Chapter Key Points ~ Exam 1 ~ Community Health

Chapter 1 ~ Population-Focused Practice: the Foundation of Specialization in Public Health Nursing 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 populations 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 population; it involves using scientific knowledge in making decisions 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 competent public health and personal health care workforce is available. Its setting is frequently viewed as the feature that distinguishes 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 masters or doctoral, with a focus in the public health sciences (Consensus Conference, 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 distinguish 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. Chapter 2 ~ History of Public Health and Public and Community Health Nursing 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 permitted 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, especially 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. The first trained nurse in the United States, who was salaried as a visiting nurse, was Frances Root; she was hired in 1887 by the Womens Board of the New York City Mission 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,

Chapter Key Points ~ Exam 1 ~ Community Health

including school nursing, insurance payment for nursing, national organization for public health nurses, and the United States Childrens 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 community health nursing services. The National Organization for Public Health Nursing (founded in 1912) provided essential leadership and coordination of diverse public health nursing efforts; the organization 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 significant 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 extension of nursing care and sometimes in retrenchment and decreased public health nursing services. By mid-twentieth century, the reduced prevalence of communicable diseases and the increased prevalence of chronic illness, accompanied by large increases in the population 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 community health nursing agencies sought to establish health insurance reimbursement for nursing care at home. Implementation of Medicare and Medicaid programs in 1966 established new possibilities for supporting community-based nursing care but encouraged agencies to focus on services 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 focused on reforming acute medical care rather than on designing a comprehensive preventive approach. The 1988 Institute of Medicine report documented the reduced political support, financing, and impact that increasingly limited public health services at national, state, and local levels. In the late 1990s, federal policy changes dangerously reduced financial support for home health care services, threatening the long-term survival of visiting nurse agencies. Healthy People 2000, Healthy People 2010, and recent disasters and acts of terrorism have brought renewed emphasis on prevention to nursing. Chapter 3 ~ Public Health and Primary Health Care systems and Health Care Transformation 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. By 2012 it is expected that programs such as Medicare, Medicaid and the Childrens Health Insurance Plan will account for over half the health care purchased in the United States. The U.S. Census Bureau reported that the number of uninsured rose to 46.3 million in 2008, from 45.7 million in 2007.

Chapter Key Points ~ Exam 1 ~ Community Health

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. A recent study found that as many as 27,000 deaths in 2006 were the result of a lack of insurance (Dorn, 2008). A study in 2007 found that 56 million people in the United States lacked adequate access to primary health care because of shortages of primary health care providers in their communities. Those who are poor, minority group members, and non-English speakers have the greatest barriers to access. Among the 18 million who received care in community health centers in 2007, one out of every five clients were low-income, uninsured individuals, one in four were low income and members of minority populations, and one in seven were rural residents (NACHC, 2009). Globalization is a process of change and development across national boundaries and oceans, involving economics, trade, politics, technology, and social welfare. Primary health care, the focus of the public health system in the United States, is defined as a broad range of services, including, but not limited to, basic health services, family planning, clean water supply, sanitation, immunization, and nutrition education. The United States, as a WHO member nation, has endorsed primary health care as a strategy for achieving the goal of health for all in the twenty-first century. The emphasis on the social and physical environment moves Healthy People 2020 from the traditional diseasespecific focus to a more holistic view of health consistent with a public health frame of reference. The U.S. Department of Health and Human Services (HHS) is the agency most heavily involved with the health and welfare concerns of U.S. citizens. Public health nursing is defined as the practice of protecting and promoting the health of populations using knowledge from nursing, social, and public health sciences. The United States is the only industrialized nation in the world that does not guarantee health care to all of its citizens. The passage of health care reform by the 111th Congress in March of 2010 was historic, and its full enactment, which will take place through 2018, will usher in an era of expanded access to health care in the United States. Chapter 10 ~ Environmental Health 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. For most chemical compounds in our homes, work, schools, and communities, no research has been completed to determine whether or not they will cause health effects. Prevention activities include education, reduction/elimination of exposures, waste minimization, energy policies, and land use planning. Control activities include use of technologies; environmental permitting; environmental standards, monitoring, compliance, and enforcement; and clean-up and remediation. Each nursing assessment should include questions and observations concerning potential and existing environmental 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 environmental hazards. Federal, state, and local laws and regulations, as well as international 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.

Chapter Key Points ~ Exam 1 ~ Community Health

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 environmental causes.

Chapter 11 ~ Genomics in Public Health Nursing 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 understand 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) in 2009 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 tailored to each persons needs; health, therefore, can be predictive 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 interventions, 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 certainly 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. Chapter 12 ~ Epidemiology Epidemiology is the study of the distribution and determinants 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 recognizes the complex interrelationships of factors that influence disease and health at both the individual level and the community 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. A key concept in epidemiology is that of the levels of prevention, 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.

Chapter Key Points ~ Exam 1 ~ Community Health

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 diagnosis and treatment. Tertiary prevention provides treatments and other interventions 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 causality and for developing effective intervention strategies aimed at primary, secondary, and tertiary prevention. Chapter 15 ~ Evidenced-Based Practice 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 practice 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 essential 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. Chapter 16 ~ Health Education Health education is a vital component of nursing because the promotion, 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 implement educational programs, and evaluate the effects of the educational program on learning and behavior.

Chapter Key Points ~ Exam 1 ~ Community Health

Nurses often use the Healthy People 2020 educational objectives as a guide to identifying community-based learning needs. Education and learning are different. Education is the establishment and arrangement of events to facilitate learning. Learning is the process of gaining knowledge and expertise and results in behavioral changes. Three domains of learning are cognitive, affective, and psychomotor. Depending on the needs of the learner, one or more of these domains may be important for the nurse educator to consider as learning programs are developed. Nine principles associated with community health education are gaining attention, informing the learner of the objectives of instruction, stimulating recall of prior learning, presenting the stimulus, providing learning guidance, eliciting performance, 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 and the Transtheoretical Model (TTM), which is 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, barriers to learning, and technological issues. Two important learner-related barriers are low literacy, especially health literacy, and lack of motivation to learn information and make the needed changes. The five phases of the educational process are identifying educational needs, establishing educational goals and objectives, selecting appropriate educational methods, implementing 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 improving health and promoting behavioral changes. Working with groups is an important skill for nurses. Groups are an effective and powerful vehicle for initiating and implementing healthful changes. A group is a collection of interacting individuals with a common purpose. Each member influences and is influenced by other group members to varying degrees. Group cohesion is enhanced by commonly shared characteristics 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 groups 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. Leadership is described as patriarchal, 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, characteristics, and norms. Nurses use their understanding of group principles to work with community groups toward needed health changes.

Chapter Key Points ~ Exam 1 ~ Community Health

Chapter 18 ~ Community as Client: Assessments and Analysis 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 institutions, informal groups, and aggregates that are interdependent 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 communitythe 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 problems 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, generating missing data, and interpreting the database. Five methods of collecting data useful to the nurse are informant interviews, participant observation, secondary analysis of existing data, surveys, and windshield surveys. Gaining entry or acceptance into the community is perhaps the biggest challenge in assessment. The nurse is usually an outsider and often represents an established health care system that is neither known nor trusted by community members, who may react with indifference or even active hostility. The planning phase includes analyzing and establishing priorities among community health problems already identified, 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 third phase of the nursing process, means transforming a plan for improved community health into achieving goals and objectives. Simply defined, evaluation is the appraisal of the effects of some organized activity or program Chapter 42 ~ The Nurse in the Schools School nurses provide health care for children and families. In the early 1900s, school nurses screened children for infectious diseases. By 2005, school nurses provided direct care, health education, counseling, case management, and community outreach. The National Association of School Nurses (NASN) is the professional organization for school nurses. School nurses have varying educational levels depending on state laws. The U.S. government supports school-based health centers, school-linked programs, and full-service schoolbased health centers. Healthy People 2020 has objectives to enhance the health of children in schools.

Chapter Key Points ~ Exam 1 ~ Community Health

Primary prevention provides health promotion and education to prevent childhood injuries and substance abuse. The school nurse monitors the children for all of their state-mandated immunizations for school entry. HIPAA privacy rules regarding the health information of children apply in schools. Secondary prevention involves screening children for illnesses and providing direct nursing care. School nurses develop plans for emergency care in the schools. Giving medications to children in the school must be monitored carefully to prevent errors. School health nurses are mandated reporters to tell the authorities about suspected cases of child abuse and/or neglect. Disaster-preparedness plans should be set up for all schools with the school nurse as a member of the crisis response team. Tertiary prevention includes caring for children with long-term health needs, including asthma and disabling conditions. School nurses carry out catheterizations, suctioning, gastrostomy feedings, and other skills in the schools. Some ethical dilemmas in the schools are related to womens health care. Some school nurses use the Internet to help communicate with children and their families. Chapter 43 ~ The Nurse in Occupational Health Occupational health nursing is an autonomous practice specialty. The scope of occupational health nursing practice is broad, including worker and workplace assessment and surveillance, case management, health promotion, primary care, management/administration, business and finance skills, and research. The workforce and workplace are changing dramatically, requiring new knowledge and new occupational health services. The type of work has shifted from primarily manufacturing to service and technological jobs. Workplace hazards include exposure to biological, chemical, enviromechanical, physical, and psychosocial agents. The Occupational Safety and Health Act of 1970 states that workers must have a safe and healthful work environment. The interprofessional occupational health team consists of the occupational health nurse, occupational medicine physician, industrial hygienist, and safety specialist. Work-related health problems must be investigated and control strategies implemented to reduce exposure. Control strategies include engineering, work practice, administration, and personal protective equipment. The Occupational Safety and Health Administration enforces workplace safety and health standards. The National Institute for Occupational Safety and Health is the education and research agency that provides grants to investigate the causes of workplace illness and injuries. Workers compensation acts are important laws that govern financial compensation of employees who suffer work-related health problems. The occupational health nurse should play a key role in disaster planning and coordination. Academic education in occupational health nursing is generally at the graduate level. Chapter 45 ~ The Nurse in the Faith Community Faith community nurse services respond to health, healing, and wholeness within the context of the faith community. Although the emphasis is on health promotion and disease prevention throughout the life span, the spiritual dimension of nursing is central to the practice. The focus of the practice is on the intentional care of the spirit (ANA and HMA, 2005).

Chapter Key Points ~ Exam 1 ~ Community Health

Faith community nursing has evolved from roots of healing traditions in faith communities; early public health nursing efforts working with individuals, families, and populations in the community; and more recently the independent practice of nursing. The faith community nurse partners with the wellness committee and volunteers to plan programs that address the health-related concerns within faith communities. To promote a caring faith community, usual functions of the faith community nurse include health counseling and teaching for individuals and groups, facilitating linkages and referrals to congregation and community resources, advocating and encouraging support resources, and providing spiritual care. Faith community nurses collaborate to plan, implement, and evaluate health promotion activities considering the faith communitys beliefs, rituals, and polity. Healthy People 2020 leading indicators and objectives are excellent and effective frameworks for health ministry efforts of wellness committees and basic to partnering for programs. Nurses in congregational or institutional models enhance the health ministry programs of the faith communities if carefully chosen partnerships are formed within the congregation, with other faith communities as well as with local health and social community organizations. Nurses working as faith community nurses must seek to attain adequate educational and skill preparation to be accountable to those served. Nurses are encouraged to consider innovative approaches to creating caring communities. These may be in individual faith communities as nurses; among several faith communities in a single locale; or in partnership with other community institutions. To sustain oneself as a faith community nurse who provides spiritual care to support individuals, families, and communities in the healing and wholeness process, the nurse must be diligent to take time for self-nurture and renewal. Chapter 46 ~ Public Health Nursing at Local, State and National Levels Local public health departments are responsible for implementing and enforcing local, state, and federal public health codes and ordinances while providing essential public health services. The goal of the local health department is to safeguard the publics health and improve the communitys health status. State health departments hold primary responsibility for promoting and protecting the publics health. Public health nursing is the practice of promoting and protecting the health of populations using knowledge from nursing and social and public health sciences. Public health is based on the scientific core of epidemiology. Marketing of public health nursing is essential to inform both professionals and the public about the opportunities and challenges of populations in public health care. A driving force behind public health nursing changes is globalization that allows rapid transmission of emerging infections and the expectation that public health nurses be active partners in emergency preparedness activities. Some of the roles public health nurses function in are advocate, case manager, referral source, counselor, educator, outreach worker, disease surveillance expert, community mobilizer, and disaster responder. Public health nurses have an important role in conducting community assessments including partnering with the community to collect and analyze data, developing community diagnosis, and implementing evidence-based interventions. Public health nurses base interventions on identified health status of populations and their related determinants of health.