious dis- eases in our highly mobile society.
Before visiting a family, the nurse should review the referral or, if this is not the first visit, the family record. If there is a time lapse between the contact and the visit, a brief telephone call to confirm the time often prevents the nurse from finding no one at home.
Personal safety is an issue that may arise either while approaching the family home or when the family has opened the door to the nurse. Nurses need to evaluate personal fears and objective threats to determine if safety is indeed an issue. Certain precautions can be taken in known high-risk situations. Agencies may provide escorts for nurses or have them visit in pairs; readily identifiable uniforms may be required; or a sign- out process indicating timing and location of home visits may be used routinely. Home visits are generally very safe; however, as with all worksites, the possibility of violence exists. Therefore, the nurse needs to use caution. If a reasonable question exists about the safety of making a visit, the visit should not be made. (See Chapter 27 for additional information about personal safety).
The nurse should be aware that families may feel that they are being scrutinized, that they are seen as being inadequate or dysfunctional, or that their privacy is being intruded upon. Nursing services, especially those from health departments, have been perceived by the public as being “public services” for needy families or those with inadequate funds to pay for care. These potential areas of concern underlie the need for sensitiv- ity on the part of the nurse, the need for clarity in information regarding the reason for visits, and the need to establish col- laborative, trusting relationships with the family.
Another factor that may affect the nature of the home visit is whether the visit is viewed as voluntary or required. A volun- tary home visit (visit requested by the client) is characterized by easier entry for the nurse, client-controlled interaction, an informal tone, and mutual discussion of frequency of future visits. An example of a voluntary visit is a new mother who has requested the nurse come to the home and assist her with learn- ing how to care for the infant. In contrast, the client may feel little need for required home visits that often may be legally mandated. In these instances, entry may be difficult for the nurse; the interaction may be nurse controlled; there may be a more formal, investigatory tone to the visit with distorted
mutual agreement between the nurse and the family. Frequently, nurses are not sure of the reason for the visit. This carries with it the potential for the visit to be compromised and to progress aimlessly or abruptly come to a premature halt. Regardless of the reason for making a home visit, it is necessary that the nurse be clear about the purpose for the visit and that this purpose or understanding be shared with the family.
Pre-visit Phase. The pre-visit phase has several compo- nents. For the most part, these are best accomplished in order, as presented in the How To box.
HOW TO Prepare for the Home Visit: Pre-Visit Phase • First, if at all possible, the nurse should contact the family by
telephone before the home visit to introduce self, to identify the reason for the contact, and to schedule the home visit. A first telephone contact should be brief, a maximum of 15 minutes. The nurse should give name and professional identity. For example, the nurse might say, “This is Karen Smith. I’m a com- munity health nurse from the Fayette County Health Depart- ment.” If the client has a first language other than English, it is important to include an interpreter during this first contact, as well as with their continuing care, as this will set the tone for the phone call and the following phases of home visits. The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (The National CLAS Stan- dards) should be used to provide respectful and quality care to clients with limited English proficiency (Office of Minority Health, 2014). The purpose of the CLAS Standards is to improve health care quality and equity in increasingly diverse U.S. neighborhoods.
• The family should be informed of how they came to the attention of the nurse—for example, as the result of a referral, or a contact from observations, or records in the school setting. If a referral has been received, it is important and useful to ascertain whether the family is aware of the referral.
• A brief summary of the nurse’s knowledge about the family’s situation will allow the family to clarify their needs. For example, the nurse might say, “I understand that your baby was dis- charged from the hospital yesterday and that you requested some assistance with learning more about how to care for your baby at home.”
• A visit should be scheduled as soon as possible. Letting the family know agency hours available for visits, the approximate length of the visit, and the purpose of the visit are helpful to the family in determining when to set the visit. Although the length of the visit may vary, depending on circumstances, approxi- mately 30 to 60 minutes is usual.
• If possible, the visit should be arranged when as many family members as possible will be available for the entire visit. It is also important for the nurse to tell the client about any fee for the visit and subsequent visits and possible methods for payment.
• The telephone call can terminate with a review by the nurse of the time, place, and purpose for the visit and a means for the family to contact the nurse in case they need to verify or change the time for the visit or to ask questions. If the family does not have a telephone, another method for setting up the visit can be used. A note can be dropped off at the family home or sent by mail informing the family of when and why the home visit will occur and providing a way for the family to contact the nurse if necessary.
636 PART 5 Health Promotion with Target Populations Across the Life Span
noises and routine activities that they do not recognize them as being potentially disruptive.
It is important that the nurse be realistic about what can be accomplished in a home visit. In some situations, one visit may be all that is possible or appropriate. In this instance, needs and the resources available to meet them are explored with the family, and it is determined whether further services are desired or indicated. If further services are indicated and the nurse’s agency is not appropriate, the nurse can assist the family in identifying other services available in the community and can help in initiating referrals. Although it is not unusual to have only one home visit with a family, multiple visits are often made. The frequency and intensity of home visits vary not only with the needs of the family, but also with the eligibility of the family for services as defined by agency policies and priorities. It is realistic to expect an initial assessment and at least the beginning of building a relationship to occur on a first visit.
Termination Phase. When the purpose of the visit has been accomplished, the nurse reviews with the family what has occurred and what has been accomplished. This is the major focus of the termination phase, and provides a basis for plan- ning further home visits. Ideally, termination of the visit and, ultimately, termination of service begin at the first contact with the establishment of a goal or purpose. If communication has been clear to this point, the family and nurse can now plan for future visits, specifically the next visit. Planning for future visits is part of another issue: setting goals and planning service. Contracting is a constructive approach to working with clients to specify and achieve agreed-on goals and is receiving increas- ing attention by health professionals (Duiveman and Bonner, 2012). The purpose and components of contracting with clients are discussed in more detail later.
nurse–client communication; and there may be no mutual dis- cussion of scheduling or frequency of future visits. Two exam- ples of a required home visit are (1) when a family member has been diagnosed with tuberculosis and the nurse needs to make certain that the client is taking medications regularly, and (2) when there is known child abuse and a new baby has arrived. The nurse may need to visit the home to observe the interaction between the parents and the child.
The changing nature of the American family can make it difficult to schedule visits during what have been traditional agency hours. The number of working single-parent or dual- income, two-parent families is increasing, which means that families have more demands on their time. Even if one parent is at home during the usual workday, the ideal is to work with the entire family unit. This often is not possible because of conflict between agency hours and school or work schedules. It may be possible to schedule a visit at the beginning or end of a day to meet with working or school-age members. In some parts of the country, agencies have reconsidered the traditional hours and Monday through Friday visits and include evening and weekend work hours. These issues are important to assess and address during the pre-visit phase so the nurse and the family will be better prepared for the visit.
Culture influences a person’s interpretation of and response to health care (Shi and Singh, 2015). It is impossible, given the diversity of the United States and the diversity within cultural groups, to cover every group extensively. Instead, practitioners need to take the responsibility to learn about their client’s culture as they prepare for visits with families or communities. Again, refer to the Office of Minority Health’s website for addi- tional information regarding culture and diversity.
In-Home Phase. The actual visit to the home constitutes the in-home phase and affords the nurse the opportunity to assess the family’s neighborhood and community resources, as well as the home and family interactions. The actual home visit includes several components. Once at the family home, the nurse pro- vides personal and professional identification and tells the client the location of the agency. Then, a brief social period allows the client to assess the nurse and establish rapport. The next step is a description by the nurse of his or her role, responsibilities, and limitations. Another important component of the home visit is to determine the client’s expectations.
The major portion of the home visit is concerned with estab- lishing the relationship and implementing the nursing process. Assessment, intervention, and evaluation are ongoing. What then occurs in the home visit is determined by the reason for the visit. Keller et al (2004a,b) recommend using the Interven- tion Wheel to guide nursing practice during home visits. The Intervention Wheel provides appropriate guidelines for the purpose of the home visit. Some reasons for visits are listed in Box 28-2.
A nurse must be flexible and anticipate that families may or may not be able to control interruptions during the visit. Tele- phones ring, pets join in the visit, people come and go, and televisions may be left on. The nurse can ask that televisions be turned off for a limited time or that other disruptive activities be limited. Families may be so accustomed to the background
Keller LO, Strohschein S, Lia-Hoagberg B, et al: Population-based public health interventions: practice-based and evidence-supported, Part I. Public Health Nurs 21:453-468, 2004.
Nursing interventions may include some or all of the 17 resources identified by the Minnesota Department of Health, Section of Public Health Nursing: • Advocacy • Case management • Coalition building • Collaboration • Community organizing • Consultation • Counseling • Delegated medical treatment and observations • Disease and other health investigation • Health teaching • Outreach • Policy development and enforcement • Case finding • Referral and follow-up • Screening • Social marketing • Surveillance
BOX 28-2 Reasons For the Home Visit
637CHAPTER 28 Family Health Risks
both the family members and the health professional. Contract- ing involves making an agreement between two or more parties and seeks to create a shift in responsibility and control toward a shared effort by client and professional as opposed to an effort by the professional alone. This active involvement of the client is reflected in several nursing models, such as that of Orem (1995). The motivational premise of contracting is family control. It is assumed that when the family has legitimate control, their ability to make healthful choices is increased.
Purposes The nursing contract is a working agreement that is continu- ously renegotiable and may or may not be written. It may be either a contingency or a noncontingency contract. A contin- gency contract states a specific reward for the client after comple- tion of the client’s portion of the contract; a noncontingency contract does not specify rewards. The implied rewards are the positive consequences of reaching the goals specified in the contract.
For family health risk reduction, it is essential that the con- tract be made with all responsible and appropriate members of the family. Involving only one individual is not sufficient if the goal is family health risk reduction, which requires a total family system effort and change. Scheduling a visit with all family members present may require extra effort. If meeting with the entire family is not possible, each family member can review a contract, give input, and sign it. This allows active participation by all family members without the necessity of finding a time when everyone involved can be present.
Process of Contracting Contracting is a learned skill on the part of both the nurse and the family (Duiveman and Bonner, 2012). All persons involved need to know the purpose and process of contracting. There are three general phases: beginning, working, and termination. The three phases can be further divided into eight sets of activities, as summarized in Table 28-4.
The first activity is collection and analysis of data and it involves both the family and the nurse. An important aspect of this step is obtaining the family’s view of the situation and its needs and problems. The nurse can present his or her observations, validate them with the family, and obtain the family’s view.
Post-visit Phase. Even after the nurse has concluded the home visit and left the client’s home, responsibility for the visit is not complete until the interaction has been recorded. A major task of the post-visit phase is documenting the visit and ser- vices provided. Agencies may organize their records by families. That is, the basic record may be a “family” folder with all members included. However, this often does not occur, although it is useful for the family history and background. More often, each family member has a separate record, and other family members’ records are cross-referenced. This is because the focus often shifts from the family to the individual. Consequently, nursing diagnoses, goals, and interventions are directed toward individual family members rather than the family unit. This approach has its shortcomings and it is important for the nurse to recognize these. Chapter 41 provides an approach for offer- ing nursing diagnoses, stating goals, and identifying interven- tions for the individual. It is important for the nurse to focus on the continuing assessment of the individual behaviors, responses, or health status and the impact on the family. Inter- ventions at the family level may become necessary, such as educating all family members on hygiene and cleanliness or on the appropriate disposal of supplies of the tuberculosis client in the home.
Record systems and formats vary from agency to agency. The nurse needs to become familiar with the particular system used in the agency. All systems should include a database; a nursing diagnosis and problem list; a plan, including specific goals; actual actions and interventions; and evaluation. These are the basic elements needed for legal and clinical purposes. The format may consist of narratives; flow sheets; problem-oriented medical records (POMRs); subjective, objective, assessment plans (SOAP); or a combination of formats. It is important that recording be current, dated, and signed.
The nurse should be sure to use theoretical frameworks that are appropriate to the family-centered nursing process. For example, a nursing diagnosis of ineffective mothering skill, related to lack of knowledge of normal growth and develop- ment, is an individual-focused nursing diagnosis. The inability for family to accomplish stage-appropriate tasks of providing a safe environment for a preschooler related to lack of knowledge and resources is a family-focused nursing diagnosis based on knowl- edge of the developmental approach to families. At times, it may be necessary to present information for a specific family member. However, the emphasis should be on the individual as a member of, and within the structure of, the family.
Contracting with Families Increasingly, health professionals are looking at working with clients in an interactive, collaborative style. This approach is consistent with a more knowledgeable public and the recent self-care movement in the United States. However, it may not be consistent with other cultures that look to health care pro- viders for more direct guidance; therefore, it is important to determine the family’s value system before assuming that con- tracting will work.
Contracting is a strategy aimed at formally involving the family in the nursing process and jointly defining the roles of
Phase Activity
I. Beginning phase Mutual data collection and exploration of needs and problems Mutual establishment of goals Mutual development of a plan
II. Working phase Mutual division of responsibilities Mutual setting of time limits Mutual implementation of plan Mutual evaluation and renegotiation
III. Termination phase Mutual termination of contract
TABLE 28-4 Phases and Activities in Contracting
638 PART 5 Health Promotion with Target Populations Across the Life Span
always have positive outcomes for clients. If families do not perceive a situation as a problem or need, offers of help may cause resentment. Providing help also may have negative con- sequences if there is not a match between what is expected and what is offered. A nurse’s failure to recognize a family’s compe- tencies and to define an active role for them can lead to the family’s dependency and lack of growth. This can be frustrating for both the nurse and the family. For families to become active participants, they need to feel a sense of personal competence and a desire for and willingness to take action. Definitions of empowerment reflect three characteristics of the empowered family seeking help: access and control over needed resources; decision-making and problem-solving abilities; and, the ability to communicate and to obtain needed resources
The last characteristic refers to the fact that families may need to learn how to identify sources of help, how to contact agencies, how to ask critical questions, and how to negotiate with agencies to meet family needs. These characteristics gener- ally reflect a process by which people (individuals, families, organizations, or communities) take control of their own lives. The outcomes of empowerment are positive self-esteem, the ability to set and reach goals, a sense of control over life and change processes, and a sense of hope for the future (Koelen and Linstrom, 2005). The Levels of Prevention box shows pre- vention strategies applied to families.
It is important that goals be mutually set and be realistic. A pitfall for nurses and clients who are new to contracting is to set overly ambitious goals. The nurse should recognize that there may be discrepancies between their professional priorities and those of the client and determine whether negotiating is required. Because contracting is a process characterized by renegotiation, the goals are not static.
Throughout the process, the nurse and family continually learn and recognize what each can contribute to meeting health needs. The exploring of resources allows both parties to become aware of their own and one another’s strengths and requires a review of the nurse’s skills and knowledge, the family support systems, and community resources.
Developing a plan to meet the goals involves specifying activ- ities, prioritizing goals, and selecting a starting point. Next, the nurse and the family need to decide who will be responsible for which activities. Setting time limits involves determining the frequency of contacts for evaluating progress toward accom- plishing goals and deciding on a deadline for accomplishing the goal. At the agreed-on time or times, the nurse and family together evaluate progress both in terms of process and outcome. The contract can be modified, renegotiated, or terminated on the basis of the evaluation.
Advantages and Disadvantages of Contracting Contracting takes time and effort and may require the family and nurse to reorient their roles (Duiveman and Bonner, 2012). Increased control on the part of the family also means increased responsibility. Some nurses may have difficulty relinquishing the role of the controlling expert professional. Contracts are not always successful, and contracting is neither appropriate nor possible in some cases. Some clients do not want to have this kind of involvement; they prefer to defer to the “authority” of the professional. Included in this group are individuals with minimal cognitive skills, those who are involved in an emer- gency situation, those who are unwilling to be more active in their care, and those who do not see control or authority for health concerns as being within their domain. Some of these clients may learn to contract; others never will.
The nursing process does not necessarily provide an active role for the family as a client; the assumption that a need exists is based on professional judgment only, and it is also assumed that changes can and should be made within the family unit. Contracting is one alternative approach that depends on the value of input from both nurse and family, on the competency of the family, on the family’s ability to be responsible, and on the dynamic nature of the process. This not only allows for but requires continual renegotiating. Although it may not be appro- priate in all situations or with all families, contracting can give direction and structure to health risk reduction and health pro- motion in families.
Empowering Families Approaches for helping individuals and families assume that an active role in promoting their health care should be character- ized by empowerment rather than enabling or providing help (Chinn, 2012). Interventions in which help is given do not
LEVELS OF PREVENTION
Primary Prevention Completing a family genogram and assessing health risks with the family to contract for family health activities to prevent diseases from developing.
Secondary Prevention Using a behavioral health risk survey and identifying the factors leading to obesity in the family.
Tertiary Prevention Developing a contract with the family to change nutritional patterns to reduce further complications from obesity.
Strategies Applied to Families
Empowerment requires a viewpoint that often conflicts with the views of many helping professions, including nursing. Empowerment’s underlying assumption is one of a partnership between the professional and the client as opposed to one in which the professional is dominant. Families are assumed to be either competent or capable of becoming competent. This implies that the professional is not an unchallenged authority who is in control. Empowerment promotes an environment that creates opportunities for competencies to be used. Finally, families need to identify that their actions result in behavior change. A nursing intervention that incorporates the principles of empowerment is directed toward the building of nurse– family partnerships that emphasize health risk reduction and health promotion. The nurse’s approach to the family should be positive and focused on competencies rather than on prob- lems or deficits. The interventions need to be consistent with
639CHAPTER 28 Family Health Risks
information with families, rehearsing with families what ques- tions to ask, preparing required materials, making the initial contact, and arranging transportation. The appropriateness and effectiveness of resources should be evaluated with families afterward. Navigating the maze of resources is often difficult, even for the nurse. It is important to remember that if a family is in crisis or does not have a phone or a home base from which to call or receive return calls, this process is even more difficult, and their sense of helplessness may be increased. Therefore, the nurse’s assistance, while promoting the family’s sense of empow- erment, is both necessary and often complex.
Telehomecare Telehomecare (also referred to as telehealth or telemedicine) is an emerging practice that allows clients to communicate with and transfer health information to providers from home. Researchers have found that telehomecare can improve certain health outcomes, such as reducing the duration of hospitaliza- tion, increasing access to care, improving patient satisfaction, and improving patient education and self-care (Bowles et al, 2011; Shea and Chamoff, 2012). Telehomecare monitoring requires less time per client interaction, so it allows nurses to feasibly care for more clients per day. Nurses may increasingly rely on this technology to assist with home visits to families.
Telehomecare can be a particularly useful option in situations where ongoing and frequent monitoring of a family member’s condition is necessary; however, it should be recognized that it is not a substitute for the in-home trust and relationship build- ing and assessment of both family and community resources that can only be accomplished by an attentive and engaged nurse spending time with the family in their home environment. Tele- homecare is currently used at Maine General Health in Augusta, Maine. It is used to manage chronic conditions such as heart failure, diabetes, and respiratory illnesses, connecting patients to their HomeCare nurse and/or doctor, while allowing the patient to stay at home (Maine General Health, 2013).
Family Policy This chapter ends where it began, with a discussion of the nurse’s role in policy development and implementation. Flor- ence Nightingale, Lillian Wald, and Mary Breckenridge were all strongly committed and involved nurses who advocated for families and influenced policy to improve the health of families and consequently the health of communities. Building on the gains made possible by these influential women is essential. Families are affected by the rules and values of their surround- ing society in general. If families—all families—are valued, the community will be strong and connected. If any family is neglected and not supported, the community will be weak and disconnected.
Family Medical Leave Act One current national policy passed to strengthen and support the family is the Family Medical Leave Act (FMLA). On Febru- ary 5, 1993, President Clinton signed the FMLA (PL 103-3) (Waldfogel 2001). This act allows covered employees to take up to 12 weeks of leave each year for certain family and medical
family cultural norms and the family’s perception of the problem. Rather than making decisions for the family, the nurse supports the family in primary decision making and bolsters their self-esteem by recognizing and using family strengths and support networks. Interventions that promote desired family behaviors increase family competency and decrease the need for outside help, resulting in families viewing themselves as being actively responsible for bringing about desired changes. The goal of an empowering approach is to create a partnership between the nurse and the family characterized by cooperation and shared responsibility.
COMMUNITY RESOURCES Families have varied and complex needs and problems. The nurse is often involved in mobilizing several resources to effectively and appropriately meet family health promotion needs. Although the specific resources vary from community to community, general types can be identified. Government resources such as Medicare, Medicaid, Aid to Families with Dependent Children, Supplemen- tary Security Income, Food Stamps, and WIC are available in most communities. These programs primarily provide support for basic needs (e.g., illness/health care, nutritional needs, funds for housing and clothing), and funds are based on meeting eligi- bility criteria (Families USA 2012 and 2013).
In addition to government agencies providing health-related services to families, most communities have voluntary (non- governmental) programs. Local chapters of such organizations as the American Cancer Society, the American Heart Associa- tion, the American Lung Association, and the Muscular Dystro- phy Association provide education, support services, and some direct services to individuals and families. These agencies provide primary prevention and health promotion services, as well as screening programs and assistance after the disease or condition is diagnosed. Local social service agencies, such as Catholic Social Services, provide direct services such as counsel- ing to families. Other voluntary organizations provide direct service (e.g., shelters for homeless or battered individuals, sub- stance abuse counseling and treatment, Meals on Wheels, trans- portation, clothing, food, furniture).
Health resources in the community may be proprietary, vol- untary, or public. In addition to private health care providers, nurses should be aware of voluntary and public clinics, screen- ing programs, and health promotion programs.
Identifying resources in a community requires time and effort. One valuable source is the telephone book. Often com- munity service organizations, such as the local chamber of com- merce and health department, publish community resource listings. These resources may be listed on the organizations’ websites. Regardless of how the resource is identified, the nurse must be familiar with the types of services offered and any requirements or costs involved. If this information is not avail- able, the nurse can contact the resource.
Locating and using these systems often requires skills and patience that many families lack. Nurses work with families to identify community resources, and as client advocates they help families learn to use resources. This may involve sharing
640 PART 5 Health Promotion with Target Populations Across the Life Span
As noted in the introduction to this chapter, nurses have an ethical obligation to provide culturally competent care to LGBTQ families. To begin, nurses should provide a safe envi- ronment for clients to discuss their sexual orientation. Some nurses may feel a degree of discomfort discussing sexual orien- tation with their clients. However, it is important to overcome this barrier to care for LGBTQ families.
Nurses should assess LGBTQ family dynamics. Just as there is great variation among heterosexual families, all LGBTQ fami- lies are not the same. In addition, same-sex couples have histori- cally had special barriers within the health care system. Some problems may stem from the lack of legal recognition for LGBTQ relationships in most areas of the country. Same-sex marriage laws vary widely from state to state. Certain states (e.g., Massachusetts) have legalized same-sex marriage, whereas others have constitutional amendments defining marriage as a union between one man and one woman. Similarly, there is great variation in LGBTQ adoption rights across the nation.
These legal barriers present challenges for LGBTQ families in the health care system. For example, it may be difficult for
reasons (U.S. DOL, 2012). Under the FMLA, employees may take a leave of absence for many reasons: for their own serious illness; for the illness of their child, parent, or spouse; and for the birth or adoption of a child (PL 103-3). While on leave, employees still receive their medical benefits and are guaranteed that their position or one similar to it will be available to them upon returning to work.
The FMLA was needed to help Americans meet the needs of their families while maintaining employment. Women in par- ticular were experiencing hardship in keeping a job while having a family. The Affordable Care Act and family policies such as the FMLS reflect a growing recognition and valuing of the healthy family unit as a key factor and contributor to the health of not only individuals, but our communities and society at large (USDHHS, n.d.). Nurses are positioned to improve the health of families thus leading to healthier communities, as well as improve the health of communities thus leading to healthier families.
Affordable Care Act Many of the family health risks discussed in this chapter involve how family stressors can negatively affect health outcomes and suggest strategies and interventions to cope with rectifying these issues. Health policy can also be part of a solution to mitigate the financial and emotional effects of family stress by increasing access and affordability of health care. The Patient Protection and Affordable Care Act of 2010 (ACA) helps women, children, and families by increasing access to health care, improving health care quality, lowering health care costs, and instituting new consumer protections (“The Affordable Care Act,” n.d.). Improving access and control over resources such as health care can (as mentioned on page 624) leads to greater empowerment of families. See Chapters 3 and 27 for additional information.
Vulnerable Populations: LGBTQ Families at Risk Lesbian, gay, bisexual, transgendered, and queer/questioning (LGBTQ) families are another vulnerable group (the Q stands for someone questioning their sexual orientation. Q may also refer to “queer” as some LGBTs have reclaimed that term for political reasons) (Stanley, 2014). Over the past decade, there has been an explosion of visibility for this population. Debates and legal battles centering on LGBTQ rights have taken place nationally and in states all across the country. Notable examples include same-sex marriage, adoption, and antidiscrimination laws. As of May 2014, 19 states and the District of Columbia had legalized gay marriage, including California, Connecticut, Delaware, Hawaii, Illinois, Iowa, Maine, Maryland, Massachu- setts, Minnesota, New Hampshire, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Vermont, and Washington. Pennsylvania was the most recent state, as of this writing, to allow gay marriage; the U.S. District Court judge struck down the state’s 1996 law that banned gay marriage, calling it unconstitutional, as have several other judges in other states (Worden & Couloumbis, 2014). And, in October 2014, the Supreme Court of the United States refused to intervene in states’ decisions.
LINKING CONTENT TO PRACTICE
Although endless hours have been spent researching ways to help parents of teenagers, it is also important to remember the teenagers who are parents. This family structure faces multiple health-related and social challenges, the most prominent being affordable and accessible health care. A closely related challenge is the recruitment and development of mentors to help teen parents acquire this health care, as it is uncharted water for nearly all teenagers. The humiliation teens experience when visiting doctors and agencies is a pain analyzed and discussed incessantly, and yet little has been done for the teenage parents.
The most common issue raised by teenage parents is their uncertainty and low self-confidence in handling adult responsibilities other than actual parent- ing. There is a great need for more teenage-instructional literature on family health policy information and health care service accessibility written from the perspective of teenagers. Single teenage parents need to be able to understand welfare and how to apply, as well as how to find support com- munities. Teenage parents who decide not to be involved in a child’s life must be able to understand child support, adoption, and legal visitation and involve- ment issues.
The rising numbers of teenagers giving birth must be met with stronger and more extensive plans for families led by teens. Education, vocational oppor- tunity, and social acceptance are “luxuries” often missed by adolescent parents. While the last of these issues can only be solved by eventual cultural assimilation, schooling and careers should be made possible.
Although it is not advisable to simply hand out opportunities to teenagers with children, it is definitely necessary to offer assistance, not only so that they may have a second chance at a successful life, but for their children as well. It is recognized that the children of teenage parents often make the same mistakes as their parents, due to factors of poor living conditions, low socio- economic status, and a rough childhood. Without adequate family care, there will be no end to the cycle of child parents. Today, many people are advocating for sex education and prevention, but it is also time now for postpregnancy programs, which accept that there is a child born to two teenagers; although they may have made a poor choice, these teenagers now have no choice but to accept parental responsibility and be shown the tools to do so.
Vulnerable Populations: Teenage Parent Families at Risk
641CHAPTER 28 Family Health Risks
In addition to providing support for the family unit as a whole, nurses may also be in a position to assess LGBTQ indi- viduals. As in all family units, the health of individual members of a family affects the entire family unit. Sexual minorities face a higher risk for depression, anxiety, substance abuse, thoughts of suicide, and suicide. Addressing mental health issues in this population may help reduce the mental health disparities the LGBTQ population faces.
LGBTQ couples living in states without same-sex marriage to make medical decisions or visit their partners in the hospital. There are similar barriers for same-sex households with chil- dren. Consider this case example:
Sarah and Maria have been in a long-term relationship for 10 years. Five years ago, the couple decided to have a baby. Sarah is the child’s biological mother, but the couple has raised Mark together since he was born. The couple lives in a state that does not recognize same-sex marriage or adop- tion. One day, Sarah and Mark were in a serious car acci- dent. When Maria arrived at the hospital, she learned she was unable to make decisions or access medical information for her partner and child.
On April 15, 2010, President Obama signed a directive instructing hospitals that accept Medicaid and Medicare to allow adult clients the right to designate specific individuals who can visit them in the hospital or make medical decisions on their behalf. This will help alleviate some issues that LGBTQ partners face when interacting with the health care system. (See http://www.whitehouse.gov/the-press-office/presidential- memorandum-hospital-visitation for more information.)
Nurses are in an optimal position to fulfill a vital role in helping LGBTQ families achieve equitable access to health care. Nurses can assist with assessing the implementation of Presi- dent Obama’s directive. In addition, nurses can help to advocate for more policies designed to reduce barriers within the health care system for LGBTQ families.
Another type of family at risk is the more “traditional” family with a nonheterosexual member. After a family member declares his or her sexual preferences, families may need initial support to process the information. Nurses may be in a position to provide support during this time. Nurses may also refer families to community resources, such as Parents and Friends of Lesbians and Gays (www.pflag.org). Check within your local community for other appropriate resources.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency Evidence-based practice integrates the best current clinical evidence with client and family preferences and values to provide optimal care. • Knowledge: Describe how the strength and relevance of available evi-
dence influences the choice of interventions in providing client-centered care.
• Skill: Question rationale for routine approaches to care that result in less than desired outcomes or adverse events.
• Attitude: Value the need for continuous improvement in clinical practice based on new knowledge.
EBP Question The PHN Quad Council identified the core competency of policy development and program planning, and suggests the beginning PHN will identify policy issues relevant to the health of individuals, families, groups, and within a community.
In this chapter several family policy issues are discussed. Choose one policy that has been passed legislatively to explore. Policy is one level of evidence used in practice. Before a policy becomes law, the strength and relevance of scientific and other data sources are explored to support the argument for developing the policy. Determine what evidence was used to support the policy. How strong and relevant was the evidence? What reasons were given for the policy becoming law or standard practice? Will the policy improve practice? Is it currently being implemented to improve family health care?
P R A C T I C E A P P L I C A T I O N The initial contact between a nursing service and a family pro- vides limited information, and the situation that develops may be much more complex than originally anticipated. The follow- ing example, based on an actual case, illustrates the issues and approaches outlined in this chapter.
The Local County Health Department was notified that Amy C., age 16, had been referred by the school counselor at the local high school for prenatal supervision. Amy was 4 months preg- nant, apparently in good health, and in the tenth grade. She lived at home with her mother, stepfather, and younger sister. The family lived in a rural area outside of a small farming
community. The father of the baby also lived in the community and continued to see Amy on a regular basis. The referral infor- mation provided the nurse with a beginning, but limited, assess- ment of the family situation. A. What would you do first as the nurse assigned to this family? B. How would you help this family empower themselves to take
responsibility for this situation? C. After the initial contact, how would you extend the assess-
ment to the entire family system? D. Would you contract with this family? How? On what terms?
Answers can be found on the Evolve site.
K E Y P O I N T S • The importance of the family as a major client system for
nurses in reducing health risks and promoting the health of individuals and populations is well documented.
• The family system is a basic unit within which health behav- ior, including health values, health habits, and health risk perceptions, is developed, organized, and performed.
642 PART 5 Health Promotion with Target Populations Across the Life Span
K E Y P O I N T S — cont’d • Knowledge of family structure and functioning, family
theory, nursing theory, and models of health behavior is fundamental to implementing the nursing process with fam- ilies in the community.
• Nurses need to go beyond the individual and family, and to understand the complex environment in which the family functions, to be effective in reducing family health risks. Categories of risk factors that are important to family health are biological risk, environmental risk (including economic factors), and behavioral risk.
• Several factors contribute to the experience of healthy/ unhealthy outcomes. Not everyone exposed to the same event will have the same outcome. The factors that influence whether disease or other unhealthy results occur are called health risks. The accumulated risks are synergistic; their combined effect is more than the sum of the individual effects.
• An important aspect of nursing’s role in reducing health risk and promoting the health of populations has been the tradi- tion of providing services to individual families in their homes.
• Home visits afford the opportunity to gain a more accurate assessment of the family structure and behavior in the natural environment. Home visits also provide opportuni- ties to make observations of the home environment and to identify both barriers and supports to reducing health risks and reaching family health goals.
• Health professionals increasingly have come to look toward working with clients in a more interactive, collaborative style.
• Contracting, which is making an agreement between two or more parties, involves a shift in responsibility and control, from the professional alone to a shared effort by client and professional.
• Families have varied and complex needs and problems. The nurse often mobilizes several resources to effectively and appropriately meet family health needs.
• Policy development and implementation is an important skill that the nurse uses to improve the health of families and thus improve the health and livability of communities.
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C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Select one of the Healthy People 2020 objectives and identify
how biological risk (including age-related risk), environ- mental risk (including economic risk), and behavioral risk contribute to family health risks for that objective. Give examples.
2. Select three to four families (hypothetically or from actual situations) that represent different ethnic and socioeco- nomic backgrounds. Complete a family genogram and ecomap for each family, and identify and compare major health risks. Summarize your findings.
3. Select one or more agencies in which nurses work, and examine the agency and nursing philosophies and objectives with emphasis on individual care, family care, illness care,
risk reduction, and health promotion. If you were to accept a position with this agency, what approach to family risk reduction would you be required to use? Is there a better way?
4. Identify three public health problems in your community, and discuss the implications of these problems for the health of families. How did you arrive at your conclusions?
5. Identify three health problems common to families in your community, and discuss the implications of the problems for the health and/or health care resources of the commu- nity. What strategies might you use to address the health problems?
643CHAPTER 28 Family Health Risks
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Child and Adolescent Health
29
Cynthia Rubenstein, PhD, RN, CPNP-PC Cynthia Rubenstein is currently the Associate Dean for the Undergraduate Program and an associate professor in the Georgia Baptist College of Nursing at Mercer University. She has over 20 years of experience in pediatric nursing, from NICU to ED to home health. She has been a practicing pediatric nurse practitioner for 16 years and has collaborated on childhood obesity prevention educational programs for Virginia.
O B J E C T I V E S After reading this chapter, the student should be able to do the following: 1. Describe significant physical and psychosocial
developmental factors characteristic of the child and adolescent population.
2. Examine the role of the nurse and discuss appropriate nursing interventions that promote and maintain the health of children and adolescents as individuals, as members of their family, and as members of the community.
3. Discuss the built environment and how it relates to major health issues of children and adolescents.
4. Explain the current status of children and their physical, emotional, behavioral, and environmental health issues.
5. Differentiate between the models for delivery of health care to the pediatric populations in the community and other settings.
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • Quiz • Case Studies • WebLinks • Glossary • Answers to Practice Application • Resource Tools
• Resource Tool 5.A: Schedule of Clinical Preventive Services
• Resource Tool 29.A: Injury Prevention in Children • Resource Tool 29.B: Common Behaviors of the School
Child and Adolescent • Resource Tool 29.C: Developmental Characteristics:
Summary for Children • Resource Tool 29.D: Feeding and Nutrition Guidelines
for Infants
• Resource Tool 29.E: Immunization Schedule for Children and Adolescents: Range of Ages for Routine Immunizations
• Resource Tool 29.F: Immunization Schedule for Children not Immunized in the First Year of Life
• Resource Tool 29.G: Immunizations: General Recommendations
• Resource Tool 29.H: Summary of Rules for Immunizations
• Appendixes • Appendix D.2: 2013 State and Local Youth Risk
Behavior Survey • Appendix E: Friedman Family Assessment Model (Short
Form) • Appendix F.1: Motivational Interviewing
K E Y T E R M S abusive head trauma, p. 657 Affordable Care Act, p. 646 body mass index, p. 652 built environment, p. 650 child feeding practices, p. 652
child maltreatment, p. 657 Children’s Health Insurance Plan, p. 646 cognitive development, p. 648 development, p. 647 developmental screening, p. 648
645CHAPTER 29 Child and Adolescent Health
C H A P T E R O U T L I N E Status of Children
Poverty Status Immigrant Children Access to Care Infant Mortality Risk-Taking Behaviors
Child Development Growth and Development Developmental Theories Developmental Screening
Immunizations Barriers Immunization Theory Recommendations Contraindications Legislation
The Built Environment Obesity Built Food Environments Obesity Prevention
Nutrition Assessment Physical Activity Schools Media Injuries and Accidents
Health Problems of Childhood Acute Illnesses SIDS/SUIDS Oral Health Chronic Health Conditions Mental Health Environmental Health Environmental Tobacco Smoke
Models for Health Care Delivery to Children and Adolescents
Family-Centered Medical Home Motivational Interviewing
Role of the Population-Focused Nurse in Child and Adolescent Health
K E Y T E R M S — cont’d environmental tobacco smoke (ETS), p. 663 family-centered medical home, p. 664 food deserts, p. 652 food landscape, p. 651 growth, p. 647 human ecology theory, p. 648 immunization, p. 648 low food security, p. 646 media, p. 654 Medicaid, p. 646
medical home, p. 664 motivational interviewing, p. 664 obesity, p. 650 overweight, p. 650 psychosocial development, p. 647 sudden infant death syndrome, p. 659 sudden unexpected infant death, p. 659 unintentional injuries, p. 655 —See Glossary for definitions
Walt Disney identified the greatest natural resource of any nation as the minds of its children. The future of the world depends on how well it cares for its youth. If this population is to thrive, it must be nurtured in an appropriate environ- ment. Focusing on the health needs and health promotion of children increases the chances that they will become adults who value and practice healthy lifestyles. Population-focused nurses have two major roles in the area of child and adoles- cent health: 1. The nurse provides direct services to children and their fami-
lies: assessing, managing care, educating, and counseling. 2. Nurses are involved in the assessment of the community and
the establishment of programs to ensure a healthy environ- ment for this population. The population-focused nurse has the opportunity to teach
healthy lifestyles to children and caregivers and to provide family-centered care in the community setting. This chapter provides information on the assessment of children and ado- lescents as well as activities to promote their health. The content
includes basic principles of childhood growth and development and major health problems seen in this population. The concept of evaluating child health and implementing health education and models of health behavioral change will be explored within the context of the child’s built environment. The family-centered medical home and motivational interviewing are discussed in this chapter as strategies to promote improved health behaviors within families. Healthy People 2020 objectives (USDHHS, 2010) are used as a framework for focusing on needs of children in the community.
STATUS OF CHILDREN Poverty Status There were 73.7 million children through age 17 in the United States in 2012, representing 22% of the population. Approxi- mately 45% of them lived in low-income families, with one out of every five children living below poverty levels and 8% of America’s children living in extreme poverty with a family
646 PART 5 Health Promotion with Target Populations Across the Life Span
immigrant children (1 in every 4 U.S. children). Of those, 89% are born in the U.S. and have citizenship (Child Trends Data Base, 2012). “Immigrant children” are defined as those who were born in a foreign country or children born in the U.S. who live with a parent(s) who was born in a foreign country. When compared to nonimmigrant children, immigrant children are more likely to have poor to fair health.
Immigrant children face many challenges to good health, including lack of health insurance, poverty, language barriers, and substandard housing. These families often experience or fear discrimination related to anti-immigration sentiment and this impacts access to health care and child health outcomes. Nurses should advocate for culturally and linguistically effective comprehensive health care, provide preventive screenings and referrals as appropriate, and encourage early education services for the support of optimal development in immigrant children (AAP, 2013).
Access to Care Access to quality health services is one of the focus areas of Healthy People 2020 (USDHHS, 2010). Children with health care coverage are more likely to have a regular and accessible source of health care. In 2012, 8.9% of all children had no health insurance. For children living in poverty, the uninsured rate for children was 13% (U.S. Census Bureau, 2013). With the imple- mentation of the Affordable Care Act (ACA), the number of children covered by government health insurance programs has been increasing.
The Medicaid program, established by the Social Security Act in 1965, is a state-administered health insurance program financed jointly by the federal and state governments. Children under 18 years of age living in a household with an income level at or below 133% of the federal poverty level or children meeting disability requirements qualify for this program. The program provides health services at no cost to participants and includes outpatient visits, hospitalization, laboratory testing, immunizations, well care/preventive services, and dental care (CMMS, 2014a).
The Children’s Health Insurance Plan (CHIP) was the result of federally mandated legislation passed in 1997 to expand health insurance to the nation’s uninsured children. The Children’s Health Insurance Program Reauthorization Act of 2009 has continued to provide insurance to over 5 million American children. CHIP is a federal and state part- nership directed toward uninsured children and pregnant women in families with incomes too high to qualify for state Medicaid programs but usually too low to afford private cov- erage. Following federal guidelines, each state determines the model of its particular CHIP program, which includes the eli- gibility parameters, benefit package, payment levels for cover- age, and administrative process. The program is jointly financed by the federal and state governments, and adminis- tered by the states (CMMS, 2014b). CHIP enrollment eligibil- ity requirements are: • Family income too high for Medicaid qualification (up to
$44,100 for family of 4) • Uninsured children under 19 years of age in the home
FIG 29-1 Percentage of children living in poverty and low income by ethnicity in 2011. (From National Center for Children in Poverty: Basic facts about low income children, 2013. Avail- able at www.nccp.org. Accessed February 19, 2015.)
70
60
50
40
30
20
10
0 White
31%
13%
65%
39%
32%
13%
63%
36%
45%
23%
65%
34%
Black HispanicAsian American Indian
Other
Low-incomePercent (%)
©National Center for Children in Poverty (www.nocp.org) Basic Facts About Low-income Children Under 18 Years, 2011
Poor
Percentage of children in low-income and poor families by race/ethnicity, 2011
income of half of the federal poverty level (Federal Interagency Forum on Child and Family Statistics, 2013; Jiang et al, 2014). About 30% of children born to immigrant parents live below the federal poverty level compared with 19% of children of native-born parents (AAP, 2013). The federal poverty level for 2012 was defined as a family income of less than $23,364 for a family of four whereas low income (the amount of income necessary to provide for the family’s basic needs) is two times the federal poverty level, or $46,728.
Minority children, most notably black and Hispanic chil- dren, have higher proportions of living at poverty or low- income levels (Figure 29-1). Characteristics that put children at risk for living in low-income families are parents without a high school degree, having a lack of parental employment, and living in a single-parent household. Children’s ability to learn in school and reach their full cognitive ability is affected by low- income status. Children living in poverty experience a higher incidence of behavioral, social, and emotional problems (Jiang et al, 2014).
In addition, U.S. children face other challenges. More than 10% of American households with children experience low food security (Wight & Thampi, 2010). Low food security, a lack of available food and access to food on a regular basis, affects children’s physical health, development, and school per- formance. Homelessness is increasing for American children and is highly correlated to poverty status and the lack of afford- able housing. It is estimated that over 200,000 children have no place to live on any given day with 1.6 million U.S. children experiencing homelessness each year (National Center on Family Homelessness, 2011).
Immigrant Children Children of immigrant families represent the largest growing portion of the U.S. population with approximately 18 million
647CHAPTER 29 Child and Adolescent Health
condoms during intercourse and 15% of teens reporting that they had sexual intercourse with four or more partners (Kann et al, 2014). These risk behaviors increase the risk for unin- tended pregnancies and sexually transmitted infections. Yet the birth rate for teenagers (15-19 years) did drop 6% to an all-time low rate of 29.4 per 1000 in 2010 (USDHHS, 2013a). This number remains a significant concern for public health nurses because teen pregnancy creates a significant socioeconomic burden on society and the family.
Nurses should be aware of the factors associated with increased adolescent risk-taking behaviors: poor academic per- formance, poor parental role models, low self-esteem, lack of a supportive social environment, and poverty. Individual assess- ment of an adolescent’s risk-taking behavior can provide the direction to focus education and interventions. Providing after- school extracurricular activities, identifying a positive adult role model, and engaging teens in support systems to build self- esteem can reduce risk-taking behaviors in at-risk adolescents.
The misuse and abuse of prescription stimulant medication to treat attention-deficit hyperactivity disorder (ADHD) has risen in past years. Misuse of these drugs occurs in 2% to 8% of children and adolescents. Misuse ranges from selling or trading the prescription stimulant, taking a prescription stimu- lant with no ADHD symptoms, taking more than the recom- mended dose, or taking it by a route other than the prescribed route (i.e., inhaling an oral medication) (Lakhan & Kirchgess- ner, 2012). It is vital to promote community and family aware- ness of this problem and educate children and adolescents on the dangers of taking others’ prescription medications.
CHILD DEVELOPMENT Growth and Development Growth is the measurable aspect of the individual’s size and follows a predictable pace that is evaluated at regular intervals to determine if a child is growing based on standard parameters. Development involves the observable changes in the individual and relates to physical, psychosocial, and cognitive achieve- ments. Growth and development in children is an ongoing, dynamic process that results in physical, cognitive, and emo- tional changes (Figure 29-2). Health visits or well-child check- ups are scheduled at key ages to monitor these processes and provide anticipatory guidance to families. Nursing assessments include growth and health status, developmental level, and the quality of the parent–child relationship. (See Tables 29-2, 29-3, 29-4, and 29-5 for considerations and issues to address at each stage.) The recommendations for preventive pediatric health care (see Resource Tool 5.A on the Evolve site) list components of well-child assessments. Further tools and specific interven- tions are included in Appendixes D and E.
Developmental Theories Many developmental theories provide perspectives on chil- dren’s growth and development. The work of Erik Erikson on psychosocial development emphasizes that personality devel- opment culminates in the achievement of ego identity, which involves accepting oneself and having the skills for healthy
CHIP coverage includes: • Primary care provider/specialist visits • Immunizations • Hospitalizations and ED visits
Under the ACA, 21 states are mandated to expand their Medicaid coverage to fully provide comprehensive coverage to children of families at 133% of the federal poverty level. This eliminates the “stairstep” eligibility rules that were previously in place in these states and limited enrollment of children in Med- icaid. Currently, Medicaid and CHIP combined provide health coverage to over 43 million children (Kaiser Family Foundation, 2013). This remains an area of outreach opportunity for nurses to identify potential families eligible for Medicaid and CHIP and provide appropriate referrals to state agencies. It is expected that as the ACA is fully implemented, health insurance coverage for children will continue to increase, improving access and health outcomes for this population.
Infant Mortality Promotion of healthy pregnancies is a focus of Healthy People 2020. The Healthy People 2020 target goal for the U.S. infant mortality rate is 4.5 infant deaths per 1000 live births. The U.S. infant mortality rate dropped to a record low of 6.15 infant deaths per 1,000 live births in 2010 (down 3.8% from 2009), although the infant mortality rate for the black population was 2.2 times greater when compared to the white population (Murphy et al, 2013). Although infant death rates have decreased, the United States has a higher infant mortality rate than 50 other nations (Central Intelligence Agency, 2014) and its position in a global ranking has consistently fallen over past years.
Infant mortality rates are critical indicators of a country’s overall health. Infant mortality rates are associated with a variety of factors such as maternal health, socioeconomic cir- cumstances, quality and access to medical care, and community health practices.
Risk-Taking Behaviors Risk behaviors are any behaviors that place early and middle adolescents at risk for physical, emotional, or psychological harm. Much progress has been made through health promotion and education to decrease risk factors in adolescents. The Youth Risk Behavior Surveillance System (YRBSS) indicates that many teens continue to engage in risk behaviors with smoking tobacco (15.7%), using marijuana (23.4%), and drinking alcohol (34.5%). Increasingly, drugs of abuse are inhalants. Nationally, 8.9% of high school students have breathed the contents of aerosol spray cans, sniffed glue, or inhaled any paints or sprays to get high one or more times (Kann et al, 2014). In regards to motor vehicle safety, 7.6% of adolescents reported never wearing a seat belt while 21.9% rode in the car with an intoxicated driver. Nationwide, 41.4% of teens shared that they texted or e-mailed while driving, an increase of 7% from 2011. The overall prevalence of risk behaviors indicates the continued emphasis on primary and secondary prevention and education with the adolescent population.
Despite extensive education campaigns, adolescents con- tinue to engage in sexual activity (34%) with only 59.1% using
648 PART 5 Health Promotion with Target Populations Across the Life Span
themselves based on environmental interactions. This theory explains that individuals do not develop in isolation but in rela- tion to their home and family, school, community, and society (Shaffer & Kipp, 2013).
Developmental Screening Developmental screening is a process designed to identify chil- dren who should receive more intensive assessment or diagnosis of potential developmental delays. These delays may be in any of the developmental domains—gross motor, fine motor, lan- guage, or social skills. Developmental screening promotes early detection of delays and improves child health and well-being for identified children. In the United States, 15% of children have a developmental disability such as autism, attention-deficit disorder, hearing loss or a language delay (AAP, 2011a). Nurses are critical to early screening and identification of developmen- tal delays in young children and appropriately initiating refer- rals to maximize school readiness and maximum achievement. Multiple screening tools are available and are selected based on the nurse’s role in the community (Table 29-1).
Children with delayed skills or other disabilities may qualify for special services that provide individualized education pro- grams in public schools that are free of charge to families. Nurses can be effective health advocates for these children within educational settings. The passage of the updated version of the Individuals with Disabilities Education Act 2004 (IDEA) promotes a collaborative focus on meeting the needs of children with disabilities (Department of Education, 2006). Parents, educators, administrators, nurses, and other team members col- laboratively develop a plan—the individualized education plan (IEP)—to help children succeed in school. The IEP explains the goals the team sets for a child during the school year as well as any special support needed to help achieve these goals.
IMMUNIZATIONS Increasing immunization coverage for children remains a sig- nificant focus of the Healthy People 2020 objectives. Currently, 92% of the nation’s 19- to 35-month-old children have received all of the polio vaccinations as well as 87% of hepatitis B vac- cinations in the recommended series but only 53% have received the complete hepatitis A series (CDC, 2013a). For adolescents, vaccination rates continue to rise steadily for this
functioning in society. According to Erickson, development is a continual process that occurs in distinct stages with a develop- mental crisis needing resolution at each stage and some degree of mastery being achieved before proceeding successfully to the next stage. All new development is rooted in prior experiences, and difficulty resolving the crisis will cause problems progress- ing through the subsequent stages.
The work of Jean Piaget is widely used to understand the process of cognitive development. According to Piaget, learn- ing results from actively manipulating objects and information followed by a mental processing of the event. As the child inter- acts with the environment, new objects and problems are dis- covered. The child creates mental schemes or thought patterns to understand the encounter. This permits the child to receive information from the world, make sense of it, and predict future events. Development occurs as the schemes increase in scope and complexity. Piaget identified four stages of cognitive devel- opment that represent increasing problem-solving ability. As one will remember from pediatric courses, these stages are sen- sorimotor, preoperational, concrete, and formal operations (Shaffer & Kipp, 2013).
Bronfenbrenner’s human ecology theory emphasizes the complex relationship between the growing child and his/her immediate environment. Children are greatly influenced by the environments in which they spend time and one of the most important environments in affecting growth is the family envi- ronment. Educational programs, communities, and other envi- ronmental factors also influence the child’s development. Children learn to accommodate to their environment and alter
FIG 29-2 Conflict between parents and teenagers is normal as teenagers experience physical and emotional growth processes.
Tool Purpose
Denver II Domain specific development (gross and fine motor, social, language)
Ages and Stages Questionnaire Social and emotional development Parents’ Evaluation of
Developmental Status (PEDS) General developmental and
behavioral screening Modified Checklist for Autism
in Toddlers (M-CHAT) Autism spectrum disorder
Pediatric Symptom Checklist Coping and mental health concerns
TABLE 29-1 Developmental Screening Tools
649CHAPTER 29 Child and Adolescent Health
Immunization Theory The goal of immunization is to protect by using immunizing agents to stimulate antibody formation (see Chapter 13 for types of immunity). Immunizing agents for active immunity are in the form of toxoids and vaccines. A toxoid is a bacterial toxin (e.g., from the bacteria that cause tetanus and diphtheria) that has been heated or chemically treated to decrease virulence but not antibody-producing ability. Vaccines are suspensions of attenuated (live) or inactivated (killed) microorganisms. Exam- ples include pertussis (inactivated bacteria); measles, mumps, and rubella (live attenuated viruses); and hepatitis B (inacti- vated virus) (see Chapter 13) (CDC, 2012a).
The neonate receives placental transfer of maternal antibod- ies. This natural passive immunity lasts for about 2 months. Protection is temporary and is only to diseases to which the mother has adequate antibodies. The immune system of both term and preterm infants is capable of adequate antibody response to immunizations by 2 months of age. Generally, this is the recommended age to start immunizations; the exception is the hepatitis B series which begins at birth (CDC, 2012a).
The interval between immunizations is important to the immune response. After the first injection, antibodies are produced slowly and in small concentrations (the primary response). When subsequent injections of the same antigen are given, the body recognizes the antigen and antibodies are pro- duced much faster and in higher concentration (the secondary response). Because of this secondary response, once an initial immunization series has been started, it does not need to be restarted if interrupted, regardless of the length of time elapsed. Once the initial series is completed, boosters are required at appropriate intervals to maintain an adequate concentration of antibodies. (Further information about immunizing agents is available on the Evolve website).
Recommendations Immunization recommendations rapidly change as new infor- mation and products are available. The recommended immu- nization schedule guidelines for children from birth through 18 years and the catch-up immunization schedule have been approved by the U.S. Public Health Services Advisory Commit- tee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), the American Academy of Family Physi- cians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG) (CDC, 2014a). Current recommenda- tions for children and adolescents can be found on the Evolve website. The main goal of the guidelines is to provide flexibility to ensure that the largest number of children will be immu- nized. All health care providers are urged to assess immuniza- tion status at every encounter with children and to update immunizations whenever possible.
Contraindications There are relatively few contraindications to giving immuniza- tions. Minor acute illness is not a contraindication. Immuniza- tions should be deferred with moderate or acute febrile illnesses because the reactions may mask the symptoms of the illness.
age group. For those aged 13 to 17 years, 84% received the recommended tetanus-diphtheria-acellular pertussis vaccine (Tdap) and 74% received the meningococcal conjugate vaccine (MCV4). Lowest immunization rates are noted for the human papillomavirus vaccine (HPV4) series, with 53% of girls receiv- ing one dose and only 34% receiving the full three-dose series by 17 years of age (CDC, 2013b). Routine immunization of children is very successful in the prevention of selected dis- eases. The ultimate challenge is making sure that children receive immunizations.
Barriers There are several barriers to successful immunizations. These include vaccine cost, vaccine refusal by parents, vaccine short- ages, and changes in vaccine scheduling and recommendations. Health disparities in vaccinations continue to exist. Children living in poverty have lower immunization rates than their peers, and African American adolescents have lower immuniza- tion rates compared with white adolescents (Burns et al, 2010). It is important to educate parents to obtain immunizations for their children and to focus on the issue at every encounter with families.
Parental fears about vaccines prevent children from getting immunized. Parents readily access the Internet for information about vaccines, and disreputable sites provide parents with incorrect vaccine information. It is critical for nurses to educate families on the safety and efficacy of vaccinations. Scientific studies have not found a relationship between immunizations and autism, sudden infant death syndrome, diabetes, neuro- logic disabilities, deafness, or cancer. Parents question the need to vaccinate because the incidence of vaccine-preventable dis- eases is low. However, Japan, Great Britain, and Sweden stopped the use of the pertussis vaccine, and within 5 years there were epidemic levels of the disease and rising death rates (CDC, 2011a). When a parent chooses not to vaccinate their child, this puts the child and others at risk.
Shortages of vaccines have periodically occurred as a result of manufacturing problems, and the U.S. Department of Health and Human Services (USDHHS) has focused on main- taining adequate manufactured supplies of vaccines. When a shortage does occur, the CDC provides priority administration guidelines for highest-risk clients. When the immunization schedule is revised, there can be delays in practitioners imple- menting the new recommended vaccination schedules. Nurses must continually review the CDC recommendations for any changes to implement within the public health and commu- nity settings.
Vaccines and vaccine administration costs are high and those families without health insurance often find following the vac- cination recommendations financially prohibitive. A federal program established in 1995, Vaccines for Children (VFC), pro- vides free vaccines to eligible children, including those without health insurance coverage, children enrolled in Medicaid, American Indians and Alaskan Natives, and children whose health insurance does not cover vaccines. Identifying children who qualify for VFC is a primary prevention strategy of population-focused nurses.
650 PART 5 Health Promotion with Target Populations Across the Life Span
The side effects of the immunization may be accentuated by the illness (CDC, 2012a).
People with the following conditions are not routinely immunized and require medical consultation: pregnancy, gen- eralized malignancy, immunosuppressive therapy or immuno- deficiency disease, sensitivity to components of the agent, or recent administration of immune serum globulin, plasma or blood (CDC, 2012a).
Legislation The National Childhood Vaccine Injury Act became effective in 1988. It requires providers to counsel parents and clients about the risks and benefits of the immunizing agent as well as pos- sible side effects. Informed consent is recommended. Vaccine information statements (VIS) are used for this purpose. The VIS is an information sheet produced by the CDC that explains both the benefits and risks of a vaccine. Federal law requires that a VIS be given to parents or legal guardians before each vaccine dose is given (CDC, 2012a).
The Vaccine Adverse Event Reporting System (VAERS) is a national safety surveillance program. It requires providers and vaccine manufacturers to report any adverse effects following the administration of routinely recommended vaccinations. The program has been effective in tracking and identifying adverse effects associated with vaccinations. In 1999, VAERS detected reports of intussusception above what would be expected to occur by chance alone after the administration of the RotaShield rotavirus vaccine. Subsequently, this vaccine was pulled from manufacturing and the vaccine formulation was redeveloped (CDC, 2012a).
California has a large Hmong population. Despite having health insurance, community providers noted that the Hmong children consistently had lower than national and state levels for immunizations. The authors conducted a study to determine the primary barriers for this cultural group related to immunizing their children. The study identified two primary barriers to immu- nization: lower socioeconomic status and greater use of traditional Hmong health care (shamans and herbalists) (Baker et al, 2010).
Nurse Use We often make assumptions about the barriers to positive health decisions or behaviors. This study demonstrates that cultural differences can be influ- ential in making health care decisions. By targeting the specific population of concern, nurses can identify the specific barriers that prevent parents from obtaining preventive health care. Public health nurses can then develop inter- ventions and education to address those specific barriers and improve pedi- atric health.
EVIDENCE-BASED PRACTICE
Baker D, Dang M, Diaz R: Perception of barriers to immunization among parents of Hmong origin in California. AJPH 100:839–845, 2010.
FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES
Targeted Competency Teamwork and collaboration: Refers to the ability to function effectively with nursing and interprofessional teams and to foster open communication, mutual respect, and shared decision making to provide quality client care • Knowledge: Recognize the contributions of other individuals and groups
in helping clients achieve health goals • Skill: Integrate contributions of others who play a role in helping clients
achieve health goals • Attitude: Respect the unique attributes and contributions of others
Question Teamwork and Collaboration Question: The PHN Quad Council defines one competency for PHNs as analytic and assessment skills. The PHN uses avail- able data and resources related to social determinants of health when plan- ning care for clients. From this chapter you know that the built environment includes the physical environment where the child client lives, plays, goes to school, shops, and seeks safety. This environment assists the child in manag- ing health risks. Many persons and groups assist the child in this endeavor. To determine the potential or real health risks of a child client, what informa- tion would you gather and from whom? How would you use the data from your assessment? Name a health risk and discuss the interventions you might plan and the health education you would offer to promote the child’s health. What would you see as the role of other individuals and groups in the com- munity to assist you or to take the lead in assisting the child and family? Be specific.
THE BUILT ENVIRONMENT A built environment is simply defined as the person’s human- made or modified surroundings in which they live, work, and partake in recreation (Renalds et al, 2010). This is the actual physical environment in which children live and includes neigh- borhood access to recreation opportunities, grocery stores, the home environment, and the consideration of general safety for children in their physical environments. A child’s built environ- ment is influential in the managing of risk factors for obesity, amount and type of physical activity, risk for injuries, and expo- sure to environmental toxins. Therefore, as nurses, assessing a child’s built environment provides a foundation for identifying interventions and education to promote health and prevent injuries and diseases. (See Evidence-Based Practice box.)
Obesity Obesity rates in American children have risen to epidemic levels over the past few decades. These increases are noted for all children aged 2 to 18 years regardless of gender or ethnicity. The CDC defines overweight as a body mass index (BMI) at or above the 85th percentile and lower than the 95th percentile, and obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex when plotted on the CDC growth charts (Table 29-2) (CDC, 2012b). Recently, it has been recommended to monitor the World Health Organization (WHO) growth standards for children younger than 2 years. Those infants and toddlers who measure above the 97.7th per- centile of WHO weight for recumbent length growth standards are considered high risk for obesity (Ogden et al, 2014).
The 2011-2012 prevalence of the overweight and the obese combined is 23% in children ages 2 to 5 years, 35% for children ages 6 to 11 years, and 35% for adolescents 12 to 19 years. The prevalence of obesity in children is approximately 8% for ages 2 to 5 years, 18% for ages 6 to 11 years, and 21% for ages 12 to
651CHAPTER 29 Child and Adolescent Health
Multiple factors contribute to the likelihood that a child will become overweight or obese. Genetics and genetic susceptibility are certainly contributing components, although the genetic composition of the population has been stable over time, thereby failing to account for a sudden rise in obesity in recent years (Garver et al, 2013). Within the literature, three modifi- able risk factors for the development of childhood obesity have been identified. These risk factors are screen time (including television, computer/tablet, phone, and video games), physical activity engagement, and dietary intake/eating behaviors (Hoel- scher et al, 2013; Vollmer & Mobley, 2013; Fakhouri et al, 2013).
A rising comorbidity for childhood obesity is type 2 diabetes mellitus (T2DM). Currently, about 151,000 U.S. children and adolescents have T2DM (CDC, 2013c). Children and adoles- cents diagnosed with type 2 diabetes are usually between 10 and 19 years old, are obese with a strong family history for T2DM, and have insulin resistance (Springer et al, 2013). Most children and adolescents with T2DM have poor glycemic control with hemoglobin A1C levels between 10% and 12%. T2DM affects all ethnic groups but occurs more frequently in non-white groups with the highest prevalence in American Indian youth (CDC, 2013c).
Screening for T2DM is recommended for children with a BMI of 85th to 95th percentile with two risk factors of family history of diabetes, belonging to a racial minority group, or with signs of insulin resistance; all children with a BMI above the 95th percentile; and at age 10 years or onset of puberty. In addition, these children should be screened for hypercholester- olemia and hypertension, which are also associated with child- hood obesity (Springer et al, 2013). Nurses can be instrumental in the management of T2DM in children by educating and counseling.
Built Food Environments A discussion on the risk factors for childhood obesity should be considered within the context of a child’s environment. The emerging research on the relationship of built environments and obesity evaluates the factors within an individual’s environ- ment that may contribute on a macro- or micro-level to the development of obesity. The current literature focuses on the role of the built environment in increasing energy consumption while decreasing energy expenditure and looks at the interac- tion of the individual with his or her environment that influ- ences health (Gose et al, 2013).
For children, the built environment as it relates to nutrition includes both macro- and micro-level considerations. On the community, or macro level, the factors of the built environment that influence nutrition and risk factors for obesity include a greater reliance on convenience foods and fast foods, increasing portion sizes, and the food landscape (He et al, 2012). The food landscape evaluates the accessibility and availability of healthy foods, and it is clear that low-income neighborhoods have limited access to stores offering fruits and vegetables (Dutko et al, 2012).
Close proximity to fast food restaurants and convenience stores are negatively correlated with daily fruit and vegetable consumption for school age children (He et al, 2012). Many
FIG 29-3 Obesity prevalence for 2 to 19 years. (Data from Fryer C, Carroll M, et al: Health E-Stat: Prevalence of obesity among children and adolescents: United States, trends 1963-1965 through 2011-2012, 2013. Centers for Disease Control and Pre- vention, National Center of Health Statistics. Available at www.cdc.gov. Accessed March 15, 2015.)
30
20 Boys Total
Girls
10
P e rc
e n t
0 1971– 1974
1976– 1980
1988– 1994
1999– 2000
2003– 2004
2007– 2008
2011– 2012
19 years (Ogden et al, 2014) (Figure 29-3). Comparing these 2012 National Health and Nutrition Examination Survey (NHANES) findings with 2004 NHANES results demonstrates that prevalence rates for obesity have remained stable with a decrease (5.5%) for the 2 to 5 year age range (Ogden et al, 2014). In addition, 8.1% of infants and toddlers had high weight for recumbent length, indicating a substantial risk for obesity in childhood.
The physiological consequences of childhood obesity are extensive and significantly impact the health status of American children. Research has clearly identified strong relationships between being obese as a child and increased disease risk and disease burden in the cardiovascular, metabolic, musculoskel- etal, respiratory, and renal systems (May et al, 2012; Papan- dreou et al, 2012; Papoutsakis et al, 2013; Paulis et al, 2014; Morandi & Maffeis, 2013). Another critical consequence for children is the negative psychological and social impact of obesity with decreased self-esteem; higher incidence of depres- sion, sadness, and anxiety; problems with social relationships; and higher reports of being the victim of bullying (Puhl et al, 2012; Ting et al, 2012; Griffiths et al, 2010).
Plotted Percentile for Age and Gender BMI Interpretation
<5th percentile Underweight 5th-85th percentile Normal 85th-95th percentile Overweight >95th percentile Obese
TABLE 29-2 Centers for Disease Control and Prevention Classification of Body Mass Index (BMI) for Children Age 2 Years and Above
From Centers for Disease Control and Prevention: Classification of body mass index, 2015. Available at http://www.cdc.gov/.
652 PART 5 Health Promotion with Target Populations Across the Life Span
From: US Department of Health and Human Services: Healthy People 2020, Wash DC, 2010, US Government Printing Office.
HEALTHY PEOPLE 2020
The Healthy People 2020 priority focus areas of prevention include a direct focus on achieving the goals of reducing the proportion of children who are overweight or obese, increasing the proportion of daily servings of fruits for children, and increasing the proportion of daily servings of vegetables for children.
*Recommendations are per day for each group. Adapted from U.S. Department of Agriculture: Choose my plate, 2015. www.USDA.gov.
Food Group* 2-3 Years 4-8 Years 9-13 Years 14-18 Years
Milk: Try to select low-fat sources of milk, cheese, yogurt 2 cups 2-2½ cups 3 cups 3 cups Meat and Beans: Lean meats, beans, eggs, seafood 2 oz 4 oz 5 oz 5-6½ oz Vegetables: Fresh vegetables best choice 1 cup 1-1½ cups 2-2½ cups 2½-3 cups Fruits: Limit fruit juices 1 cup 1-1½ cups 1½ cups 2 cups Grains: Half of grains should be whole grains
Cooked pasta or rice, bread, cereals 3 oz 5 oz 5-6 oz 6-8 oz
TABLE 29-3 Daily Dietary Recommendations: Childhood and Adolescence
urban and rural Americans live in areas termed as food deserts, which are defined as having limited access to affordable and nutritious foods. The inability to easily obtain nutritious foods has been identified as a contributing factor to the development of obesity and obesity-related diseases. More than 23.5 million American households live in low-income areas more than 1 mile from a supermarket (Dutko et al, 2012).
The factors on the macro level interact closely with those factors on the micro level. For children, the micro-level factors of the built environment that influence nutrition include the home food environment. The home food environment factors include home availability and accessibility of fruits and vegeta- bles, parent role modeling, child feeding practices, and general parenting style (Osei-Assibey et al, 2012).
Obesity Prevention A united national movement is underway to reduce risk factors for developing obesity in children. The current White House administration is promoting the “Let’s Move!” campaign as a comprehensive and coordinated initiative to prevent childhood obesity. The initiative emphasizes four primary components: healthy schools, access to affordable and healthy food, raising children’s physical activity levels, and empowering families to make healthy choices (White House, 2014).
mealtime environment and routine. The resulting learned eating behaviors then follow an individual through adolescence and into adulthood (Anzman et al, 2010).
Collaboration between agencies is critical to implementing community based interventions to reduce childhood obesity. Shape NC is an innovative partnership that provides grant funding and training resources to improve obesity risk factors for young children. The resources extend to 100 North Carolina counties and improve policies, practices and outdoor environments in child care centers and communi- ties so that more children are entering kindergarten at a healthy weight. Within 18 months of implementation, Shape NC has shown an increase from 49% to 65% of daycares meeting best practices for obesity prevention. The program is well on its way to reaching the goal of 75% of all daycares meeting best practices and supporting young chil- dren in maintaining a healthy weight (National Institute for Health Care Management, 2012).
Nutrition Assessment Physical growth serves as an excellent measure of adequacy of the diet. Measurements of height and weight, plotted on appro- priate growth curves at regular intervals, allow assessment of growth patterns. Head circumference is followed until age 3. For children less than 2 years, the weight for recumbent length is assessed at regular intervals. Those infants and toddlers who measure above the 97.7th percentile of WHO growth standards are considered high risk for obesity. For children 2 years and older, the body mass index (BMI) should be calculated (kilo- grams/[meters]2) based on the weight and height measure- ments. BMI for age and gender is plotted on the standardized BMI-for-age charts available through the CDC. Children falling outside the expected growth patterns can then be identified and interventions implemented (ADA, 2008).
A 24-hour diet recall by the parent is a helpful screening tool to assess the amount and variety of food intake. If the recall is fairly typical for the child or adolescent, the nurse can compare the intake with basic recommendations for the child’s or ado- lescent’s age. It is important to ask about parent’s concerns regarding diet. It is also helpful to look at the family’s meal pat- terns. Other important parts of the nutrition assessment include amount of physical activity and any behavior problems that occur during meals. Table 29-3 offers guidelines to daily require- ments for all ages.
Promoting good nutrition and dietary habits is a key to maintaining child health. The first six years are the most impor- tant for developing sound lifetime eating habits. Parents as primary caregivers are most influential in teaching children specific eating behaviors through their own child feeding prac- tices. Child feeding practices are a primary factor in the devel- opment of eating behaviors for children and include the level of control the parent or caregiver exerts over the type and amount of food the child eats, the role modeling of eating behaviors, the feeding cues given to the child, and the actual
653CHAPTER 29 Child and Adolescent Health
Data from American Academy of Pediatrics: Policy statement: active healthy living: prevention of childhood obesity through increased physical activity. Pediatrics 117(5):1834–1842, 2006. Reaffirmed by the American Academy of Pediatrics, as a continuing policy May 2009.
Age Group Recommendations
Infants and toddlers (0-2 years) Safe, minimally structured play environment Promote outdoor activities and exploration under supervision of a responsible adult No television viewing Organized exercise classes are not recommended
Preschoolers (2-6 years) Encourage free play and exploration under proper supervision Provide unorganized play with opportunity for running, swimming, tumbling, throwing, catching with supervision Take short walks with family member; limit use of strollers for transportation Limit television viewing to <2 hours/day
Elementary school age (6-9 years) Encourage free play with emphasis on basic skills acquisition Promote walking, dancing, jumping rope Organized sports (soccer, baseball) can be started but should be flexible with rules, allowing free time in practice Take walks, short bike rides together as a family Limit television viewing, video games to <2 hours/day
Middle school age (10-12 years) Encourage physical activities enjoyed with families and friends Emphasize skills acquisition with increased focus on strategies Participation in complex sports (football, basketball) is appropriate Weight training can begin with good supervision and small weights Limit television viewing, video games to <2 hours/day
Adolescents Encourage physical activities that are enjoyed with friends and considered fun to the teen Promote personal fitness—running, yoga, dance, swimming Encourage active transportation—biking and walking Weight training is safe for this age Limit television viewing, video games to <2 hours/day
TABLE 29-4 Physical Activity Recommendations by Age Group
Physical Activity Physical activity levels contribute significantly to the overall health of children, particularly related to their risk for obesity. Fewer children are meeting the recommended physical activities levels today compared with previous generations. There are several contributing factors including the physical built envi- ronment, changes in school practices for physical education, and increased screen time.
Some children are at higher risk for not getting enough physical activity, particularly those children living in poverty in urban neighborhoods that are unsafe for outdoor playtime and with limited access to playgrounds and parks (CDC, 2010a). Even in suburban areas, parents are wary of allowing their chil- dren to play unsupervised outdoors. Few families live in loca- tions where they can regularly walk or bike to school or for errands. As a society, Americans have become increasingly sed- entary, which contributes greatly to obesity and the develop- ment of many chronic diseases.
The CDC recommends that every child and adolescent gets 60 minutes of physical activity daily. This should primarily consist of moderate-intensity aerobic activity and it is recom- mended that vigorous-intensity aerobic, muscle strengthening, and bone strengthening activities be incorporated at least three times a week (CDC, 2011b). This can be accumulated through- out the day with smaller increments of activity, those obtained during school, at home, and while engaged in leisure or sports activities. It is important to encourage families to be active
together since this promotes greater physical activity levels in children. It also provides family time for promoting family engagement, connection, and communication. Table 29-4 shows developmental guidelines for physical activity promotion.
According to the most recent NHANES data, all age groups are failing to meet recommended daily activity levels. For chil- dren 6 to 11 years of age, 41.8% get 60 minutes of moderate activity daily; this drops to 7.6% for 12- to 15-year-olds and just 7.7% for 16- to 19-year-old adolescents (Tudor-Locke et al, 2012). Of significant note, girls are much more sedentary than boys, with the disparity increasing with age.
Schools Children and adolescents spend much of each weekday in school. Based on the results of a recent study, there is strong evidence that physical activity improves academic achievement with grades and standardized tests (CDC, 2010b). Currently, 48% of high school students attend physical education classes one or more days a week with only 29.4% attending physical education classes five days per week (Kann et al, 2014). In addi- tion, 54% of adolescents in the United States play on at least one sports team, with more males participating in sports than females.
Schools have a vital ability to influence student health and academic achievement through federal and state school policies. Quality physical education requires adequate time (at least 150 minutes for elementary schools and 225 minutes for secondary
654 PART 5 Health Promotion with Target Populations Across the Life Span
appropriate content, avoid exposing young children to PG-13 or R-rated movies, and role model limited media usage.
Nurses are uniquely positioned within the community to effect change in the childhood obesity rates. With the knowl- edge and skills to identify children as at risk or obese, nurses can develop interventions for healthy change for these families and refer to providers appropriately. Education on healthy eating, child feeding practices, and physical activity levels are necessary for individuals, families, and groups within the com- munity. Nurses have the abilities and knowledge to develop creative programs to provide families with the skills to grow their own gardens and cook healthy meals. Advocating for exer- cise trails and physical activity programs within the community will improve the health of families living in the vicinity. It is clear from obesity research that a community-based approach is most effective at reducing obesity rates and improving health. The following list highlights some guidelines on nutrition edu- cation for families: • Breastfeeding is the recommended exclusive feeding choice
for infants from birth to 6 months and should be continued until 1 year of age. Breastfeeding is associated with a lower risk for developing childhood obesity.
• Parents’ responsibilities are to provide healthy meals and snacks for their children. It is their child’s responsibility to decide how much to eat.
• Limit 100% fruit juices and avoid all other sugary bever- ages. These are empty calories and fill children up so they are not hungry at meals. Appropriate beverages are milk and water.
• For toddlers and preschoolers, it sometimes takes 10 to 15 tastes of a new food before they learn to like that food. Be persistent!
• Parents should role model good eating behaviors—lots of fruits and vegetables, no sugary beverages, and little to no “junk” food or “fast” food.
• Family meals are important for teaching manners, listening to hunger cues, and having quality family time together.
• Encourage children to help with food selection and prepara- tion as appropriate to developmental skills. Allow them to select new foods to try in the produce section of the grocery store.
• Avoid using food as a punishment or reward. Do not expect your child to “clean their plate.” These feeding techniques have been associated with increased risk for obesity.
• Turn off the television during meals and do not let your child eat in front of the television. Children do not listen to their cues of satiety when distracted.
• Cook meals at home. Broil, bake, stir-fry, or poach foods rather than frying.
• Modify family eating habits to include low-fat food choices. Serve calorically dense foods that incorporate the food guide pyramid: whole grains, fruits, vegetables, lean protein foods, and low-fat dairy products.
• Encourage family members to stop eating when they are satisfied. Encourage recognizing hunger and satiation cues.
• Schedule regular times for meals and snacks. Include break- fast and do not skip meals.
schools per week), teacher preparation and professional support, and adequate facilities and class size. Recommendations to meet high levels of physical activity in schools include strategies that integrate physical activity into structured classroom activities, encouraging more unstructured play, expanding extracurricu- lar activities promoting physical activity, and guiding adoles- cents in developing their own personal fitness goals and plans (CDC, 2013d).
The Healthy People 2020 objectives include a focus on increasing the proportion of adolescents and children who engage in moderate to vigorous activity on a daily basis, increasing the proportion of adolescents who spend at least 50% of school physical education class time being physically active, and increasing the proportion of adolescents who par- ticipate in daily school physical education. Nurses will want to be active in educating school administrators and school boards on the benefits of physical activity in improving chil- dren’s and adolescents’ physical health, cognitive performance, and behavior. Nurses should be engaged in policy revisions in the school systems to restore compulsory, quality, daily physi- cal education classes; retain school recess; and expand extra- curricular activities that promote physical activity before and after schools.
Media The concept of “media” has changed significantly over the past decade. In addition to television and movies, media now includes the Internet, video games, computers/tablets, and cell or smartphones. Social media is another avenue in which Americans interact with peers, family, and friends. With the extensive incorporation of media and social media into our society, its impact on children and adolescents is significant. Children and adolescents now spend more time engaged with media than any other activity except for sleeping; on average over 7 hours each day. Currently, 20.8% of 6- to 11-year-olds and 26.1% of teens have excessive screen time (Wethington et al, 2013). With video viewing alone, adolescents spend an average of 5 hours online, 8 hours on a mobile device, and 99 hours per month watching videos of some type (Office of Ado- lescent Health, 2013).
Research has strongly correlated increased use of media with an increased sedentary lifestyle, obesity, hypercholesterolemia, and hypertension. In addition to the negative physiological effects, exposure to such extensive media has been correlated to desensitization to violence and increased aggression, greater sexual content exposure and increased sexual activity, and lower academic performance if the child or adolescent has a television in the bedroom (AAP, 2009a).
Interventions need to be based on the goal of lifestyle changes for the entire family. The AAP recommends that children and adolescents over the age of 2 years be limited to 2 hours per day of media screen time and that children under 2 years do not have any screen time (Strasburger et al, 2010). Televisions, video game systems, tablets, phones, and computers should be kept out of the child’s or adolescent’s bedroom and in open spaces in the home (Wethington et al, 2013). Parents should engage in media and social media viewing with their children to discuss
655CHAPTER 29 Child and Adolescent Health
is suffocation (Table 29-5). From 2000 to 2009, the rates of unintentional infant suffocation deaths increased by 54% leading to an overall increase in newborn and infant death rates (MMWR, 2012). To effectively implement prevention strategies, nurses need to understand the developmental factors that place this population at risk.
Developmental Considerations Infants. Infants have the second highest injury rate of all
groups of children; their small size contributes to some types of injury. The small airway may be easily occluded. The small body fits through places where the head may be entrapped. In motor vehicle crashes, small size is a great disadvantage and increases the risk for crushing or being propelled into surfaces.
The second half of infancy brings major accomplishments in gross motor activities. Rolling, sitting, pulling up, and walking bring safety concerns. Their developing motor skills remain immature, which limits their ability to escape from injury and places them at risk for drowning, suffocating, and burns (CDC, 2012c).
Toddlers and Preschoolers. This population experiences a large number of nonfatal falls and being struck by or against an
• Have low-calorie, nutritious snacks ready and available. Avoid having empty-calorie junk foods in the home. Plan for healthy snacks when eating “on the run,” such as granola, fruits, and nuts.
• Decrease salt, sugar, and fat. Increase complex carbohydrates—whole grains.
• Maintain regular activity (e.g., exercise, sports) and limit television viewing.
• Select family activities and vacations that include or focus on physical activity (hiking, bicycling, swimming).
Injuries and Accidents Unintentional injuries are the leading cause of morbidity and mortality in the United States for young people ages 1 to 19 years. Unintentional injuries are any injuries sustained by acci- dent such as falls, drowning or motor vehicle accidents. It is one of the most under-recognized public health problems facing the United States today, with more than 9,000 children dying from a preventable injury in 2009. Reducing injuries from unintentional causes, as well as from violence and abuse, is a goal of Healthy People 2020. More than 8.4 million children were seen in emergency departments in 2009 for treatment from an unintentional injury (MMWR, 2012).
Motor vehicle crashes remain the leading cause of death for unintentional injuries in children and teens. One research study found that 72% of almost 3500 observed car and booster seats were mishandled in a way that could possibly increase a child’s risk of injury during a crash. It is recom- mended by the National Highway Traffic Safety Administra- tion for children to remain in booster seats until they are at least 8 years of age or 4 feet, 9 inches tall (Figure 29-4). A study found that booster seats reduced injury risk by 59% compared with seat belts alone for children ages 4 to 7 years. National standards recommend that all children ages 12 years and younger ride in the back seat because they are at signifi- cant risk of injury from airbag deployment, and the back seat is known as the safest part of the vehicle if a crash occurs. Even for adolescents to age 16 years, sitting in the back seat is associated with a 40% decrease in the risk of serious injury (Borse et al, 2008; CDC 2014b).
Drowning, poisonings, and burns account for most of the other deaths. For infants, the leading cause of death
FIG 29-4 Children should always be restrained while riding in a vehicle.
Rank 0-1 Years 1-4 Years 5-9 Years 10-14 Years 15-19 Years
1 Suffocation (77%) Drowning (31%) MVT-related* (49%) MVT-related* (68%) MVT-related* (67%) 2 MVT-related* (8%) MVT related* (25%) Drowning (15%) Transportation
Other (15%) Poisoning (9%)
3 Drowning (4%) Fire burns (12%) Burns/fire (11%) Drowning (10%) Drowning (6%) 4 Fire burns (2%) Transportation
Other (10%) Transportation
Other (9%) Burns/fire (6%) Transportation
Other (4%) 5 Poisoning (2%) Suffocation (9%) Suffocation (3%) Suffocation (5%) Falls (1%)
TABLE 29-5 Leading Causes of Unintentional Injury Death Among U.S. Children 0 to 19 Years, 2000-2009
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control: National Action Plan for Child Injury Prevention, Atlanta (GA), 2012C, CDC, NCIPC.
*MVT-related: Motor vehicle traffic–related includes motor vehicle injuries, pedestrian injuries.
656 PART 5 Health Promotion with Target Populations Across the Life Span
object. They are active and lack an understanding of cause and effect, and their increasing motor skills make supervision dif- ficult (CDC, 2012c). They are inquisitive and have relatively immature logic abilities.
School-Age Children. The school-age group has the lowest injury death rate. At this age, it is difficult to judge speed and distance, placing them at risk for pedestrian and bicycle acci- dents. Boys are twice as likely as girls to sustain a nonfatal bicycle injury, and the highest injury rate is at 10 to 14 years of age. Universal use of bicycle helmets would prevent most deaths. Peer pressure and lack of parental role modeling often inhibits the use of protective devices such as helmets and limb pads (CDC, 2012c).
Adolescents. Motor vehicle–related injuries and violence are the leading causes of morbidity and mortality for adoles- cents. Risk-taking becomes more conscious at this time, espe- cially among boys. The injury death rates for boys are twice as high as those for girls. Adolescents are at the highest risk of any age group for motor vehicle deaths and fatal poisonings. Use of weapons and drug and alcohol abuse play an important role in injuries in this age group. Homicides are the second leading cause of death for U.S. adolescents (Borse et al, 2008; CDC, 2012c).
In a survey of adolescents, 24.7% reported being in a physical fight at least one time in the previous 12 months, and 7.1% reported missing school at least one day in the previous month because they felt unsafe at school or on their way to school. Suicide is the third leading cause of death among youths between the ages of 15 and 24 years. Poor social adjustment, psychiatric problems, and family disorganization increase the risk for suicide (Kann et al, 2014; Federal Interagency Forum on Child & Family Statistics, 2013).
For all ages, families should be given anticipatory guidance in the high-risk areas for each age group to promote safety and injury prevention. Nurses can use community centers, schools, workplaces, and health centers to provide teaching to families on how to prevent injuries in their children.
Sports Injuries Encouraging participation in team sports and individual sports and active leisure activities can increase the physical activity of children and adolescents. Children who are active in sports should have annual sports physicals, and guidelines for sports safety should be discussed as follows: • Children should be grouped according to weight, size, matu-
ration, and skill level. • Qualified and competent persons should be available for
supervision during games and practices. • Adequate and appropriate-size equipment should be
available. • Goals should be developmentally and physically appropriate
for the child. Approximately 2.6 million children a year are seen in the emergency department for sports and recreational injuries (CDC, 2012c).
To protect children and adolescents during sports, families require education on selecting age and physically appropriate
FIG 29-5 Involvement in developmentally appropriate sports promotes physical activity and skills acquisition.
activities, using the correct safety gear, maintaining the safety gear in good condition, and practicing good body mechanics (Figure 29-5). Management of acute injuries sustained during sports should be monitored closely by coaches and primary care providers. The incidence of concussions, or brain injuries, is 3.8 million per year in the United States (USDHHS, 2013b).
The state of Washington passed the first law on concussion in sports in 2009, the Zackery Lystedt Law. Between 2009 and 2012, 43 states (as well as the District of Columbia) passed laws on concussions in sports for youth and/or high school athletes. Many of these laws are known as “Return to Play” laws. The CDC’s Heads Up program provides recommendations and edu- cational materials to health professionals, coaches, and parents to increase knowledge related to sports-related concussions in youth. Recognition of concussions and proper treatment is critical to prevent repeat concussions, which can cause long- term problems (USDHHS, 2013b) (Table 29-6).
Child Maltreatment In 2011, 3.7 million children were reported abused or neglected with about 681,000 cases confirmed by Child Protective Services. For the same year, about 1750 U.S. children (2.1 deaths per 100,000 children) died as a result of maltreatment (CDC, 2013e). In 2011, 35% of victims of child maltreatment
657CHAPTER 29 Child and Adolescent Health
Child maltreatment occurs in all socioeconomic, racial, and ethnic groups. Yet African American, American Indian/Native American, and multiracial children experienced higher rates of victimization. Children under the age of 4 years and those children with special needs are at highest risk. Children are most likely to be maltreated by their parents, and common parental characteristics include a poor understanding of child development and children’s needs, history of abuse in the family of origin, substance abuse in the household, and nonbio- logical transient caregivers in the home (e.g., mother’s boy- friend). Families at highest risk for maltreatment are those families experiencing social isolation, family violence, parenting stress, and poor parent–child relationships (Zimmerman & Mercy, 2010).
The consequences of child maltreatment are often devastat- ing. Children experience long-term physical consequences as well as negative psychological and behavioral consequences. Abusive head trauma (AHT), also known as shaken baby syndrome, results from violent shaking or shaking and impact- ing of the head of an infant or young child. Intracranial injury, subdural bleeding, retinal hemorrhages, and skull fractures can result, leading to death or survival with associ- ated motor impairments, visual deficits, and cognitive deficits (AAP, 2012a).
Preventive strategies are necessary to reduce the incidence of child maltreatment. Parental education should be started pre- natally to prevent AHT. Nurses can use home visiting programs, peer mentoring programs, preschool and Head Start programs, and public health centers to identify at-risk families and provide support and education to prevent child maltreatment. Nurses can provide education to those individuals in the community who work with children on recognizing signs of abuse and how to report suspected maltreatment. Increased awareness within the community and early intervention can prevent maltreat- ment from occurring and rescue children from violent and unsafe abuse situations.
Injury Prevention Health care provider offices, schools, community centers, public health centers, and daycare/preschool facilities provide oppor- tunities to teach children, adolescents, and their families about prevention of injuries. Safety and health promotion can be incorporated into required health education courses within the school systems. Community-sponsored car seat and seat belt safety checks and safety fairs are another way to educate families (CDC, 2012c). Early home visitation programs to high-risk families resulted in a reduction of 48% in child abuse. Injury prevention is a topic that should be addressed at all health visits (Zimmerman & Mercy, 2010).
Reducing Gun Violence. Although rates have fallen, deaths of children and adolescents from firearm-related injuries were 11.4 per 100,000 in 2009. The NYRBSS survey of adolescents found that 5.1% had carried a gun on at least one day during the previous month. Witnessing gun violence or knowing the victims affects children indirectly (AAP, 2012b).
A recent study compared firearm-related mortality rates in urban and rural settings. The study found no significant
were less than 3 years of age and infants less than 1 year of age had the highest incidence of abuse.
Child maltreatment is defined as any act or series of acts of commission or omission by an adult that results in harm, potential for harm, or threat of harm to a child. Acts of commission (abuse) include physical abuse, sexual abuse, and psychological abuse; acts of omission (neglect) include failure to provide (physical neglect, emotional neglect, medical/ dental neglect, educational neglect) and failure to supervise (inadequate supervision, exposure to violent environments) (Figure 29-6) (Leeb et al, 2008).
FIG 29-6 U.S. child deaths from maltreatment, 2013. Estimated 1,217 deaths in 2013. (U.S. Department of Health and Human Services, Administration for Children and Families, Administra- tion on Children, Youth and Families, Children’s Bureau: Child Maltreatment 2138, 2013. Available from http://www.acf.hhs .gov/programs/cb/stats_research/index.htm#can.)
90
80
70
60
50
40
30
20
10
0 Other*
0.6
31.7
52.3
15.6
Sexual abuse
Percent Maltreatment by Type, 2013
Neglect/ Medical neglect
Physical/ Psychological
abuse
Signs Observed by Coaches/Parents
Symptoms Reported by Athlete
• Appears dazed, stunned, confused
• Headache or “pressure” in head
• Forgets sports plays • Nausea or vomiting • Moves clumsily • Balance problems, dizziness,
double/blurred vision • Answers questions slowly • Sensitivity to light and/or noise • Loses consciousness (even briefly) • Feeling sluggish, foggy, or
groggy • Shows behavior or personality
changes • Concentration or memory
problems • Cannot recall events prior to or
after hit or fall • Confusion or does not “feel
right”
TABLE 29-6 Recognizing a Concussion in an Athlete
From U.S. Department of Health and Human Services: Heads up, concussion in youth sports: a fact sheet for coaches, 2013b. Available at www.cdc.gov.
658 PART 5 Health Promotion with Target Populations Across the Life Span
strangulation (56%) and falls (20%) to the playground surface, with most of these deaths (70%) occurring on home play- grounds (CDC, 2012d).
The U.S. Consumer Product Safety Commission has pub- lished guidelines for public and home playground safety. Guide- lines cover structure, materials, surfaces, and maintenance of equipment: • Playgrounds should be surrounded by a barrier to protect
children from traffic. • Activity centers should be distributed to avoid crowding in
one area. • Surfaces should be finished with substances that meet Con-
sumer Product Safety Commission (CPSC) regulations for lead.
• Durable materials should be used. • Sand, gravel, wood chips, and wood mulch (not CCA treated)
are acceptable surfaces for limiting the shock of falls. • Equipment should be inspected regularly for protrusions
that could puncture skin or entangle clothes. • Inspect equipment for openings/angles that allow for pos-
sible head entrapment. • Multiple-occupancy swings, animal swings, rope swings, and
trampolines are not recommended. The developmental skills of specific ages are incorporated, as well as recommendations for physically challenged children. Nurses can use these guidelines to help the community establish standards for play areas (Figure 29-7).
Nurses share responsibility in the prevention of intentional and unintentional injuries in the pediatric population. Assess- ment of the characteristics of the child, family, and environment identifies risk factors. Interventions include anticipatory guid- ance, modification of the environment, and safety education. Education focuses on age-appropriate interventions based on knowledge of leading causes of death and risk factors. Topics to consider are listed in Box 29-1.
differences in the death rates between the settings but noted a difference in the firearm intent that resulted in deaths for chil- dren and adolescents. The urban victims died from high rates of firearm homicide while the rural victims experienced high rates of firearm suicide and unintentional firearm-related acci- dental deaths. This study provides evidence that to reduce firearm mortality effectively, prevention strategies should be geared for the specific type of firearm injury issue within the community of interest (Nance et al, 2010).
Characteristics associated with gun violence include history of aggressive behaviors, poverty, school problems, substance abuse, and cultural acceptance of violent behavior. Young chil- dren are inquisitive and often imitate in play what they see in the media and on television. A significant number of accidental firearm injuries and deaths in children occur in the homes of friends and family members (AAP, 2012b). Interventions must begin early and address each of these factors.
The Healthy People 2020 objectives seek to reduce the number of high school students who carry weapons. Nurses can actively participate in efforts to reduce gun violence among young people in the following ways (AAP, 2012c): • Urge legislators to support gun control legislation, assault
weapons bans, and eliminate gun show loopholes. • Collaborate with schools to develop programs to discourage
violence among children. • Encourage families to remove guns from their homes. If
unable to do this, educate families to: • Store all firearms unloaded and uncocked in a securely
locked container. Only the parents should know where the container is located.
• Store the guns and ammunition in separate locked locations.
• When handling or cleaning a gun, never leave it unat- tended, even for a moment; it should be in the parent’s view at all times.
• Initiate community programs focusing on gun storage and safety at school.
• Educate parents on communicating with the homeowners of the homes their children visit regarding gun access and safety.
• Children and adolescents learning to hunt in rural areas should take gun safety courses.
• Identify populations at risk for violence and target aggres- sion or anger management.
• Discourage mixing alcohol or drugs with guns. • Encourage families to avoid gun violence in media sources
at home. Promoting Safe Playgrounds and Recreation Areas. Schools,
daycare centers, families, and community groups often need guidance toward developing safe places for children to play. Each year, more than 200,000 children are treated in emergency departments for injuries sustained on playgrounds and play sets. Approximately 45% of playground-related inju- ries are severe injuries and include fractures, internal injuries, concussions, dislocations, and amputations. Between 1990 and 2000, 147 children under the age of 14 died from playground-related injuries. These deaths were attributable to
FIG 29-7 Playground injuries are frequent among young children.
659CHAPTER 29 Child and Adolescent Health
is diagnosed with influenza, parents can be instructed to keep children at home until symptoms have improved and fever has been gone for 24 hours. Nurses can be actively involved in developing community-based policies in the event of a pan- demic, and this may include plans for mass immunizations, specific flu clinics, and protocols for school closures (Aronson & Shope, 2013).
SIDS/SUIDS Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant under 1 year of age that remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history (AAP, 2011b). Sudden unexpected infant death (SUID) is a term that describes any sudden and unexpected death that occurs in infancy; this includes both explained (i.e., suffocation, infection, trauma) and unex- plained cases (SIDS). The peak age for SIDS deaths occurs between 2 and 3 months of age, although SIDS may occur up to 1 year of age. There are specific independent risk factors for SIDS (AAP, 2011b): • Prone or side-lying sleep position • Sleeping on a soft surface • Maternal smoking during pregnancy • Overheating • Late or no prenatal care • Young maternal age • Preterm birth and/or low birth weight • Male gender • Lack of immunizations
HEALTH PROBLEMS OF CHILDHOOD Acute Illnesses Acute illnesses are those illnesses with an abrupt onset and are usually of a short duration. For children, it is common for viruses to spread easily through daycares, preschools, and school systems. Nurses use developmental factors at each age to plan assessment and intervention strategies to prevent the spread of illnesses between children. Community-focused interventions, education, and programs can prevent many childhood illnesses.
Hand washing is a simple and reliable strategy to reduce the incidence of acute illnesses in children. The How To box below provides guidelines for the nurse to teach families about hand washing. Infants and young children are particularly at risk for contracting viral and bacterial illnesses spread by contact because their immune systems are not yet fully developed. Focusing community education on preschools, daycare centers, and other programs that serve the families of infants and young children can reduce the occurrence of acute illnesses (Aronson & Shope, 2013).
Several strategies can be used to reduce the occurrence of acute illnesses as follows: sanitizing objects such as toys that are handled by multiple children each day to prevent the spread of diseases; practicing good hand hygiene and diaper disposal techniques in daycares to prevent the spread of illnesses; and educating parents, daycares, and schools on when to keep chil- dren home to prevent putting others at risk for illness (Aronson & Shope, 2013).
Influenza is a common viral illness that affects children and adolescents primarily during the winter months. It is a highly contagious acute febrile illness of the nose, throat, and lungs that leads to missed school days and can result in complications including pneumonia and infrequently death. The best preven- tion strategy is vaccinations for all children ages 6 months and above. It is important to educate families about the need for vaccination and home management of symptoms (Aronson & Shope, 2013).
Nurses can focus on preventive measures and promote high vaccination rates, good hand washing hygiene and early identi- fication to prevent the spread of illness. If a child or adolescent
HOW TO Teach Families About Hand Washing Use the guidelines below when counseling families about hand washing.
Always wash your hands before: • Preparing foods • Eating • Touching someone who is sick • Inserting or removing contact lenses Always wash your hands after: • Preparing foods, particularly raw meats or poultry • Using the toilet • Changing a diaper • Touching animals, animal toys, leashes, or animal waste • Blowing your nose, coughing, or sneezing into your hands • Touching someone who is sick
Or anytime you feel that your hands need washing! How to wash your hands: • Wet your hands with warm running water • Apply soap (liquid, bar, or powder) • Lather your hands well • Rub your hands vigorously for at least 20 seconds (sing the
“Happy Birthday” song)—scrub all surfaces including between your fingers, under your nails, backs of your hands, and your wrist
• Rinse your hands well • Dry your hands with a clean towel, disposable towel, or air dryer • Use your towel to turn off the faucet if possible
(See also the Evolve website)
• Car restraints, seat belts, air-bag safety • Preventing fires, burns • Poison prevention • Preventing falls • Preventing drowning, water safety • Bicycle safety • Safe driving practices • Sports safety • Pedestrian safety • Gun control • Decreasing gang activities • Substance abuse prevention
BOX 29-1 Injury Prevention Topics
660 PART 5 Health Promotion with Target Populations Across the Life Span
• What types of treatments and therapy are required and with what frequency?
• How often are health care visits and hospitalizations required?
• To what degree are the family routines disrupted? The common issues nurses will want to evaluate for these
families include the following: • All children and adolescents with chronic health problems
need routine health care. The same issues of pediatric health promotion and acute health care need to be addressed with this group. The use of the medical home (discussed later in the chapter) is very important for this population.
• Ongoing medical care specific to the health problem needs to be provided. Examples include monitoring for complications of the health problem, medications manage- ment, dietary adjustments, and coordination of therapies. Evaluation of the effectiveness of the treatment plan is critical.
• Care is often provided by multiple specialists. There is a need for coordinating the scheduling of visits, tests or procedures and the treatment regimen.
• Skilled care procedures are often required and may include suctioning, positioning, medications, feeding techniques, breathing treatments, physical therapy, and use of appliances.
• Equipment needs are often complex and may include moni- tors, oxygen, ventilators, positioning or ambulation devices, infusion pumps, and suction machines.
• Educational needs are often complex. Communication between the family, the team of health care providers, school administrators, and teachers is essential to meet the child’s health and educational needs.
• Safe transportation to health care services and school must be available. Several barriers may exist, including family resources, location, and the burden of supportive equipment.
• Financial resources may not be adequate to meet the needs. • Behavioral issues include the effect of the condition on the
child’s behavior as well as on other family members. The ultimate goal is for children with chronic health condi-
tions to achieve optimal health and functioning. Identifying barriers for individual families and overall community barriers is a focus for nurses. Developing support groups, advocating for improved community access to resources, and educating those working with these children on their conditions and needs will promote the family’s functioning. The How To box below details a community nursing approach to supporting a child with ADHD.
Mental Health Psychosocial stressors have increased over the years for children and mental health issues are a priority health concern for chil- dren and adolescents. There are many underlying causes for mental health problems in children, ranging from lead poison- ing to exposure to violence in the home. Approximately 1 in 5 children and adolescents in the United States has a diagnosable mental health disorder. Children who live in poverty, live with
There are consistently higher rates of SIDS in non-Hispanic black and American Indian/Alaska Native infants—two to three times the national average. The incidence has decreased more than 50% since the “Back to Sleep” campaign was promoted in 1994. There is no test to identify infants who may die, making this a frustrating clinical problem. Nurses should teach the pre- ventive measures that follow: • Supine position only for infants—no side lying or prone • No smoking during pregnancy or in home after birth • Use a firm sleep surface—no soft bedding, no pillows, no
stuffed animals, no sleeping on chairs or sofas, no sleeping with adults or in a waterbed
• Offer a pacifier at naptime and bedtime—reduces risk • Avoid overheating and overbundling—room temperature
should be between 68° and 72° F • Continue “Back to Sleep” campaign (AAP, 2011b)
When an infant dies from SIDS, the family requires tremen- dous support. The nurse provides empathetic support and assists the family as they progress through the grief process and provides guidance for siblings and other family members. Referral to support groups may be helpful.
Oral Health Oral health is recognized as an integral component of overall health for children and adolescents. Dental caries in early child- hood has been identified by the CDC as one of the most preva- lent infectious diseases and the incidence is more common in children living in poverty or low socioeconomic status. Access to pediatric dental care is a barrier to meeting the oral health care needs of children in the United States (Hallas & Shelley, 2009).
Nurses are well positioned to provide oral health screenings and to educate families on preventive oral health topics. Chil- dren should be referred to a qualified dentist by 1 year of age. Families should receive anticipatory guidance on optimal use of fluorides, proper nutrition and dietary practices, prevention of poor oral health habits and tooth decay, age-appropriate dental injury prevention, and proper care of teeth and gingival tissue (AAP, 2008).
Chronic Health Conditions Improved medical technology has increased the number of chil- dren surviving with chronic health problems. In addition, envi- ronmental factors are leading to an increase in certain chronic health conditions. At present, it is estimated that about 26% of American children have a chronic health condition (Van Cleave et al, 2010). Some examples of common chronic conditions in children are Down syndrome, spina bifida, cerebral palsy, asthma, ADHD, diabetes, congenital heart disease, cancer, hemophilia, bronchopulmonary dysplasia, and AIDS.
Despite the differences in the specific diagnoses, all of these families have complex needs and face similar problems. Several variables exist to assess for each child and family: • What is the actual health status? Is the condition stable or
life threatening? • What is the degree of impairment to the child’s ability to
develop?
661CHAPTER 29 Child and Adolescent Health
Bullying Bullying has always been an issue for children and adolescents. With the extensive use of texting, e-mails, social networking, and other means of electronic communication among tweens and adolescents, cyber bullying has become a significant problem within communities. Girls are more likely to be victims of cyber bullying, and victims report thinking about self-harm and/or suicide as a result of bullying. Cyber bullying includes sending hurtful messages, starting rumors and uploading and sharing unflattering or altered photographs of the victims via an electronic means. Many cyber bullies use avatars or other ways of disguising their true identity, which makes it difficult for the victim to know who the bully is. The victims often do not report cyber bullying for fear of retaliation from the bully and experience emotional and behavioral symptoms along with school-related problems (Suzuki et al, 2012).
Environmental Health The built environment that children and adolescents live in directly affects their health. Growth, size, and behaviors place the pediatric population at greater risk for damage from various toxins. Lead poisoning is one of the most common environmental health hazards. Pesticides, mercury exposure, plasticizers, and poor air quality also pose serious risks (National Institute of Environmental Health Science, 2014). Common toxins and sources of pediatric exposure are listed in Table 29-7.
Growing tissues absorb toxins readily. Developing organ systems are more susceptible to damage. Smaller size means increased concentration of toxins per pound of body weight. The fact that children are short exposes them to lower air spaces, where heavy chemicals tend to concentrate. Outdoor play, espe- cially during summer months, increases the opportunity for exposure to air pollutants. Chewing and mouthing behaviors offer contact to toxins such as lead. Playing on the floor increases exposure to chemicals in rugs and flooring. Rolling and playing in grass can result in pesticide exposure and playground materi- als that are treated with chemicals put children at risk. Exposure risks for adolescents are similar to those for adults and are pri- marily through work, school, and hobbies (NIEHS, 2014).
It is critical to assess for these environmental health hazards during health care visits. Referral for treatment may be neces- sary. Counseling families on risk reduction is important to chil- dren’s health. Population-focused nurses identify environmental problems within the community and target at-risk populations with community interventions (see Table 29-8 for examples). Bringing screening programs into neighborhoods at risk may facilitate early identification and prevent complications. Lobby- ing efforts and education can effect public policy changes to make the environment healthier. The following case presenta- tion gives an example of how a school environment can lead to health problems.
A child’s built environment includes exposure to media and the resulting influence on behavior and choices. Food and bev- erage corporations spend over $1.6 billion each year on advertis- ing that specifically targets children. Much of this advertising uses licensed cartoon characters to promote food products, and
a single parent, or are exposed to violence are at higher risk for developing a mental health condition. Only 21% of children with a mental health or substance abuse problem are currently receiving treatment (AACAP, 2009).
Some of the common mental health problems diagnosed in children and adolescents are anxiety disorders, autism spectrum disorders, depression, bipolar disorder, conduct disorder, oppo- sitional defiant disorder, and substance abuse (AACAP, 2009). Each of these mental health diagnoses has a specific set of cri- teria for diagnosis found in the DSM-V. Early recognition and coordinated management of pediatric mental health issues is critical to a child’s functioning in school, home, and the community.
More than 2 million U.S. children during the past 10 years have experienced the stress and emotions associated with being separated from a parent deployed for active duty. These children experience symptoms of depression (25%), excess worry (50%), and sleep problems (50%). By understanding the stressors of military deployment, nurses can identify and provide the support (and referrals) needed to help these children (Siegle & Davis, 2013).
Many families can be at a loss for the behaviors or symptoms they observe in their child. A sense of embarrassment may prohibit parents from seeking help. Nurses can be instrumental in promoting community awareness about common mental health problems in children and identifying resources for families. The use of the medical home to coordinate manage- ment of mental health problems is important in the ability to provide oversight of subspecialties, medications, and therapies. A challenge for treating pediatric mental health disorders is an inadequate number of practitioners specializing in pediatric mental health, which may leave some families without adequate support and resources (AAP, 2009b).
HOW TO Implement a Community Nursing Approach to a Chronic Illness: ADHD The following describes the steps the nurse in the community will follow to support a child with ADHD: • Assessment: Obtaining history, physical, parent/family assess-
ment, environmental assessment, learning, and psycho- educational evaluations
• Behavioral modifications: (home and school) Teaching families techniques to support clear expectations, consistent routines, positive reinforcement for appropriate behavior, and conse- quences for negative behaviors
• Classroom modifications: Consulting with family and teachers to meet individual needs for remediation or alternative instruction methods if necessary; structuring activities to respond to the child’s needs
• Support: Referring family to family therapy/counseling, support groups, or mental health services to assist development of posi- tive coping behaviors
• Medications: Consulting with physician to monitor and evaluate therapeutic and adverse effects
• Follow-up: Assessing at 3- to 6-month intervals when stable; dynamic process affected by relationships with others; behaviors will change with age; problem may persist through adulthood
662 PART 5 Health Promotion with Target Populations Across the Life Span
From: National Institutes of Environmental Health: Your Environment your health, 2015, Triangle Park, North Carolina, Accessed at www.NIEHS. Nih.gov. March 24, 2015.
Toxins Sources
Arsenic Food, water Asbestos Building materials: insulation, ceilings, floor tiles Carbon monoxide Space heaters, woodstoves, fireplaces, engine exhaust, tobacco smoke Dioxins Contaminated foods, water, and soil Lead Paint, dust, soil, water, occupational exposure (e.g., battery plant), hobbies (e.g., stained glass) Mercury Water contamination, fish, thermometer/sphygmomanometer breakage Molds Food, ubiquitous to moist outdoor and indoor environment Nitrites, nitrates Water, food Nicotine, benzene, tars Environmental tobacco smoke Particulate matter-nanomaterials Outdoor air pollution, dust mites, animal dander, roach parts Pesticides Food, soil, plants, water, air, topical application for lice treatment, home and school insect management Phthalates and bisphenol (BPA) Linings of canned foods, children’s toys, vinyl flooring, hard plastics made of polycarbonate (many sports water bottles
and baby bottles) Radon Soil and rock, the air, ground water, surface water Solvents/volatile organic compounds Furniture, carpet, building materials, solvents and degreasers, cleaning products, acetone, formaldehyde Styrene vapors from building materials, photocopiers, tobacco smoke Ultraviolet light Outdoor sun exposure, tanning beds
TABLE 29-7 Common Environmental Agents Hazardous to Children
Prevention Strategies Examples
Primary Identification of at-risk populations Substandard housing communities
Pregnant women Children with asthma
Health education about environmental risks Poison prevention Responses to poor air quality alerts Discontinue use of plasticizers
Formation of public health policies Air/water quality standards Safety inspections: playgrounds, schools, daycare centers Standards for lead levels in imported products intended for children
Research to assess impact of environmental hazards on the pediatric population
Developing reference ranges/biological markers to assess toxic levels in children Identify long-term physiological and cognitive consequences of exposure to environmental toxins
Secondary Early detection, treatment, and referral for
management of environmental toxins Removal of at-risk persons when lead hazards are detected
Assessment of lead levels of populations of at-risk children with treatment of individuals as indicated
Tertiary Restoration of environment and occupants
to healthier state Asbestos/lead abatement of buildings
Radon remediation of homes Replacement of heating, ventilation, air conditioning, systems contaminated with mold Chelating agents for individuals with lead toxic levels
TABLE 29-8 Prevention Strategies Applied to Environmental Hazards
Modified from Burns C, Dunn A, Sattler B: Resources for environmental health problems. J Pediatr Health Care 16:3, 2002.
the majority of those products are of poor nutritional value. The heart of the question is whether this advertising is effective in influencing children’s food choices. A study by Roberto et al (2010) looked at the preferences of preschool children for food packaged with a licensed cartoon character. The study found that preschoolers rated the taste of the foods packaged with the licensed character over the identical food without the character packaging. The children also selected the high-density character- packaged foods more often. Nurses in the community can use
this information to provide guidance to parents to limit expo- sure to television and media, make healthy food choices for their children, and avoid unhealthy foods packaged with licensed cartoon characters. Nurses can also advocate for stricter adver- tising laws for those unhealthy foods targeted to children.
Lead Poisoning Lead is a heavy metal that is absorbed into the body primarily through ingestion. Lead poisoning is defined as a serum lead
663CHAPTER 29 Child and Adolescent Health
Mercury Mercury is another heavy metal that is highly toxic. The most common exposure for humans is the ingestion of contaminated fish. Mercury poisoning is determined with a blood mercury level of 5.8 µg/L or above. Mercury poisoning can result in significant developmental deficits with the fetuses of pregnant women at particular risk. Screening for dietary intake and other possible exposures is critical to identification of risk factors (Bose-O’Reilly et al, 2010). The nurses’ responsibility is to educate families on how to minimize mercury exposure risks. It is recommended that families eat commercially caught fish that are low in mercury (tilapia, Alaskan salmon, herring). For pregnant women, women of child-bearing age, breastfeeding mothers, and young children, these steps are recommended: • Avoid ingesting shark, tilefish, and king mackerel because of
the high mercury levels • Limit intake of tuna to 4 to 6 ounces each week and all other
fishes to 12 ounces each week
Plasticizers Phthalates and bisphenol (BPA) are chemicals that are commonly added to plastics to create flexibility and durability. Exposure to these products has caused significant adverse health effects in animal studies. Human studies have noted a link between BPA and cardiovascular and liver disease. The possible exposures for children are many and include the linings of canned foods (ready- to-feed formulas), children’s toys, and hard plastics made of poly- carbonate (many sports water bottles and baby bottles). Increased exposure occurs when these products are exposed to high heat, which occurs with the sterilization of baby bottles. The half-life of these plasticizers is very short, which makes it difficult to thoroughly screen for exposure (Galvez et al, 2009).
The Consumer Products Safety Improvement Act of 2008 provided guidelines for eliminating these plasticizers nationally from children’s products. Continued education of families is needed until all of these plasticizers are no longer available for purchase; recommendations on avoiding second-hand chil- dren’s products should be promoted (Consumer Product Safety Commission, 2013).
Environmental Tobacco Smoke Environmental tobacco smoke (ETS) is exhaled smoke, smoke from burning tobacco or smoke from the mouthpiece or filter end of a cigarette, cigar or pipe. Cigarettes have many known poisons, and both cigarettes and ETS were classified as Class A known human carcinogens in 1992 by the Environmental Pro- tection Agency (EPA). Parents often do not understand or believe the effects of smoking on children. Children, particu- larly those under age 5 years and those living in poverty, have higher levels of exposure to ETS. The recent introduction of electronic cigarettes is also considered to be a risk for ETS. An initial study found cancer-causing substances in all of the e-cigarette samples that were tested (Goniewicz et al, 2013).
Children exposed to ETS experience increased episodes of middle ear infections, asthma, upper respiratory tract infec- tions, and more missed school days. Prenatal exposure to ETS is linked to preterm births, low birth weight, and increased risk
LEVELS OF PREVENTION
Lead Poisoning Obesity
Primary Prevention Primary Prevention Community education about lead
exposure, lead sources in the community, and the adverse health consequences for children.
Offer healthy cooking classes for families in the community.
Secondary Prevention Secondary Prevention Implement universal screening for all
children ages 1 and 2 years that present to the community health centers and primary care practices.
Conduct child body mass index screenings in community daycares and preschools.
Tertiary Prevention Tertiary Prevention Provide families with guidance and
resources for lead abatement and to eliminate lead exposure for children with blood lead levels >10 µg/dL.
Develop individualized weight loss plans and counsel children identified as obese on lifestyle changes.
• Read recall notices from the CPSC (www.cpsc.gov) and do not buy recalled toys.
• Check old toys at home to make sure they have not been recalled. • Avoid purchasing toys secondhand from yard sales and flea markets. • Check labels and recommended ages on all toy labels and follow
recommendations. • Do not purchase children’s costume jewelry or allow children to play with
adult costume jewelry.
BOX 29-2 Steps to Minimize Lead Exposure in Contaminated Toys and Products
level above 10 µg/dL and it causes significant neurologic, car- diovascular, and renal disease. A Healthy People 2020 goal is to eliminate elevated blood lead levels in all children. More than 310,000 children younger than 5 years have elevated lead levels, and the most common exposure is through lead-based paints and lead-contaminated soil and dust in houses built before 1987 (Warniment et al, 2010).
Another exposure risk is through imported toys and costume jewelry that are painted with a lead-based paint. Young children are exposed through their mouthing behaviors. If a piece of contaminated costume jewelry is accidentally swallowed, the high lead concentration can result in death. In 2007, the U.S. Consumer Products Safety Commission (CPSC) issued numer- ous recalls for these toys and passed the Consumer Product Safety Improvement Act in 2008 which requires third-party testing and certification of all imported toys and products mar- keted to children (Galvez et al, 2009).
Universal screening for lead poisoning of all children at ages 1 and 2 years is recommended. This screening is recommended when children receive well-child or EPSDT screening at regular intervals. In addition, families should be assessed for environ- mental risk factors to determine the need for screening at other ages. Specific guidelines for minimizing lead exposure through contaminated toys are included in Box 29-2.
664 PART 5 Health Promotion with Target Populations Across the Life Span
for several childhood cancers. Prenatal exposure is also linked to the fetal brain becoming sensitized to nicotine, leading to greater addiction when exposed at an older age. Children living in smoking households with a parent role modeling smoking are more likely to start smoking (AAP, 2009c).
Interventions to discourage smoking focus on the parent, the child or adolescent, and public policy. Nurses in public health should offer educational programs for parents dealing with the negative effects of smoking on children, specific interventions to stop smoking, and ways to create a smoke-free environment. Anti-smoking programs directed toward children and teenagers are more successful if the focus is on short-term effects rather than on long-term effects. Developmentally, children and teenagers cannot visualize the future to imagine the conse- quences of smoking. Teaching social skills to resist peer pressure is critical (CDC, 2014c).
Nurses should become politically active in the area of smoking. Policies to ban tobacco advertising, enforce restric- tions of sale to minors, increase funds for anti-smoking educa- tion, and restriction of public smoking may reduce the incidence of smoking. Community-based interventions to reduce smoking and ETS exposure are included here. • Collaborate with schools to provide tobacco-free environ-
ments (for all school facilities, vehicles, and events). • Work with schools to provide prevention curricula in ele-
mentary, middle, and high schools. • Develop or identify smoking cessation programs and provide
information to health care providers and workplaces in the community.
• Provide education to families on the dangers of ETS expo- sure for children and adolescents.
• Partnership with community merchants to enforce minors’ access laws
• Advocate for local policy change to limit smoking in public and private enterprises (CDC, 2014c).
MODELS FOR HEALTH CARE DELIVERY TO CHILDREN AND ADOLESCENTS Nurses are in a position to work with specific populations through programs targeting the health care needs of children and particu- larly those at risk. In the following section, strategies for promot- ing the health care of children and adolescents are described.
Family-Centered Medical Home A family-centered medical home is a partnership between a child or adolescent, the child or adolescent’s family, and the pediatric team who oversees the child or adolescent’s health and well-being within a community-based system that provides uninterrupted care to promote optimal health outcomes. The medical home incorporates preventive, acute, and chronic care from birth through transition to adulthood. The medical home emphasizes an integrated health system with collaboration of care from an interprofessional team of primary care physicians, specialists and subspecialists, other health professionals, hospi- tals and health care facilities, public health, and the community working with children and families (Malouin, 2013).
Approximately 58% of all children have a medical home com- pared with 47% of children with special health care needs. It is imperative to increase the use of medical homes for all children, particularly children with special health care needs (Homer et al, 2008). A child with Down syndrome will greatly benefit from col- laborative care from the primary care provider, subspecialty physi- cians, school system, community therapists, family support groups, and other community resources to achieve optimal health.
A successful medical home relies on the multitude of sup- ports that are brought to the service delivery system that sur- rounds the family and community. Families can trust that there is a place where their child or adolescent is provided holistic care that addresses all aspects of physical, mental, and emo- tional health. The medical home is not a specific building, but it is a system of care that is accessible, continuous, compre- hensive, coordinated, compassionate, and culturally effective. Nurses in the community play an active role as a team member of the medical home by identifying resources for families, refer- ring families to a medical home, and participating in the health care of children in medical homes.
Motivational Interviewing Motivational interviewing is a focused communication strat- egy in which the parents are encouraged to set goals, identify personal barriers, and identify potential mechanisms to over- come the barriers to make safety and health promotion changes for their child. This can be an effective intervention to promote healthy changes within the family environment (Barnes, 2012). It can be easily implemented by nurses in primary care settings and public health clinics under limited time constraints and is readily incorporated into the medical home model.
Motivational interviewing emphasizes a collaborative approach to behavior change instead of a prescriptive approach (Figure 29-8). Nurses use open-ended questioning and reflec- tion to encourage the parent or adolescent to share their identi- fied barriers to change. When individuals demonstrate positive comments toward change, the nurse expands upon those
FIG 29-8 Motivational interviewing is an effective way for nurses to intervene with families and promote positive behav- ioral change in the home.
665CHAPTER 29 Child and Adolescent Health
• Children’s service clinics • Well-child clinics • Immunization clinics • Infectious disease clinics • Children’s specialty services • Family violence/child abuse centers • Homeless shelters • School health programs • Head Start • Parents Anonymous • Crisis hotlines • Community education classes • Early intervention/developmental services • Childbirth education classes • Breastfeeding support groups • Parent support groups • Family planning clinics • Women, Infants, and Children (WIC) programs • Medicaid and CHIP • Youth employment/training programs
BOX 29-3 Community Resources for Pediatric Health Care
LINKING CONTENT TO PRACTICE
In this chapter, emphasis is placed on the community health needs of children and adolescents within the context of the family. The public health core func- tions of disease prevention, health promotion, and the three levels of health services are directly related to the pediatric population and their specific popula- tion needs. To meet the core public health competencies, nurses must learn how to assess children and adolescents using developmental principles to determine safety risks for injury and environmental health exposures. Policy and program development for the pediatric population is geared toward improving the built environment in which a child grows and providing parents with education on health promotion strategies like smoking cessation to improve their child’s
health. Nurses develop competencies in communication strategies with children of varying developmental levels and recognize the various locations in the com- munity that need education on promoting the health of children (e.g., daycare centers, schools). Basic health services such as well-child care and immuniza- tions are critical to the health of the pediatric population, and the nurse is poised as a leader within the medical home model of health care delivery for children and adolescents. This chapter prepares the community health nurse to provide comprehensive, developmentally appropriate education to families; deliver basic health care services in a holistic approach; and develop community programming to improve safety and environmental wellness for children and adolescents.
comments and provides further support for that change. This strategy is very effective with positive health behavior changes such as smoking cessation, healthy eating, and safety behaviors. (See Appendix F.1 in the back of the book.)
ROLE OF THE POPULATION-FOCUSED NURSE IN CHILD AND ADOLESCENT HEALTH Population-focused nurses have the opportunity to work with families to achieve growth toward many of the Healthy People 2020 objectives. They practice in a variety of settings, including community health centers, school-based clinics, and home health programs. They provide care through well-child clinics, immunization programs, federally mandated programs (such as the nutrition program Women, Infants, and Children [WIC]) or specific state-funded programs, such as Head Start.
With passage of the ACA, strategies to implement improved access include expanding the role of nurses and the settings for practice. The nursing process and a knowledge base of the factors unique to the pediatric population provide a framework of care. Nursing, through developing and coordinating community ser- vices and through formation of public policies, promotes the well-being of children and families within the community. Assessments are made to identify the needs and target popula- tions at risk. Programs based on the needs of specific at-risk populations are developed for the delivery of health care.
The nursing plan of care includes three major components. The first is the management of actual or potential health prob- lems. The second involves both education and anticipatory guidance. This enables families to understand what to expect in the areas of growth and development as well as social,
emotional, and cognitive changes. Nurses offer information to promote healthy lifestyles and to prevent acute and chronic health problems as well as unintentional injuries. A third role is case management or coordination of care. For example, the nurse coordinates referrals to community agencies, other health care services or providers or assistance programs. Box 29-3 lists community resources.
666 PART 5 Health Promotion with Target Populations Across the Life Span
From: US Department of Health and Human Services: Healthy People 2020, Wash DC, 2010, US Government Printing Office.
HEALTHY PEOPLE 2020
Education and Community-Based Programs • ECB-4: Increase the proportion of elementary, middle, and senior high schools
that provide school health education to promote personal health and wellness in the following areas: hand washing or hand hygiene; oral health; growth and development; sun safety and skin cancer prevention; benefits of rest and sleep; ways to prevent vision and hearing loss; and the importance of health screenings and checkups.
• ECB-7: Increase the proportion of middle, junior high, and senior high schools that provide comprehensive school health education to prevent health prob- lems in the following areas: unintentional injury; violence; suicide; tobacco use and addiction; alcohol or other drug use; unintended pregnancy; HIV/AIDS and STD infection; unhealthy dietary patterns; inadequate physical activity; and environmental health.
Environmental Health • EH-8: Eliminate elevated blood lead levels in children.
Immunizations and Infectious Disease • IID-7: Achieve and maintain effective vaccination coverage levels for univer-
sally recommended vaccines among young children.
Injury/Violence Prevention • IVP-16: Increase use of age appropriate child restraints in cars.
Nutrition and Weight Status • NWS-10: Reduce the proportion of children and adolescents who are over-
weight or obese.
Physical Activity and Fitness • PA-4: Increase the proportion of the nation’s public and private schools that
require daily physical education for all students.
Tobacco Use • TU-15: Tobacco-free environments in schools, including all school facilities,
property, vehicles, and school events.
Objectives Focused on Children and Adolescents
P R A C T I C E A P P L I C A T I O N Sam is a 4-year-old boy brought to the clinic by his mother for his 4-year well-child check and immunizations. Sam will be attending the local Head Start program in the fall. He is the oldest of three children and his siblings are 9 months and 35 months. His mother is a single parent who works at a local restaurant as a waitress. Sam and his siblings are insured by Medicaid. Sam’s mother is 24 years old and the family lives with the maternal grandparents. Sam’s mother is in good health and does not smoke or abuse drugs. Sam has been watched by his grandmother since birth and is exposed to cigarette smoke in the home by both grandparents.
On the developmental exam, Sam is very cooperative, eager to please, and speaks clearly. His development is significant for failure to identify three colors, count to 5, or recognize any letters. His gross motor skills are appropriate but he only scrib- bles when given a crayon. Sam reports watching television shows with his family for fun. On physical examination, Sam has a >95th percentile BMI for age/gender but no other abnor- mal exam findings are noted. Hearing and vision are within normal limits for age.
Based on the previous scenario, answer the following questions: A. What additional history and assessment information should
you collect based on the child’s home environment? B. What immunizations and lab tests are indicated based on his
age and risk factors? C. What education should you give this mother on changes in
the home to promote development? To reduce ETS expo- sure? To ensure safety?
D. Based on the BMI percentile, what additional nutrition and dietary practices information should you obtain?
E. What interventions and education should you provide to this mother regarding Sam’s obesity and associated risk factors?
F. In an analysis of the Medicaid child population in Sam’s medical home, the population-focused nurse found that a number of children had similar risk factors. Is there a population-level intervention the nurse may want to use to reduce the risk in the future child population? Answers can be found on the Evolve site.
K E Y P O I N T S • Physical growth and development is an ongoing process
resulting in physical, cognitive, and emotional changes that affect health status.
• Good nutrition is essential for healthy growth and develop- ment, and it influences disease prevention in later life.
• Childhood obesity is increasing in prevalence. Modifiable risk factors include dietary intake, physical activity, and screen viewing time.
• Immunizations are successful in prevention of selected dis- eases. Barriers to immunizing children are parental concerns,
667CHAPTER 29 Child and Adolescent Health
K E Y P O I N T S — cont’d cost, vaccine shortages, and changes in recommended vaccine scheduling.
• The built environment is influential on a child’s physical, emotional, and psychosocial health. Nurses can design inter- ventions for families and communities to improve a child’s environment if improvement is indicated.
• The family is critical to the growth and development of the child. Social support has a powerful influence on successful parenting.
• Unintentional injuries are the major cause of morbidity and mortality in the child and adolescent population. Most are preventable. Nurses have a major role in anticipatory guid- ance and prevention.
• Population-focused nurses have a strong role in the preven- tion of, identification of, and education about child mal- treatment. Child advocacy is critical to reduce the incidence of abuse and neglect in childhood.
• Minimizing complications of the major health risks to the pediatric and adolescent population follows the goals of Healthy People 2020 initiatives.
• The pediatric population is vulnerable to environmental hazards. Decreasing exposure and identifying problems early are important areas for interventions by population-focused nurses.
• Nurses are involved in strategies to meet the needs of the pediatric population and their families in the community.
• The family-centered medical home is a successful system for coordinating health care for children and for facilitating con- tinuous family support and health management.
• Children who are low income or live in poverty are at increased risk for violence, injuries, and environmental hazards.
• The use of motivational interviewing can facilitate positive health behavior changes for families with children.
REFERENCES American Academy of Child and
Adolescent Psychiatry: Committee on health care access and economics task force on mental health: improving mental health services in primary care: reducing administrative and financial barriers to access and collaboration. Pediatrics 123(4):1248–1251, 2009.
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C L I N I C A L D E C I S I O N - M A K I N G A C T I V I T I E S 1. Develop a plan of immunization for a 5 1 2-year-old who has
had one DTaP, Hib, and IPV. Be specific about due dates for immunizations.
2. Develop a screening program for children and adolescents who live in a low-income older neighborhood with a large percentage of Hispanic residents. What risk factors would you consider in the process? Have you examined the thoughts of others in the community that might affect the success of the screening program? Be specific.
3. Plan a survey of a school district to determine its “friendli- ness” to children with chronic health problems. How would you implement changes?
4. Develop a community program for smoking cessation. Iden- tify how you will target parents and caregivers of children.
Discuss how you will incorporate the concept of ETS expo- sure in your program.
5. Develop nutrition education programs for (1) mothers who are breastfeeding their infants, (2) a group of 5-year-olds in a kindergarten class, and (3) a group of high school sopho- mores. What factors do these programs have in common? How do they differ?
6. Administer a safety survey (e.g., the Injury Prevention Program [TIPP] from the American Academy of Pediatrics, or develop your own) to assess the home environment of a 6-month-old and a 5-year-old. Develop a plan of education and anticipatory guidance for the family. How would you apply this information to a larger population?
668 PART 5 Health Promotion with Target Populations Across the Life Span
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669CHAPTER 29 Child and Adolescent Health
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Major Health Issues and Chronic Disease Management of Adults Across the Life Span
30
A D D I T I O N A L R E S O U R C E S Evolve Website http://evolve.elsevier.com/Stanhope
• Healthy People 2020 • Quiz • Case Studies • WebLinks—Of special note see the links for these sites:
• American Cancer Society • American Diabetes Association • American Heart Association • American Stroke Association • CDC Men’s Health • Food and Drug Administration • Men’s Health Network • National Cancer Institute
• National Center for Complementary and Alternative Medicine
• National Institute of Mental Health • National Women’s Health Information Center • United States Department of Health and Human
Services • Glossary • Answers to Practice Applications • Resource Tools
• Resource Tool 30.A: Lifestyle Assessment Questionnaire
• Resource Tool 30.B: Health Risk Appraisal for Older Adults
O B J E C T I V E S After reading this chapter, the student should be able to: 1. Define terms commonly used in the care of adults. 2. Describe historical and current perspectives of adult health
and health policy.
3. Discuss sources of population-based public health data and health status indicators about adults to be used to align community resources to support adults with chronic illnesses.
Monty Gross, PhD, RN, CNE, CNL Dr. Monty Gross is Clinical Nurse Educator for the Veterans Health Administration in Las Vegas, Nevada. He received his BS in Communications from Clarion University of Pennsylvania and his BSN and MSN from the University of Virginia. In 2006 he completed his PhD from Virginia Tech. He has practiced nursing in acute care, critical care, and underserved communities in Latin America. He has taught nursing as an Associate Professor at the undergraduate and graduate levels. Staying engaged in academia, he teaches as an adjunct faculty.
Dr. Linda Hulton is Professor of Nursing at James Madison University (JMU) and Coordinator of the Doctor of Nursing Practice (DNP) program. She received her BSN in nursing from Roberts Wesleyan College and her Masters and PhD in nursing from the University of Virginia. Her areas of research interest and practice are adolescent health promotion, unintended pregnancy, and health care for the homeless. In 2012, she received the James Madison University CISAT Distinguished Teaching Award. She has had her scholarly work published in Issues in Comprehensive Pediatric Nursing, Sigma Theta Tau’s Online Journal of Knowledge Synthesis in Nursing, the Journal of Gynecological and Neonatal Nursing, The Journal of School Nursing, and the Journal for Specialists in Pediatric Nursing. At JMU, she teaches graduate courses in research, community health, and analytic methods.
Dr. Sharon Strang is an Associate Professor of Nursing and faculty in the Graduate School at James Madison University. She is a Board Certified Family Nurse Practitioner who practices at a free clinic. She received her BSN from Duquesne University in Pittsburgh, PA, and her Masters of Science in Nursing from the University of Pennsylvania at Edinboro. Sharon completed a Post Masters Nurse Practitioner Certificate Program at Old Dominion University and received her DNP from the University of Virginia. The focus of her doctoral studies and grant writing is chronic disease. She has presented at national nursing and education conferences and published in nursing education and nurse practitioner journals. In 2005 she received the Virginia Council of Nurse Practitioner’s nurse practitioner in education award and in 2011 she received the Virginia Council of Nurse Practitioner’s Distinguished Nurse Practitioner award. She is licensed as a Chronic Disease and Diabetes Self-Management Master Trainer by Stanford University.
Linda Hulton, PhD, RN
Sharon Strang, RN, DNP, APRN, FNP-BC
671CHAPTER 30 Major Health Issues and Chronic Disease Management
C H A P T E R O U T L I N E Historical Perspectives on Adult Men and Women’s Health Health Policy and Legislation
Ethical and Legal Issues and Legislation for Older Adults Environmental Impact
Health Status Indicators Mortality Morbidity
Adult Health Concerns Chronic Disease Cardiovascular Disease
Hypertension Stroke Diabetes Mental Health Cancer STDs/HIV/AIDS Weight Control
Women’s Health Concerns Reproductive Health Gestational Diabetes
O B J E C T I V E S — cont’d 4. Use appropriate assessment tools and development
strategies to care for adults across the life span. 5. Discuss the concepts of self-management and the
implementation of the Chronic Care Model to support adults with chronic illness.
6. Explain the dynamic forces that contribute to shared and gender specific diseases, health disparities, cultural diversity, and the role of social and behavioral factors that contribute to culturally competent care of adults in their communities.
K E Y T E R M S abuse, p. 673 adult day health, p. 688 advanced medical directives, p. 674 Americans with Disabilities Act (ADA), p. 673 anorexia, p. 681 assisted living, p. 688 bisexual, p. 686 body mass index, p. 680 bulimia, p. 681 cancer, p. 679 cardiovascular disease, p. 677 caregiver, p. 673 caregiver burden, p. 673 Chronic Care Model (CCM), p. 676 chronic disease, p. 672 community-based model, p. 687 diabetes, p. 678 do-not-resuscitate order, p. 674 durable medical power of attorney, p. 674 erectile dysfunction, p. 685 Family and Medical Leave Act (FMLA), p. 673 financial exploitation, p. 674 frail elderly, p. 687 gay, p. 686 gestational diabetes mellitus (GDM), p. 681 health, p. 672 health screenings, p. 683 health status indicators, p. 674 heart disease, p. 677 home health, p. 688 hospice, p. 688 hypertension, p. 678 injury, p. 687 impoverished, p. 686
lesbian, p. 686 life expectancy, p. 675 living will, p. 674 long-term care, p. 688 menopause, p. 682 men’s health, p. 683 mental health, p. 678 neglect, p. 674 obesity, p. 680 Office on Women’s Health, p. 681 Older Americans Act (OAA), p. 673 osteoporosis, p. 682 palliative care, p. 688 patient-centered medical home, p. 687 Patient Self-Determination Act, p. 674 Personal Responsibility and Work Opportunity
Reconciliation Act, p. 673 physical activity, p. 678 preconceptual counseling, p. 681 prostate cancer, p. 684 rehabilitation, p. 689 reproductive health, p. 681 respite care, p. 688 self-management, p. 677 sexually transmitted disease, p. 679 sexually transmitted infection, p. 679 stroke, p. 678 Temporary Assistance for Needy Families
(TANF), p. 673 testicular cancer, p. 684 unintended pregnancy, p. 681 weight control, p. 680 women’s health, p. 672 —See Glossary for definitions
672 PART 5 Health Promotion with Target Populations Across the Life Span
C H A P T E R O U T L I N E — cont’d Menopause Breast Cancer Osteoporosis
Men’s Health Concerns Cancers Unique to Men Depression Erectile Dysfunction
Health Disparities Among Special Groups of Adults Adults of Color Incarcerated Adults
Lesbian/Gay/Bisexual Adults Adults with Physical and Mental Disabilities Impoverished and Uninsured Adults Frail Elderly
Community-Based Models for Care of Adults Nursing Roles Community Care Settings
This chapter provides an overview of major health issues of adults that occur at various stages of life. Nurses struggle with these numerous and complex topics. Changes in population demographics signal challenges of limited resources and increased prevalence of persons living with multiple chronic conditions. Unhealthy lifestyles, environmental pollution, and politics are a sample of factors a nurse will need to consider in population-centered health care. Descriptive statistics are fre- quently provided to help illustrate the significance of a disease or condition. Despite many pressing issues and political debates, there are abundant opportunities to improve the health of the population. There is strong evidence that community interventions, such as those designed for disadvantaged popula- tions to improve diabetes care, can improve health through political involvement and strategies such as implementing well- planned programs (Brownson et al, 2009). Significant changes are rapidly occurring in health care and in the communities through policy changes and research. Nurses will be better pre- pared to practice by having a better understanding of these major health issues.
HISTORICAL PERSPECTIVES ON ADULT MEN AND WOMEN’S HEALTH Men and women have always faced a wide array of health issues that transition over time to impact their lives and the commu- nity. Gender is a major social determinant of health. Gender equity positively impacts a variety of factors, such as decision making, income allocation, and application and observance of norms, which affect health. Gender inequalities span through- out time and all societies, damaging the health of both genders, but in the majority of societies throughout the world women lose out to men (Fernández-Sáez et al, 2013). Social and politi- cal climates influence research and funding agendas that ulti- mately affect how health care is delivered in the community. A gender gap has existed where the emphasis on health issues and community focus has given priority to one gender over the other through research, policies, and funding. This has resulted in the focus of prevention and treatment being on one or the other gender, depending on social and political time period.
Historically men have dominated the medical and research professions because of cultural and societal norms. At the
beginning of the twentieth century, discussions of women’s health focused primarily on reproduction and women’s roles as mothers. In the 1920s, with the birth control movement in its initial stages, women’s health expanded to address family planning and reproductive health. Women began to be empow- ered by the suffragette movement, winning the right to vote in 1920. As the women’s rights movement gained momentum, women’s health issues and the research of those issues dis- placed many issues of men. In the 1980s recommendations were made by the U.S. Public Health Services Task Force on Women’s Health Issues to increase gender equity in biomedical research and the establishment of guidelines for including women in federally sponsored studies (Alexander et al, 2007; Public Health Reports, 1985). In 1990 the Society for Women’s Research was founded. Through political action of the National Institute of Health (NIH), legislation once again included women and other minorities in research studies (NIH Revital- ization Act of 1993).
During the nineteenth and twentieth centuries, illness and death rates from infectious diseases decreased and those of chronic diseases increased for men and women in western countries. Due to refinement and understanding of germ theory and the use of medical and public health strategies such as immunizations, pasteurization, and antibiotics, primary infec- tions declined (Egger, 2012). Health policies and programs were implemented to reduce the spread of infections and increase life span. These activities began the shift in focus to chronic ill- nesses, such as cardiovascular disease and cancers.
HEALTH POLICY AND LEGISLATION Health policy is action taken by public and private agencies to promote health. It is a reflection of the values held in society and can greatly influence the health of the citizens overall. Legislation consists of laws that regulate health care and promote health. Nursing practice and the care provided is impacted by policy and legislation. Nurses can serve as change agents to improve health care through engaging in health policy. To be fully engaged in improving health care from the bedside to the community level, nurses must understand how policy and legislation, along with other system factors such as social, cultural, and economic forces, can be incorporated into
673CHAPTER 30 Major Health Issues and Chronic Disease Management
responsibilities are frequently coupled with financial strain, which can lead them to experience caregiver burden.
In 1996 Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act, commonly known as “welfare reform.” This law targeted women who received public assistance and changed the previous Aid to Families with Dependent Children (AFDC) to Temporary Assistance for Needy Families (TANF)—a work program that mandates that women heads-of-household find employment to retain their benefits. The Administration for Children and Families (ACF), within the Department of Health and Human Services (USDHHS) is responsible for federal programs such as TANF that promote the economic and social well-being of families, children, individuals, and communities (ACF, n.d.).
The Patient Protection and Affordable Care Act (2010), also known as the Affordable Care Act (ACA) was passed by Con- gress and signed into law by President Obama in March 2010. The ACA has been considered the most significant reform law passed since Medicare and Medicaid were enacted in 1965. Some of the key features of the ACA include an end to health plans limiting or denying benefits to children under 19 years of age due to a pre-existing condition. Children under the age of 26 can be covered under their parent’s health plan, lifetime coverage limits were stopped, no copayment is needed for pre- ventive care, and access to insurance is provided for uninsured individuals (Kominski, 2014). The law is complex and expen- sive. As such, ACA is a continuing source of debate.
The nurse serves in a unique position for advocacy and support of health legislation and policy that supports the physi- cal, mental, and social well-being of adults. Advocacy can be accomplished in a variety of ways such as lobbying, public speaking, participating in grassroots activities, and staying abreast of proposed legislation that influences the health of men and women, their families, and communities.
Ethical and Legal Issues and Legislation for Older Adults Ethical issues regarding the care and treatment of older adults arise regularly. As the population continues to age and techno- logical advances contin
