Public and Population Health – Cheap Research Essays

This discussion is based on a case study. As in all case studies, review the facts of the case and consider the various steps of the nursing process in order to address the critical thinking questions.
At a staff meeting in the community health center there is extensive discussion about how to implement the Affordable Care Act in the community. The nurses are having a lot of difficulty understanding how healthcare politics and policy are developed when it appears that not all public health stakeholders are adequately considered.
1. Developing and adopting health care policies is a process. Identify four factors with supporting rationales that must be addressed in the policy-making process within public health.
2. Identify four population health concerns with supporting rationales that should be addressed when health policies are formulated.
3. Identify four nurse-led strategies with supporting rationale to improve population and community health

CHAPTER 1: Public Health Nursing: Present, Past, and Future
Gail A. Harkness
• For additional ancillary materials related to this chapter, please visit thePoint.
Nursing is based on society’s needs and therefore exists only because of society’s need for such a service. It is difficult for nursing to rise above society’s expectations, limitations, resources, and culture of the current age.
Patricia Donahue, Nursing, the Finest Art: An Illustrated History
I believe the history of public health might be written as a record of successive redefinings of the unacceptable.
George Vicker
Some people think that doctors and nurses can put scrambled eggs back into the shell.
Dorothy Canfield Fisher, social activist and author
The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d rather not.
Mark Twain
chapter highlights
• Healthcare changes in the 21st century
• Characteristics of public health nursing
• Public health nursing roots
• Challenges for practice in the 21st century
objectives
• Outline three major changes in healthcare in the 21st century.
• Identify the eight principles of public health nursing practice.
• Explain the significance of the standards and their related competencies of professional public health nursing practice.
• Discuss historical events and relate them to the principles that underlie public health nursing today.
• Consider the challenges for public health nurses in the 21st century.
key terms
Aggregate: Population group with common characteristics.
Competencies: Unique capabilities required for the practice of public health nursing.
District nurses: Public health nurses in England who provide visiting nurse services; historically, they cared for the people in the poorest parish districts.
Electronic Health Records: Digital computerized versions of patients’ paper medical records.
Epidemiology: Study of the distribution and determinants of states of health and illness in human populations; used both as a research methodology to study states of health and illness, and as a body of knowledge that results from the study of a specific state of health or illness.
Evidence-based nursing: Integration of the best evidence available with clinical expertise and the values of the client to increase the quality of care.
Evidence-based public health: A public health endeavor wherein there is judicious use of evidence derived from a variety of science and social science research.
Healthcare disparities: Gaps in healthcare experienced by one population compared with another.
Health information technology: Comprehensive management of health information and its secure exchange between consumers, providers, government and quality entities, and insurers.
Public health: What society does collectively to ensure that conditions exist in which people can be healthy.
Public health interventions: Actions taken on behalf of individuals, families, communities, and systems to protect or improve health status.
Public health nursing: Focuses on population health through continuous surveillance and assessment of the multiple determinants of health with the intent to promote health and wellness; prevent disease, disability, and premature death; and improve neighborhood quality of life (American Nurses Association [ANA], 2013).
Telehealth: Use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration.
Social determinants of health: Social conditions in which people live and work.
Case Study
References to the case study are found throughout this chapter (look for the case study icon). Readers should keep the case study in mind as they read the chapter.
The Department of Health and Human Services (HHS) in a southeastern state has begun implementing the recommendations from both the U.S. Institute of Medicine’s publication The Future of the Public’s Health in the 21st Century and the 10-year national objectives for promoting health and preventing disease in the United States established by Healthy People 2020. A task force is developing a new vision for public health in the state. Sandy is a program developer in the state’s Department of Public Health, with the primary responsibility of assisting local public health departments in developing, implementing, and evaluating public health nursing initiatives. Sandy represents public health nursing on the task force. (Adapted from Jakeway, Cantrell, Cason, & Talley, 2006).
HEALTHCARE CHANGES IN THE TWENTY-FIRST CENTURY
A worldwide phenomenon of unprecedented change is occurring in healthcare. There are new innovations to test, ethical dilemmas to confront, puzzles to solve, and rewards to be gained as healthcare systems develop, refocus, and become more complex within a multiplicity of settings. Nurses, the largest segment of healthcare providers in the world, are on the frontline of that change.
Demographic characteristics indicate that people in developed countries are living longer and healthier lives, yet tremendous health and social disparities exist. The social conditions in which people live, their income, their social status, their education, their literacy level, their home and work environments, their support networks, their gender, their culture, and the availability of health services are the social determinants of health. These conditions have an impact on the extent to which a person or community possesses the physical, social, and personal resources necessary to attain and maintain health. Some population groups, having fewer resources to offset these effects, are affected disproportionately. The results are healthcare disparities, or gaps in care experienced by one population compared with another.
For example, the World Health Organization (WHO) estimates that almost half of all countries surveyed have access to less than half the essential medicines they need for basic healthcare in the public sector. These essential medicines include vaccines, antibiotics, and painkillers. Children in low-income countries are 16 times more likely to die before reaching the age of 5 years, often because of malnourishment, than children in high-income countries. The double burden of both undernutrition and overweight conditions causes serious health problems and affects survival (WHO, 2013). Globally, resources exist to remedy these circumstances, but does the political commitment exist?
The development of society, rich or poor, can be judged by the quality of its population health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill health.
World Health Organization
Role of the Government in Healthcare
A government has three core functions in addressing the health of its citizens: (1) it assesses healthcare problems; (2) it intervenes by developing relevant healthcare policy that provides access to services; and (3) it ensures that services are delivered and outcomes achieved. The United States, the United Kingdom, the European community, and some newly industrialized countries have embraced these principles. However, governments in other countries struggle to build any semblance of a health system. Unstable governments do not have the concern, motivation, or resources to address healthcare issues.
There were unprecedented public health achievements in the United States during the 20th century. The Centers for Disease Control and Prevention (CDC) has listed the Ten Great Public Health Achievements based on supportive epidemiologic analyses and comparisons of health factors over 30 years (Box 1.1). However, healthcare expenditures are now more than $2.6 trillion per year (CDC, 2013). Infant mortality, longevity, and other health indicators still fall behind those of many other industrialized nations. The current U.S. healthcare system faces serious challenges on multiple fronts. Although the United States is considered the best place for people to obtain accurate diagnoses and high-quality treatment, until 2014 nearly 45 million Americans lacked health insurance and therefore access to care. These uninsured Americans were primarily young people, low-income single adults, small-business owners, self-employed adults, and others who did not have access to employer-sponsored health insurance.
box 1.1: Ten Great Public Health Achievements in the United States, 1900–1999
Vaccination
Motor vehicle safety
Safer workplaces
Control of infectious diseases
Decline in coronary heart disease and stroke deaths
Safer and healthier foods
Healthier mothers and babies
Family planning
Fluoridation of drinking water
Recognition of tobacco as a health hazard
Source: Centers for Disease Control and Prevention. (1999). Ten Great Public Health Achievements — United States, 1900–1999. Morbidity Mortality Weekly Report, 48 (12), 241–243.
The Patient Protection and Affordable Care Act (PPACA) was signed into law by President Barack Obama in 2010. The goal of the PPACA is to help provide affordable health insurance coverage to most Americans, lower costs, improve access to primary care, add to preventive care and prescription benefits, offer coverage to those with preexisting conditions, and extend young adults’ coverage under their parents’ insurance policies. It is estimated that 95% of legal U.S. residents will ultimately be covered by health insurance, although implementation will evolve over time (Doherty, 2010). The passage of the PPACA was the first step in providing Americans with the security of affordable and lifelong access to high-quality healthcare. More information about the Affordable Care Act, unofficially known as “Obamacare,” is found in Chapter 3.
It is cheaper to promote health than to maintain people in sickness.
Florence Nightingale
PRACTICE POINT
Making healthcare a right rather than a privilege has global implications.
The United States assesses and monitors people’s health through an intricate system of surveillance surveys conducted by the HHS, the CDC, and the state and local governments. Health policy development focuses on cost, access to care, and quality of care. Access is defined as the ability to get into the healthcare system, and quality care is defined as receiving appropriate healthcare in time for the services to be effective. Outcomes are ensured by a continual evaluation system linked in part with the CDC surveys. Despite this elaborate healthcare system, health disparities related to race, ethnicity, and socioeconomic status still pervade the healthcare system. Health disparities vary in magnitude by condition and population, but they are observed in almost all aspects of healthcare, in quality, access, healthcare utilization, preventive care, management of chronic diseases, clinical conditions, and settings, and within many subpopulations.
The National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) measure trends in the effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. The reports present, in chart form, the latest available findings on quality of and access to healthcare (Agency for Healthcare Research and Quality, 2014). For example, Figure 1.1 indicates that although quality is improving slowly for all groups, significant health disparities continue to exist in many populations.
figure 1.1

Number and proportion of all quality measures that are improving, not changing, or worsening, overall and for select populations.
The challenge for the United States in the 21st century is to create a dynamic, streamlined healthcare system that produces not only the finest technology and research but also the most accessible, efficient, low-cost, and high-quality healthcare in the world. The current healthcare system also must be transformed to become one of the most competitive and successful systems in the world. Innovative and creative changes will be needed to create a patient/client–centered, provider-friendly healthcare system that is consumer-driven. The political will does exist to create a better future: patient/client–centered care is evolving, new technology is shaping delivery of care, and people are assuming more responsibility for maintaining their health.
Patient/client–centered care
Healthcare has been evolving toward a multifaceted system that empowers patients and clients rather than providers, as was common in the past. This transformation is considered the best way to ensure that patients have access to high-quality care, regardless of their income, where they live, the color of their skin, or how old or ill they are.
Patient/client–centered care considers cultural traditions, personal preferences, values, families, and lifestyles. People requiring healthcare, along with their families or significant others, become an integral part of the healthcare team, and clinical decisions are made collaboratively with professionals. Clients become active participants in their own care, and monitoring health becomes the client’s responsibility. Support, advice, and counsel from health professionals are available, along with the tools that are needed to carry out that responsibility. The shift toward patient/client–centered care means that a broader range of outcomes needs to be measured from the patient’s perspective to understand the true benefits and risks of healthcare interventions.
PRACTICE POINT
The Agency for Healthcare Research and Quality (AHRQ) has developed a series of tools to assist clients in making healthcare decisions.
To help clients and their healthcare providers make better decisions, the AHRQ has developed a series of tools that empower clients and assist providers in achieving desired outcomes. Tools include questionnaires to help determine important treatment preferences and decisions, symptom severity indexes, client fact sheets, client-reported functional status indicators, and other helpful decision-making guidelines. These are available to both consumers and healthcare providers at the AHRQ website.
For the system to work effectively, transitions between providers, departments, various healthcare settings, and the home must be coordinated and efficient so that unneeded or unwanted services can be reduced. Americans are sophisticated, empowered consumers in almost every aspect of their lives and will make the best decisions both for themselves and, collectively, for the healthcare economy and society itself.
Technology
Rapidly advancing forms of technology are dramatically improving lives. Thousands of new ideas are investigated each year, with hundreds of new medical devices submitted to the U.S. Food and Drug Administration annually. Medical devices vary considerably, such as computer-assisted robotic surgical techniques, artificial cervical disks, new diagnostic techniques, implantable microchip-containing devices that control dosing from drug reservoirs, continuous glucose-monitoring systems for detecting trends and tracking patterns in people with diabetes, and many more.
The benefits of biomedical progress are obvious, clear, and powerful. The hazards are much less well appreciated.
Leon Kass, physician
Although massive investments in medical research have been made, there has been an underinvestment in both research and the infrastructure necessary to translate basic research into results. For example, studies indicate that it takes physicians an average of 17 years to adopt widely the findings from basic research. The healthcare sector invests nearly 50% less in information technology than any other major sector of the U.S. economy. More comprehensive knowledge bases of healthcare information, computerized decision support, and a health information technology (HIT) infrastructure with national standards of interoperability to promote data exchange are necessary.
Health information technology
Health information technology is defined as the comprehensive management of health information and its exchange between consumers, providers, government, and insurers in a secure manner. HIT makes it possible for healthcare providers to better manage patient care through secure use and sharing of health information. It is viewed as the most promising tool for improving the overall quality, safety, and efficiency of the health delivery system.
Health information technology and electronic health information exchange have emerged as a primary means of shaping a healthcare system that is effective, safe, transparent, and affordable. When linked with other health system reforms, technology can support better quality healthcare, reduce errors … and improve population health.
State Alliance for e-Health
Health information technology includes the use of electronic health records (EHRs), digital computerized versions of patients’ paper medical records, to maintain people’s health information. EHRs and other HIT systems are powerful tools that are having a significant impact on healthcare. Consumers are empowered with more information, choices, and control, and providers have reliable access to complete personal health information that can help them make the right decisions. All necessary health information, from medical histories to billing information, will be accessible from the Internet and readily available to all appropriate healthcare facilities and providers of care (with permission of the client). With faster diffusion of medical knowledge through the Internet, decision-making will be expedited, medical errors reduced, and duplication of tests and misdiagnosis decreased. However, to protect these records from unauthorized, inappropriate, or unethical use, national privacy laws must be in place.
In the United States, The Office of the National Coordinator for Health Information Technology (ONC) is the principal federal entity responsible for the coordination and safety of information technology issues. It is a resource to the entire health system to support the adoption of HIT and to promote nationwide health information exchange to improve healthcare. ONC is organizationally located within the Office of the Secretary for the U.S. HHS. The ONC has developed SAFER guides for EHRs, consisting of nine guides organized into three broad groups that enable healthcare organizations to address EHR safety in a variety of areas. The guides identify recommended practices to optimize the safety and safe use of EHRs and can be found on the ONC website (see Web Resources on ).
The ONC funds the Nationwide Health Information Network (NwHIN), a collaborative organization of federal, local, regional, and state agencies. Its mission is to develop the envisioned secure, nationwide, interoperable health information infrastructure to connect providers, consumers, and organizations involved in supporting health and healthcare. The major goals of NwHIN are to enable health information to follow the consumer, to be available for clinical decision-making, and to support appropriate use of healthcare information beyond direct client care to improve the health of communities. The conceptual model that guides NwHIN is illustrated in Figure 1.2. The NwHIN has developed a set of standards, services, and policies that enable the secure exchange of health information nationwide over the Internet. Health information will follow the patient and be available for clinical decision-making as well as for uses beyond direct patient care, such as measuring quality of care. It is proposed that the NwHIN will be the vehicle through which health information will be exchanged.
figure 1.2

The nationwide health information network conceptual model. (From Nationwide Health Information Network [NwHIN]. Retrieved from http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/highlights.html).
Telehealth
Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration (Health Resources and Services Administration, 2014). Telehealth is becoming a necessity, due in part to the aging population, the rising number of people with chronic conditions, and the need to increase healthcare delivery to medically underserved populations.
Advances in technology, specifically those involving videoconferencing, medical devices, sensors, high-speed telecommunication networks, store-and-forward imaging, streaming media, and terrestrial and wireless communications have made it possible to assess clients’ conditions remotely in their homes. Information can be stored for later access or assessments can be performed in real time using Internet video systems. It is also possible to obtain the advice of expert specialty consultants without meeting in person. The increasing complexity of telehealth requires ongoing communication, training, cultural sensitivity, and customization for individual clients. However, access, availability, and cost issues can be barriers to use of this technology (Ackerman, Filart, Burgess, Lee, & Poropatich, 2010).
EVIDENCE FOR PRACTICE
The use of home telehealth devices as an alternative for chronic disease management by nurses has the potential to assist many older people in their homes, and therefore, their acceptance of these devices is of significant importance. Lu, Chi, and Chen (2013) used a qualitative approach using face-to-face interviews with a semistructured interview guideline and a focus group discussion. Twenty clients who had received the telehealth service for 3 months and were willing to share their experiences were recruited.
Qualitative content analysis identified four key themes: (1) perceived support and security, (2) enhanced disease self-management, (3) concern regarding use of the devices, and (4) worries about the cost. Subjects favored using the service to control their chronic conditions because of convenience and accessibility. Since their condition could be measured daily, the subjects’ sense of security was enhanced. They could determine and understand changes in their condition, and compliance with medical regimens improved. Subjects felt empowered to revise their lifestyles for better disease self-management. Since telehealth was in the stage of pilot testing, concerns were related to being unfamiliar with operation of the equipment and doubts about quality of the home health-monitoring equipment. Users also expressed concerns about future costs and policy changes in the future.
The authors concluded that most users perceived telehealth care as a convenient and useful model for healthcare delivery. It increased the availability of healthcare and improved the self-care ability of clients. Concern about the home monitoring devices suggests a need for further consumer education regarding use of home-monitoring devices and systems, a function normally performed by public health nurses (PHNs). Proper training and support for any problems when adopting the system will foster clients’ willingness to use telehealth services. Further research is recommended to assess client perceptions of their current health status and their functional limitations in relation to their use of monitoring devices in the home.
Personal responsibility for Health
Increased personal responsibility for preventing disease and disability is a vital component of healthcare change. The underlying premise holds that if people have a vested interest in their health, they will do more to maintain it. However, if a person is healthy, he or she may not focus on maintaining individual health, yet no one is more seriously affected when illness or disability occurs. Preventing or modifying unhealthy behaviors can save both lives and money, but can personal responsibility regarding one’s health be truly mandated and regulated?
Personal responsibility for health involves active participation in one’s own health through education and lifestyle changes. It includes responsibility for reviewing one’s own medical records, including laboratory test results, and monitoring both the positive and negative effects of prescription and over-the-counter medications. It means showing up for scheduled tests and procedures, following dietary recommendations, losing weight if needed, avoiding tobacco and recreational drug use, engaging in exercise programs, and educating oneself about one’s own conditions. Ultimately, people must take the responsibility for making their own choices and healthcare decisions
The…patient should be made to understand that he or she must take charge of his own life. Don’t take your body to the doctor as if he were a repair shop.
Quentin Regestein, psychiatrist, Harvard University
U.S. government initiatives have been implemented to encourage personal responsibility for health. Healthy People 2020 is a national, science-based plan designed to reduce certain illnesses and disabilities by reducing disparities in healthcare services in people of different economic groups. Since 1979, Healthy People programs have measured and tracked national health objectives to encourage collaboration, guided people toward making informed health decisions, and assessed the impact of prevention activity. Specific objectives with baseline values for measurement are developed, setting specific targets to be achieved by 2020. The four major overarching goals that incorporate these objectives are listed in Box 1.2 (Healthy People 2020, n.d.)
box 1.2: Healthy People 2020 Overarching Goals
• 1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
• 2. Achieve health equity, eliminate disparities, and improve the health of all groups.
• 3. Create social and physical environments that promote good health for all.
• 4. Promote quality of life, healthy development, and healthy behaviors across all life stages.
PUBLIC HEALTH NURSING TODAY
The shorter length of stay in acute care facilities, as well as the increase in ambulatory surgery and outpatient clinics, has resulted in more acute and chronically ill people residing in the community who need professional nursing care. Fortunately, these people can have their care needs met cost-effectively outside of expensive acute care settings. As a result, demand has increased for nurses in ambulatory clinics, home care, and care management.
Hospitals remain the most common workplace for RNs in the United States (62.2%). However, the number of RNs working in home health service units or agencies is increasing (6.4%) (Department of Health and Human Services, Health Resources and Service Administration, 2014). Public health, ambulatory care, and other noninstitutional settings have historically had the largest increases in RN employment. These statistics indicate a shift in the roles of nurses, particularly for those working in public health settings.
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.
American Nurses Association
Public Health nursing
A decades-long debate about terminology has fostered confusion regarding the roles of nurses who serve the community. However, public health professionals nationwide have come together to define the principles of public health (Box 1.3). Embracing these fundamental principles for all public health professionals, the Quad Council of Public Health Nursing Organizations established eight principles of public health nursing practice (Box 1.4). The Quad Council of Public Health Nursing Organizations is an alliance of four national nursing organizations that address public health nursing issues in the United States, comprising the following:
box 1.3: Principles of Public Health
Focus on the aggregate.
Promote prevention.
Encourage community organization.
Practice the ethical theory of the greater good.
Model leadership in health.
Use epidemiologic knowledge and methods.
box 1.4: Principles of Public Health Nursing: The public health nurse is guided by adherence to all of the following principles
The client or unit of care is the population.
The primary obligation is to achieve the greatest good for the greatest number of people or number of people as a whole. Public health nurses collaborate with the client as an equal partner.
Primary prevention is the priority in selecting appropriate activities.
Public health nursing focuses on strategies that create health environmental, social, and economic conditions in which populations may thrive.
A public health nurse is obligated to actively identify and reach out to all who might benefit from a specific activity or service.
Optimal use of available resources and creation of new evidence-based strategies is necessary to assure the best overall improvement in the health of populations.
Collaboration with other professions, populations, organizations, and stakeholder groups is the most effect way to promote and protect the health of the people.
Source: American Nurses Association. (2013). Public health nursing: Scope and standards of practice. Silver Spring, MD: Nursesbooks.
• Association of Community Health Nurse Educators (ACHNE)
• ANA’s Congress on Nursing Practice and Economics (CNPE)
• American Public Health Association (APHA)—Public Health Nursing Section
• Association of State and Territorial Directors of Nursing (ASTDN)
Public health is what we, as a society, do collectively to assure the conditions in which people can be healthy.
Institute of Medicine, 1988
Scope and Standards of Practice
The American Nurses Association sets the scope and standards for all professional nursing practice. The publication Public Health Nursing: Scope and Standards of Practice establishes the characteristics of competent public health nursing practice and is the legal standard of practice. It defines the essentials of public health nursing, the activities, and the accountabilities that are characteristic of practice at all levels and settings. An important component of this document is the designation of competencies required to meet each standard of practice. This scope and standards document can be used by PHNs from entry-level to senior management in a variety of practice settings and is an indispensible publication reference for every practicing PHN (ANA, 2013).
Competencies for Public Health Nursing Practice
The Core Competencies for Public Health Nurses (CCPHN) defined in the ANA (2013) publication are aligned with core competencies developed by other public health organizations. The CCPHN reflect the unique capabilities required for the practice of public health nursing. Three tiers of practice are defined, along with competencies associated with that level of practice. Tier 1 core competencies apply to entry-level public health professionals at the basic or generalist level. For example, individuals who have limited experience working in the public health field and are not in management positions would be considered practicing at Tier 1. Tier 2 core competencies apply to individuals with management and/or supervisory responsibilities and are considered specialists or mid-level practitioners. Tier 3 core competencies apply to senior managers and leaders at the executive level who deal with multisystems. Essentially, these competencies underlie the wide variety of roles and responsibilities that PHNs accept in the workplace.
The CCPHN are integrated into the Standards of Practice for Public Health Nursing (ANA, 2013). Each standard of practice is followed by the essential competencies required to meet that standard. Following each standard of practice, additional competencies are presented for practice as an advanced PHN.
Public Health Nursing Interventions
The public health nursing intervention (wheel) model, illustrated in Figure 1.3, is (1) a population-based model that (2) is applied to individuals, families, communities, or within systems and (3) defines 17 public health interventions focusing upon prevention. It is a way of defining public health nursing by the type of actions taken on behalf of clients to protect or improve health status. The interventions in the wheel model complement the competencies that each PHN must demonstrate for safe practice. The competencies define what should be done while the interventions provide a means to accomplish those actions. Table 1.1 describes the 17 interventions illustrated in the wheel. Other interventions have been suggested, such as that of change agent, culture broker, and researcher. The wheel creates a structure for identifying and documenting interventions, thereby capturing the nature of public health nursing practice.
figure 1.3

READ ALSO : Health

Public health intervention wheel.
table 1.1: Public Health Nursing Interventions
Intervention Definition
Surveillance Monitors health events through ongoing, systematic collection, analysis and interpretation of health data for planning, implementing, and evaluating public health interventions
Investigation of disease and other health events Systematically gathers and analyzes data about threats to population health, determines the source, identifies cases and those at risk, and determines control measures
Outreach Locates populations at risk, provides information, identifies possible actions, and identifies access to services
Screening Identifies individuals with unrecognized risk factors or asymptomatic conditions
Case-finding Locates individuals and families with identified risk factors and connects them with resources
Referral and follow-up Assists in identifying and accessing necessary resources to prevent or resolve concerns
Case management Coordination of a plan or process to bring health services, and the self-care capabilities of the client, together as a common whole in a cost-effective way
Delegation Direct care tasks an RN entrusts to other appropriate personnel
Teaching Develop a health education plan and teach clients and other caregivers leading to behavior change
Counseling Develops an interpersonal relationship with the client to increase their capabilities to address or solve issues
Consultation Seeks information and generates solutions to health problems or issues through interactive problem-solving
Collaboration Work with people or representatives of organizations to achieve a common goal
Coalition building Foster, mobilize, and participate in community-wide alliances to achieve a specific goal
Community organizing Help community groups to identify common problems or goals, mobilize resources, and develop and implement strategies for reaching those goals
Advocacy Act on behalf of clients who have lost control of factors that affect their health and a need is unmet; strengthen clients’ capacity to act
Social marketing Use marketing principles and technology to design programs to address needs of the client
Policy development Promote beneficial social changes that influence the health of groups and populations
Policy enforcement Compels others to comply with the laws, rules, regulations, and ordinances created in conjunction with policy development
Source: Adapted from Public Health Interventions: Application for Nursing Practice. Retrieved from www.health.state.mn.us/divs/opi/cd/phn/wheel.html Two years ago, Sandy participated in a statewide survey of both the public health nurses in the state as well as their employers. The purpose of the survey was to determine the characteristics of public health nursing practice, especially the use of principles of population health. Results indicated that the majority of the public health nurse’s time is spent in the provision of primary care and clinical services to individual clients. The major factors that contribute to this finding include the number of uninsured people (16%) and a large population of medically underserved people.
Define the type of practice (Tier) that the public health nurses were performing.
The new vision for public health being designed by the task force promotes a shift from a predominantly individual and clinic-based care model to a population health practice model. The public health nurses in the state were unprepared for this transition and lacked a strong understanding of population health concepts and competencies. Using the standards of practice and associated competencies outlined in Public Health Nursing: Scope and Standards of Practice, and with assistance from faculty members at the state university, the task force is helping to develop an online population-based health course to meet the needs of the public health nurses in the state. The priorities of the online course are as follows:
• Community assessment and diagnosis
• Interpreting and presenting health information
• Using computer technology in health planning and policy development
• Building community coalitions
Using Public Health Nursing: Scope and Standards of Practice, choose the appropriate standards and competencies that the public health nurses should demonstrate to meet the priorities listed above.
Education for Public Health nursing Practice
The educational credential for entry into public health nursing practice is the baccalaureate degree in nursing. This can be a baccalaureate in nursing (BS or BSN) or a generalist master’s degree as a clinical nurse leader (CNL). Public health nursing specialists in population health may have a master of science in nursing (MSN), master of public health (MPH), a joint MSN/MPH, or a doctoral degree. Doctoral degrees may be doctor of philosophy (PhD), doctor of nursing practice (DNP), or doctor of public health (DrPH). Diploma-and associate degree–prepared RNs and licensed practical nurses may practice in some public health settings. In these positions, nurses provide care for individuals or families, but not for populations (ANA, 2013).
Certification for Public Health Nursing Specialty Practice
Advanced nursing practice at the master’s level is considered a specialty practice in public health nursing, and the standard credential awarded for passing the American Nurses Credentialing Center (ANCC) certification examination is Advanced Public Health Nurse–Board Certified (APHN–BC). The advanced practice student must study pathophysiology, physical assessment, and pharmacology, with an emphasis on caring for people in communities to affect public health interests positively, to qualify for the examination. The ANCC website explains eligibility criteria, the application process, steps to maintain certification, and the process for renewal.
ROOTS OF PUBLIC HEALTH NURSING
Exploring the roots of the healing professions provides the background for understanding the characteristics of nursing practice today (Table 1.2). Since the beginning of civilization, people in all cultures have focused on birth, health, illness, and death. Historical records indicate that early societies engaged in public health measures by burying wastes away from water supplies, developing sewage systems, and draining marshes to control communicable disease. In these times, people spent their lives with their family and community, especially when they were ill and needed care. Early caregivers, usually women, cultivated healing herbs, applied poultices, applied heat and cold, immobilized fractures, delivered babies, and attended the dead.
table 1.2: Milestones in Public Health and Public Health Nursing
1601 Poor Law instituted in England; beginning of state-supported assistance for the poor
1617 Sisters (or Daughters) of Charity founded in France
1789 First local permanent health department in the United States founded in Baltimore, Maryland
1798 Marine Hospital Service established in the United States; later became the Public Health Service
1809 Sisters of Charity founded by Elizabeth Ann Seton in Maryland
1813 Ladies’ Benevolent Society of Charleston, South Carolina, established to provide home care to the sick
1825 154 hospitals had been established in England
1836 Training school for deaconesses established by Theodore Fliedner, a German Lutheran pastor
1840/1841 Dorothea Dix began her lifelong campaign to improve the life of the mentally ill
1850 Shattuck Report published by the Massachusetts Sanitary Commission; recommended the establishment of a state health department and local health boards in every town, collection of vital statistics, sanitation, disease control, health education, town planning, and teaching of prevention in medical schools
1851 Florence Nightingale attended Fliedner’s school for deaconesses
1859 William Rathbone established district nursing in England
1860 Florence Nightingale established the first school for nurses at St. Thomas Hospital in London
1861 Soldiers in the American Civil War attended by visiting nurses
1870s First nursing schools opened in the United States based on the Nightingale model
1872 American Public Health Association established
1882 Clara Barton convinced the U.S. Congress to establish the American Red Cross with an extended mission to provide aid for natural disasters
1885/1886 Visiting nurse associations established in Boston, Philadelphia, and Buffalo
1893 Lillian Wald established the Henry Street Settlement in New York City for the sick poor
1895 Ada Steward employed by Vermont Marble Works as the first occupational health nurse
1898 Significant use of trained nurses in military hospitals
1901 U.S. Army Nurse Corps established
1908 U.S. Navy Nurse Corps established
1912 National Organization for Public Health Nursing established, with Lillian Wald the first President; U.S. Children’s Bureau established; Marine Hospital Service changed to U.S. Public Health Service
1914 First postgraduate program in public health nursing at Teachers College in New York City, affiliated with the Henry Street Settlement, established by Mary Adelaide Nutting
1920 90% of the ill were cared for at home with assistance from the community
1925 Frontier Nursing Service in the United States established by Mary Breckinridge to provide access to healthcare in remote Appalachian regions of southeastern Kentucky
1933 Pearl McIver became the first nurse employed by the U.S. Public Health Service
1935 U.S. Social Security Act passed
1943 Frances Payne Bolton was instrumental in founding the Cadet Nurse Corps as a part of the Public Health Service to train nurses during World War II
1953 U.S. Department of Health, Education, and Welfare established
1957 Nationalized Canadian healthcare system established
1965 Public health pediatric nurse practitioner program established at University of Colorado
1966 Medicare for the elderly established in the United States
1967 Medicaid for the medically indigent established in the United States
1970 Occupational Safety and Health Administration established
1974 National Health Planning and Resources Development Act passed
1975 Certification for community health nurses established by the American Nurses Association (ANA)
1979 Smallpox eradication worldwide certified by the WHOa1980 First national health objectives for the United States established: Promoting Health/Preventing Disease: Objectives for the Nation
1980 Direct reimbursement through Medicaid for nurse practitioner in rural health clinics, United States
1984 Behavioral Risk Factor Surveillance System (BRFSS) established
1989 Guide to Clinical Preventive Services (standardizing screening and prevention strategies) published by the U.S. Public Health Services Task Force
1990 Healthy People 2000: National Health Objectives for Health Promotion and Illness Prevention published
1991 Nursing’s Agenda for Health Care Reform published by a coalition of more than 60 nursing organizations
1998 The Public Health Workforce: An Agenda for the 21st Century published by U.S. Public Health Service
2000 Healthy People 2010 published
2002 European region of WHO declared free of polio
2002 U.S. Office of Homeland Security established
2003 U.S. Institute of Medicine recommends that undergraduate nursing students understand the ecological model of health and core competencies of population-based practice
2010 Patient Protection and Affordable Care Act (PPACA) passed
a
WHO = World Health Organization.
In the Middle Ages, care of ill people was based in the household. Care was haphazard. The few hospitals that existed were run by monks and nuns, primarily for residents of monasteries, and only the wealthy could afford assistance with their care. Changes in social structures encouraged the development of cities, but overcrowding, lack of sanitation, and an ever-increasing susceptible population contributed to recurring epidemics. During the 14th century, the Black Plague alone killed approximately one-fourth of the population of Europe. From the 1500s through the 1700s, the Renaissance in Europe stimulated the rise of scientific thought and inspired social consciousness.
The English Poor Law of 1601 marked the beginning of state-provided relief for the poor, placing a legal responsibility on each district to care for people within its boundaries who, either because of age or infirmity, were unable to work. The Sisters (or Daughters) of Charity, known as the “Grey Sisters,” was founded in 1617 in France, with members taking vows to provide care to the sick poor. The organization was so successful that it spread from the rural districts to Paris, and a training program was established in 1633 for young women who were devoted to serving people in need. From that time through the 19th century, this nursing community spread throughout the world. Today, the mother house is located in Paris.
In the 1800s, a variety of reforms were initiated to care for the sick poor throughout Europe that interacted and built on one another. Hospitals were established. By 1825, there were 154 in England alone. However, the fatality rates in these institutions were high, particularly for newborns and people with open wounds; the hospitals were called “death houses.” So-called “ward maids,” equivalent to housekeepers, provided care.
In Holland, Mennonites recruited women of the church to form deaconess groups to care for the poor. In 1836, Theodore Fliedner, a German Lutheran pastor, established a 3-year training school for deaconesses, which was associated with a new hospital. Fliedner also founded parish districts by dividing towns geographically into smaller areas to provide care to residents.
In Victorian times, poorhouses or workhouses existed for chronically ill poor people who were often elderly, without families. The primary reason for poverty was illness, and tuberculosis was rampant. Each parish had its own poorhouse. “Pauper nurses” were poor residents themselves, given the responsibility to care for the destitute. Conditions in many of these poor houses were deliberately harsh and often abysmal. Unfortunately, some pauper nurses were illiterate, irresponsible drunks who were vicious to residents, prolonging their illness (The Public Health [Scotland] Act, 1897). One of the most famous comical, fictional characters in Charles Dickens’ works is nurse Sairey Gamp in The Life and Adventures of Martin Chuzzlewit. She was a nurse of sorts who dealt with the “lying in and the laying out” extremities of life, representing some of the more questionable characteristics of the so-called nurses at the time (Fig. 1.4).
figure 1.4

Dickens’ character, Sairey Gamp. (From Kalisch, P. A., & Kalisch, B. J. [2004]. American nursing: A history. Philadelphia, PA: Lippincott Williams & Wilkins.)
During the latter part of the 19th century, when district nursing was established, meeting the needs of the ill became more organized in England. At that time, William Rathbone, a Quaker merchant and philanthropist in Liverpool, England, organized help for the poor. In 1859, he hired Mary Robinson, a nurse who previously had cared for his terminally ill wife, to provide care for the people in one of the poorest parish districts in Liverpool. Mary became the first district nurse in England. Box 1.5 lists the duties of district nurses in Liverpool. District nursing soon sprang up in other towns, cities, and rural areas in England, funded by local philanthropists.
box 1.5: Duties of District Nurses in Liverpool, England: 1865
Investigate new referrals as soon as possible.
Report to the superintendent situations in which additional food or relief would improve recovery.
Report neglect of patients by family or friends to the superintendent.
Assist physicians with surgery in the home.
Maintain a clean, uncluttered home environment and tend fires for heat.
Teach the patient and family about cleanliness, ventilation, giving of food and medications, and obedience to the physician’s orders.
Set an example for “neatness, order, sobriety, and obedience.” Hold family matters in confidence.
Avoid interference with the religious opinions and beliefs of patients and others.
Report facts to and ask questions of physicians.
Refer acutely ill to hospitals and the chronically ill, poor without family to infirmaries.
Source: Brainard, M. (1985). The evolution of public health nursing (pp. 120–121). New York, NY: Garland. (Original work published in 1922. Philadelphia, PA: W.B. Saunders.)
Rathbone devoted the rest of his life to expanding services for the sick poor, with assistance from his friend Florence Nightingale and others. Nightingale, the daughter of a wealthy English landowner, devoted her life to the prevention of needless illness and death. In 1851, she attended Theodore Fliedner’s program for deaconesses—for nurse training—in Kaiserwerth, Germany. She formed a team of nurses that assisted soldiers during the Crimean War (1854– 1856) and statistically documented her successes saving lives through prevention of infections and improving environmental conditions (Fig. 1.5). In 1860, following the war, Nightingale opened the first school of nursing, and Rathbone hired several graduates as district nurses. Two years later, with Nightingale’s assistance, he established a nursing school in Liverpool (see Chapter 6).
figure 1.5

Florence Nightingale, the “Lady with the Lamp.” (From Kalisch, P. A., & Kalisch, B. J. [2004]. American nursing: A history. Philadelphia, PA: Lippincott Williams & Wilkins.)
Public Health Initiatives in Early America
American social values were strongly influenced by British traditions, including care for the sick poor. Care of destitute and infirm residents was the responsibility of the town or county, similar to the English Poor Law of 1601. In the 1700s, early public health efforts in the colonies were focused on sanitation, collection of vital statistics, and control of infectious diseases. People with contagious diseases were isolated in “pesthouses,” and home quarantines were instituted. Women of the house were responsible for care of the ill, and treatments consisted of home remedies that were often passed down through generations.
Occasionally, a board of health would be established to address a specific problem, but it was then disbanded. In 1789, the first local health department with a permanent board of health was formed in Baltimore, Maryland. In 1798, the Marine Hospital Service was established by Congress to provide for the temporary relief and maintenance of sick and disabled seamen, as a means to protect the public from contagious diseases brought into port by the sailors. This was the first prepaid medical care program in the United States, financed through compulsory employer tax and federally administered.
At the beginning of the 1800s, people recognized that they needed a more organized public health system. In 1809, Elizabeth Ann Seton founded the Sisters of Charity in Maryland. The Sisters of Charity (also called Daughters of Charity) established and operated many hospitals, orphanages, and educational institutions over the years. In 1813, the Ladies’ Benevolent Society of Charleston, South Carolina, was established to provide organized home care to the sick. Knowing the threats that sick merchant seamen posed to the general population, Congress passed the Act for the Relief of Sick and Disabled Seamen in 1798 (amended in 1802) to establish hospitals for merchant seamen. However, conditions in many cities remained nearly intolerable.
The Industrial Revolution resulted in the transformation of primarily agricultural economies to large industrial centers. Large numbers of people migrated into cities, living in crowded tenement houses. Working conditions were poor, people were overworked and underpaid, and child labor was prevalent. Poor nutrition and overcrowded living conditions led to the rapid spread of communicable diseases. For example, New York City’s streets were piled with garbage and sewage, and tenements were filthy and crowded, providing breeding grounds for tuberculosis, smallpox, and typhus. Although initial attempts were made to protect residents from infectious diseases by providing healthcare to merchant seamen, diseases became epidemic and quarantine became inadequate. Few advances in public health were made other than scattered smallpox regulations until the Shattuck Report was published.
Lemuel Shattuck
Lemuel Shattuck prepared a report for the Massachusetts Sanitary Commission that pointed out that much of the ill health and disability in American cities in 1850 could be traced to unsanitary conditions. The report is now considered one of the fundamental documents in public health in the United States. It provided for the first systematic use of birth and death records and demographic data to describe the health of a population. The recommendations became the foundation of the sanitation movement in the United States, which laid the framework for the dramatic increase in life expectancy that occurred in the next 150 years. In 1850, the average life span was 25 years, and by 2000, it was more than 75 years. The Shattuck Report recommended the establishment of a state health department and local health boards in every town, and resulted in the first attempt to write a comprehensive public health code. Following the Civil War, many states and localities adopted these recommendations, ultimately resulting in the public health system that exists today.
Perhaps the most significant single document in the history of public health—I know of no single document in the history of that science quite so remarkable in its clarity and completeness and in its vision of the future.
C.-E. A. Winslow, bacteriologist and public health expert, on the Shattuck Report
Dorothea Dix
Dorothea Dix was also an American political activist in the 19th century who became aware of the dreadful conditions in prisons and mental hospitals, and she vigorously lobbied state and federal officials to remedy the situation. She had traveled to England in 1836, and during her time there, she met William Rathbone, who was spending a year as a guest at the family estate in Liverpool. In addition, she met political activists who believed that government should take an active role in social welfare. The lunacy reform movement was underway in England at the time, and the detailed investigations of the madhouses were published, resulting in legislative changes. After returning from England in 1840, Dix traveled the state of Massachusetts, visiting jails and insane asylums. She was appalled by conditions there and compiled a report that she presented to the Massachusetts Legislature. Considered the most progressive state in the union, Massachusetts quickly allocated funds to establish the first hospitals for the mentally ill. After making changes in Massachusetts, Dorothea moved on to other states and other countries, establishing hospitals and improving life for the mentally ill.
I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience.
Dorothea Lynde Dix
Clara Barton
Clara Barton achieved widespread recognition during the Civil War, distributing supplies to wounded soldiers and caring for the casualties with the help of her team of nurses. As a result of these experiences, she recognized the need for a neutral relief society in the United States that could be activated in times of war, similar to the International Committee of the Red Cross that was founded in 1863 in Geneva, Switzerland, by Henry Dunant. Barton lobbied tirelessly, and in 1882, she convinced Congress to ratify the Treaty of Geneva, and the American Red Cross was established with an extended mission—to provide aid for natural disasters.
Lillian Wald
In the 1880s, 20 years following the establishment of district nursing in England, a similar movement began in the United States. Urban tenement houses in the large American cities across the country were crowded and unsanitary, and infectious diseases such as tuberculosis, typhoid fever, smallpox, and scarlet fever were prevalent. A number of initiatives were undertaken in the major cities to improve the life of residents. An increased understanding of communicable disease indicated that education about prevention of infections would reduce these illnesses. Teaching methods to prevent infectious disease, implementing sanitary reforms, and fostering better nutrition became the foundations of community nursing practice in the United States.
Lillian Wald, the founder of public health nursing, was born into a life of privilege (as was Florence Nightingale) (Fig. 1.6). At the age of 22, Wald attended the New York Hospital School of Nursing. While taking classes at the Women’s Medical College, she became involved in organizing a class in home nursing for poor immigrants on New York’s Lower East Side. Distressed by the living conditions in the dingy multistory flats, Wald moved to the neighborhood, and she and her classmate Mary Brewster volunteered their services. With the aid of several patrons, they founded the Henry Street Settlement in 1893; fees were based on the patient’s ability to pay. In addition to providing acute and long-term care for the sick, Wald and Brewster taught health and hygiene to the immigrant women, stressing the importance of preventive care. Wald called her services “public health nursing.” Similar settlement houses in other American cities developed rapidly.
figure 1.6

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The public health approach to problem-solving.
Sandy and other members of the task force think that evidence-based practice should be part of the online population-based health course. What activities could be assigned that would foster evidence-based practice?
PRACTICE POINT
Systematic reviews of research evidence, such as those included in the Cochrane Database of Systematic Reviews, are instrumental in implementing evidence-based practice.
Helping Eliminate Health Disparities in Underserved Populations
Eliminating health disparities is a combined effort of health professionals in all settings, but PHNs deal directly with these issues, often on a personal basis. Ultimately, the most important changes occur at the local level. By participating in the development, implementation, and evaluation of culturally appropriate, community-based programs, nurses use their expertise to remedy the conditions that contribute to health disparities.
Demonstrating Cultural Competence
Countless cultures in the world are constantly changing. The shared cultural symbols and meanings that are a part of people’s daily social interactions have an impact on their acceptance or rejection of actions taken to promote their health. Therefore, nursing strategies that are focused on people with little attention as to how they think, feel, and interact with their world are not sufficient.
Cultural competency is an expected component of nursing practice, but it will become even more essential as interaction and integration among cultures increases. The characteristics of the major cultural groups that make up a community must be understood, along with those aspects of the community that give it its own unique subculture. It is necessary for nurses to be aware of cultural interpretations of healthcare activities so that they know what questions to ask and interventions to suggest. To achieve cultural competence, nurses should respect differences, understand their own beliefs, and not let personal beliefs have an undue influence on others. Nurses need to communicate curiosity and openness to others’ ideas and ways of life, respect their decisions, and demonstrate patience and humility (see Chapter 10).
Misunderstanding a culture’s symbols is a common root of prejudice.
Dan Brown, The Lost Symbol
EVIDENCE FOR PRACTICE
The delivery of culturally competent public health nursing that can address health disparities depends on competent nursing practice. Understanding the nurse characteristics, care situations, and training associated with culturally competent awareness and behavior provides a basis for planning and developing interventions to ensure competent nursing care. To meet this objective, a cross-sectional, descriptive, and exploratory study was conducted among 31 PHNs in a southeastern U.S. public health department using a cultural competence assessment tool with an internal consistency reliability of 0.90.
The self-reported study findings showed moderate competence in awareness and sensitivity. Although nursing care was consistent with guidelines and mandates found in the National Standards for Culturally and Linguistically Appropriate Services in Health Care (U.S. Office of Minority Health), the nurses did not assess their behaviors at comparable levels. While providing care, the nurses encountered multiple racial/ethnic and special population groups, including many that are at risk for or experiencing health disparities and poor outcomes. Therefore, being culturally competent in both thought and actions is necessary and important for these nurses. These nurses felt frustrated in their attempts to provide care that was consistent with their perceptions of culturally competent care. Lack of human or financial resources, interpreters, gender-specific providers, and time were the most common barriers. In addition, the nurses expressed a desire for additional diversity training.
To meet the goals of a culturally competent workforce, formal courses, continuing education programs, and practical experiences should focus on awareness, sensitivity, and behaviors consistent with culturally competent care. To develop additional evidence-based knowledge for practice, additional studies of clients’ perceptions and evidence of culturally competent care is needed. This information is necessary for the development of practice interventions with measurable outcomes that can be evaluated for effectiveness in addressing health disparities (Starr & Wallace, 2009).
Planning for Community Change
Change in healthcare at all levels can occur through behavior change, or through modifications in the environment, public policy, social or cultural norms, or healthcare delivery. Often, interventions at institutional or societal levels may lead to significant changes in public health without the need for behavior change on the part of individual people; fluoridation of water is an example. Even small changes in health behavior at the community or population level have the potential to significantly affect health status. The use of gel alcohol in hospitals and the availability of disinfectant wipes in grocery stores and other public places are examples.
Change should be planned and should meet specific needs to be the most effective. The impetus for change varies considerably. For example, installation of home monitoring devices may require new responsibilities, an influx of immigrants may increase the healthcare needs of a community, data may indicate that drug abuse and violence are increasing in specific groups, or new state regulations may require the establishment of new programs. On a community basis, health planning occurs on both an ongoing and an episodic basis depending on the need, and usually is a collaborative effort between multiple groups and organizations. A good example is the development of emergency preparedness plans in cities and towns (see Chapter 20).
Monitoring and evaluating the health status of individual people, families, and community groups are primary components of nursing practice in the community, as is the investigation of emerging health and environmental problems. Therefore, accepting responsibility for contributing to community health change as a policy advocate and political activist is essential. Few practitioners are as well prepared to address community health issues as PHNs. See Chapter 9 for more information on planning for community change.
The state department of public health recognizes that increasing the knowledge base of PHNs in population-based practice is just one step in implementing the new vision of public healthcare delivery. Knowledge alone cannot change practice from a clinical focus to a population-based focus if the work environment does not support the transition. Sandy is preparing another survey to determine current practices that need to be discontinued, strengthened, or developed within the next 5 years. Although the new vision for PHNs will include primary care, the majority of skills in the new model of practice will focus on population-based competencies.
Design a simple public health nursing model that incorporates the basic principles of population-based nursing.
EVIDENCE FOR PRACTICE
Domestic abuse and neglect have escalated in the United States to the point of overwhelming health and social service agencies that are attempting to address the safety of their clients. To address the need for a screening method that would identify people at risk, with funding from the U.S. Department of Commerce, investigators used a Home Health Visiting Nurse Association (HHVNA) in the Merrimack River valley to conduct a project that demonstrated innovative use of screening technology in clients’ homes, followed by appropriate interventions through the use of community resources (Hawkins, Pearce, Skeith, Dimitruk, & Roche, 2009).
Researchers adapted an initial risk screening tool and a follow-up risk assessment tool from several existing tools and research findings. All healthcare providers received training in the use of these screening tools via their personal digital assistants (PDA). The sample consisted of clients served by HHVNA during the study period. When a person screened positive on the initial risk screening tool, resources were mobilized for a same-day follow-up risk assessment and referrals were made to appropriate community agencies. Through the combination of technology and the skills and knowledge of healthcare professionals, the screening for domestic abuse and neglect has been mainstreamed into routine care at the agency, providing a new level of efficacy in prevention and early intervention.
Contributing to a Safe and Healthy Environment
Where people live, work, and spend their time can have direct consequences on their health. In every community in the world, clients are part of the environment, which has a direct impact on their health and well-being. The WHO (2014) reports that 23% of the global burden of disease is attributable to the environment. There are two ways to examine the effects of the environment on human health. The first focuses on how contaminants in the environment, such as asbestos, lead, or radon, influence human health. The second focuses on how the entire environment surrounding the community, such as the climate, neighborhood safety, access to grocery stores, and the physical layout of the community, affects health. Often, the two types of environmental effects interact.
The challenge for environmental health nurses is to use the best science available to assess how the local environment affects human health, to formulate evidence-based or best-practice interventions, and to evaluate the effectiveness of those interventions. Nurses are in a strong position to advocate for healthier environments in both the workplace and community (see Chapter 19).
Responding to Emergencies, Disasters, and Terrorism
All disaster response begins at the local level, and PHNs have always responded to community emergencies and disasters. They play an important role in all phases of the disaster management continuum, whether anticipating potential emergencies, developing appropriate community preparedness plans, building system-wide partnerships, practicing implementation of disaster management plans and skills on a regular basis, or evaluating outcomes (see Chapter 20).
Disaster preparedness plans are proactive planning efforts that are developed in anticipation of disaster scenarios, providing structure to a response before the disaster occurs. In an all-hazards event plan, the response must be a coordinated community effort, in which members of the community are engaged in ongoing preparedness activities focused on a variety of disaster situations. The capacity to respond to threats depends in part on the ability of healthcare professionals and public health officials to rapidly and effectively detect, manage, and communicate during an event. The terrorist attacks in 2001 identified a lack of workers in all areas of public health, as well as a growing appreciation of the first responders, primarily firemen, police, and healthcare personnel. Increased competency in disaster response added a new dimension to nursing practice. The public health workforce continues to be mobilized to ensure the training and education of communities across the nation regarding biological, chemical, and radiological attacks. It is necessary to learn how to prepare for events that are difficult to imagine, and it is even more challenging to mount a response.
Responding to the Global Environment
The burden of disease is growing disproportionately in the world and is largely affected by climate, public policy, age of the population, socioeconomic conditions, and factors that place people at risk for illness. Most of the countries burdened by disease have the least amount of human and economic capacity to effect change. Extreme poverty is the driving force behind increased mortality, and women are disproportionately affected.
Although maternal deaths have dropped worldwide by almost 50% in the last decade, maternal mortality is still unacceptably high. On any given day, approximately 800 women die from preventable causes related to pregnancy and childbirth, nearly all (99%) occurring in developing countries. Many of the complications resulting from childbirth can be prevented by skilled care before, during, and after childbirth by midwives and nurses. When a mother dies or is disabled, her children may be forced to live in poverty. Presently, about 6.6 million children younger than 5 die each year; poor nutrition is the underlying cause of death (WHO, 2014).
The leading causes of mortality and global burden of disease worldwide have shifted from communicable to non-communicable, chronic diseases as a result of population aging and better control of infectious diseases. Cardiovascular disease is already the leading cause of death in the world, followed by stroke. Figure 1.9 shows the 10 leading causes of death worldwide. Only lower respiratory infections, diarrheal diseases, and HIV/AIDS are infectious diseases remaining in the top 10. Chronic diseases such as trachea, bronchus, and lung cancers and diabetes mellitus are causing increased numbers of deaths worldwide. Traffic injuries worldwide are expected to grow from the ninth leading cause of death in 2004 to the fifth in 2030. The global burden of disease and methods to improve global quality of care are discussed in Chapter 4.
figure 1.9

The 10 leading causes of death in the world.
With the world becoming a global village, problems that affect people in other countries also affect people in their own countries. Nurses and community healthcare providers need to be knowledgeable about the needs of all people, as well as their patients, in the global society. Opportunities have expanded for nurses to work internationally in a wide variety of roles: working side by side with local people in healthcare, initiating health education programs, establishing local primary healthcare programs, and participating in countless other activities. Advanced technology and knowledge transfer techniques will allow rapid transfer of information from electronic monitoring equipment, presenting exciting opportunities to improve health in remote locations. New cooperative healthcare ventures will occur throughout the world in the 21st century.
PRACTICE POINT
In this dynamic time, care will be transformed as needs rapidly evolve. Newly prepared nurses will experience events never before thought possible.
STUDENT REFLECTION
Over the spring vacation, a group of eight undergraduate nursing students, three graduate students, and three faculty members flew to Nicaragua to work in a clinic for the week. There was one person who stands out in my mind. She was a 25-year-old woman who came to the clinic complaining of diarrhea, accompanied by her 6-year-old son and 3-year-old daughter. One of our nurse practitioners (NPs) cared for her while I observed. After the NP determined that the woman had a gastrointestinal parasite that was common in Nicaragua and prescribed treatment, the nurse asked the client about her wishes to have more children. The woman responded quietly that she did not want more children, but that her husband was adamant that she not use birth control. When the NP asked if birth control was a sensitive subject between them, the woman began to cry. She told us that after the birth of her daughter, she began birth control without consulting her husband, and when he found out, he became verbally and physically abusive. Since that point, their relationship had become increasingly violent and the woman said she feared for her life, along with the lives of her children. Her husband felt that if she used birth control she was cheating. He told her that he was not going to use a condom, and if she did not want to have his children, she didn’t love him.
This situation made me realize just how dismal it can be for women in violent relationships. Because of lack of resources, it is very difficult for abused women to find help, and many lose hope, believing that nothing can be done. Their situation is complicated since the majority of women are financially dependent on their partners. Our client was in a similar situation. She was afraid of her husband, vulnerable financially, and had two children to protect. Her situation would be further complicated if she continued without birth control.
During the visit, the NP and I listened and provided the emotional support that she so desperately needed. We began to discuss some options and actions that she might be able to take. Just as we would in the United States, we discussed the necessity of formulating a plan before acting, helping to ensure success and safety. We talked about the possibility of staying with a family member and reviewed the important documents and birth certificates that she should take with her. Also, I told her about a domestic violence support group that the clinic provided. Finally, we discussed multiple forms of birth control that she could use, such as the hormone injection that lasts for 3 months to prevent pregnancy, if she were unable to leave for any reason. I think the woman left feeling relieved and somewhat hopeful for what the future held for her family. Even if I was only able to get my client thinking about her options, I feel that our time together was a success.
key concepts
• Three major changes in healthcare in the 21st century include the development of patient/client–centered care, increased use of technology, and increased personal responsibility for health.
• The practice of public health nursing is defined in the ANA (2013) publication Public Health Nursing: Scope and Standards of Practice. It defines the essentials of public health nursing, the activities, and the accountabilities that are characteristic of practice at all levels and settings. It is the legal standard of practice set by the profession.
• In the ANA (2013) publication, each standard of practice is followed by the essential competencies required to meet that standard.
• The Public Health Intervention Wheel defines 17 interventions—actions taken on behalf of individuals, families, communities, and systems to protect or improve health status.
• Entry into public health nursing practice requires a baccalaureate degree.
• The historical roots of public health nursing have set the framework for current nursing practice in the community.
• Multiple challenges face PHNs in the 21st century: Engaging in evidence-based practice Helping eliminate health disparities in underserved populations Demonstrating cultural competence Planning for community change Contributing to a safe and healthy environment Responding to emergencies, disasters, and terrorism Responding to the global environment
critical thinking questions
1.
Review the public health milestones presented in Box 1.1. What potential health successes might be cited in the next decade?
2.
Identify a new role for nursing that will most likely evolve in the first half of the 21st century.
3.
Analyze the roots of public health nursing and its influence on practice today.
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web resources
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