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Populations

A collection of individuals who have one or more personal or

environmental characteristics in common

Prevention

Anticipatory action taken to prevent the occurrence of an event or

minimize its effect after it has occurred

The Determinants of Health

Factors that influence the health of individuals, families, and populations

Health of Populations

Historically gains in the health of populations have come largely from

public health changes
o Improved sanitation, control of disease, immunizations
o Gain in life expectancy

Public Health

Scientific discipline

Community-oriented

Population-focused

Mission is to organize community efforts to use scientific and technical

knowledge to prevent disease and promote health

Public Health Nursing

Public health nursing is the practice of promoting and protecting the

health of populations using knowledge from nursing, social, and public
health sciences (APHA, 1996).

Guided by an assessment of health status

o Community assessment

Considers the determinants of health-

What makes some people healthy and others unhealthy?

How can we create a society in which everyone has a chance to live

long healthy lives?

Committed to Communities, Families, and Individuals

o Social Justice

Relationship Based

Public Health Nurses:

Practice in a variety of public and private organizations

Partners with communities and populations

Must understand and apply concepts from various disciplines

Practice in partnership with the community and numerous other groups

Are proactive with respect to social and health care concerns, policy, and
legislative activities

Levels of Public Health Nursing Practice

Individual / Family Level of Practice

o A family is defined as two or more people who identify them selves
as family

Share emotional bonds

carry out the functions of a family

Community/ Level of Practice

o A community can refer to :

A group of people or population group

Physical place and time in which the population lives and

works

Cultural group that has shared beliefs, values, institutions

and social systems

Systems Level of Practice

o A system is an institution or organization that can be in one of
more communities. Key systems include:

Health care systems

Public health systems

Schools

Churches

Government Agencies

Non Profits

Businesses

Core Functions of Public Health

Assessment
o Systematic data collection about a population

Includes monitoring the populations health status and

providing/ disseminating information about the health of the
community

Policy Development
o Developing policies that support the health of the population
through leadership and research

Assurance
o Making sure that essential community-oriented health services are
available

Includes providing essential personal health services for individuals as

well as a competent PH workforce

PHNs and Core PH Functions: Assessment

Participate in and provide leadership for:

o Assessing community needs, health status of populations within the
community, and environmental and behavioral risks

Look at trends in the health determinants

Identify priority health needs

Determine the adequacy of existing resources within the

community

Engage in policy-development efforts

PHNs and Core PH Functions: Assurance

Focuses on the responsibility of public health agencies to make certain

that activities have been appropriately carried out to meet public health
goals and plans

Includes the development of partnerships between public and private

agencies

PHNs and Core PH Functions: Policy Development

Core function AND core intervention strategy

Seeks to build constituencies that can help bring about change in public
policy

Examples:

o Development of Healthy People 2020 state objectives

o

National effort to control acquired immunodeficiency syndrome

(AIDS)

Anti-smoking ordinances

The Ten Essential Public Health Services

1. Monitor health status to identify community health problems.

2. Diagnose and investigate health problems and health hazards in the
community.

3. Inform, educate, and empower people about health issues.

4. Mobilize community partnerships and action to identify and solve
health problems.

5. Develop policies and plans that support individual and community

health efforts.

6. Enforce laws and regulations that protect health and ensure safety.

7. Link people to needed personal health services and assure the

provision of health care when otherwise unavailable.

8. Assure competent public and personal health care workforce.

9. Evaluate effectiveness, accessibility, and quality of personal and
population-based health services.

10. Research for new insights and innovative solutions to health

problems.

Public Health Nursing as a Field of Practice

Public health nursing is a specialty because it has a distinct focus and

scope of practice and requires a special knowledge base.
o Population focused and community oriented
o Concerned with health of all members of population or community
o Focus on health, prevention, and interventions at the community
and population levels
o

Public Health Nursing : Scope and Standards of Practice (ANA)

Educational preparation
o Baccalaureatebeginning staff public health nurse
o Mastersassumed for specialist in public health nursing who has
expertise in population focused care
o

DNP

Core Competencies of Public Health Professionals

Necessary skills to implement the core functions and the 10 essential

services.
o 8 domains include: Analytic assessment, basic public health
sciences, Cultural competency, Communication, Community
dimensions of practice, Financial planning & mgmt, Leadership &
systems thinking, Policy development/program planning skills.
o

Quad council has list of skills PHNs should attain for each of the
competencies

IOM document in 2003 identifies 8 new areas PH workers should

know: informatics, genomics, cultural competence, communitybased participatory research,

policy and law, global health, &

ethics

Distinguishing Public Health Nursing from Other Nursing Specialties

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 the population as a while.

The processes used by public health nurses include working with the client
as an equal partner

Primary prevention is the priority in selecting appropriate activities

Public health nursing focuses on strategies that create healthy

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 may benefit from a specific activity or service.

Optimal use of available resources to assure the best overall improvement

in the health of the population is a key element of the practice.

Collaboration with a variety of other professions, populations,

organizations, and other stakeholder groups is the most effective way to
promote and protect the health of the people.

Public Health Nursing: Focuses on Health Promotion and Disease Prevention

PH Nursing considers all levels of prevention, with a preference for

primary prevention

Levels of Prevention
o Primary
o

Secondary

Tertiary

Primary Prevention

Measures that actively promote health, prevent illness, and provide

protection
o Health Promotion and Education
o Specific Protective Measures

Is implemented before a problem develops

Targets essentially well populations

Secondary Prevention

Early diagnosis and prompt interventions to limit disabilities

Identifies risks or hazards and modifies, removes, or treats them

before a problem becomes more serious

Targets populations that have risk factors in common

Screenings

Testing

Tertiary Prevention

Reduce impairments and disabilities, minimize suffering, promote

adjustment to immediate condition, and rehab
o Limits further negative effects from a problem

Prevent complications, keeps existing problems from getting worse

Seeks to restore person to optimal level of functioning

Target prevention after a disease or injury has occurred

Population-Focused Practice Versus Individual-Focused Practice

Population-Focused Practice:
o Diagnoses, interventions, and treatments are carried out for
population or subpopulation

Levels of prevention (primary, secondary, tertiary)

Population-level decision making is different

Concerned with more than one subpopulation

Individual-Focused Practice:
o Diagnoses, interventions, and treatments are carried out at
individual client level

Community Health Nursing VS. Public Health Nursing

Community-Based Nursing

Managing acute or chronic conditions among individual clients and

families

Care is family-centered

Setting is community-based

Goal
o

Manage acute and chronic conditions

Focus in on illness care of individuals and families across the life span
o Provide acute and chronic illness care and the provision of
comprehensive, coordinated, and continuous care

o A setting-specific practice, care is provided where people live, work,

and attend school

Community-Oriented Nursing

Goal
o

Prevent disease and disability; promote, protect, and maintain

health

Focus is on health care of individuals, families, and groups in community

as a whole
o Provide health care to promote quality of life

o Community diagnosis, health surveillance, monitoring and

evaluation of community and population
o

Coordination of health care, disease prevention, health promotion,

health education.

Community Oriented versus Community-Based Nursing

Looking to the Future

Barriers to specialization in PH Nursing

o Mindset of only role: direct care
o

Few nurses with graduate-level preparation

Need to establish population-focused nurse leaders

o Organizational changes occurring in the delivery system offer
opportunities for new roles and population thinking.
o

Need for more masters and doctoral programs in public health

nursing

Health Care System Overall

o We can anticipate the focus of the health care systems of the
future to be on community oriented strategies for health promotion
and disease prevention and community- based strategies for
primary care and much of secondary care.

Healthy People 2020

Healthy People provides science-based, 10-year national objectives for

improving the health of all Americans.

For 3 decades, Healthy People has established benchmarks and monitored

progress over time in order to:
o Encourage collaborations across sectors.

Guide individuals toward making informed health decisions.

Measure the impact of prevention activities.

Vision
o A society in which all people live long, healthy lives.

Mission
o Healthy People 2020 strives to:

Identify nationwide health improvement priorities.

Increase public awareness and understanding of the

determinants of health, disease, and disability and the
opportunities for progress.

Provide measurable objectives and goals that are applicable

at the national, State, and local levels.

Engage multiple sectors to take actions to strengthen policies

and improve practices that are driven by the best available
evidence and knowledge.

Identify critical research, evaluation, and data collection

needs.

Overarching Goals
o Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death.
o

Achieve health equity, eliminate disparities, and improve the health

of all groups.

Create social and physical environments that promote good health

for all.

Promote quality of life, healthy development, and healthy behaviors

across all life stages.

National Prevention Strategy

Called for under the Patient Protection and Affordable Care Act

Developed by the National Prevention Council

Four Strategic Directions:

o Building Healthy and Safe Community Environments: .

Expanding Quality Preventive Services in Both Clinical and

Community Settings

o Empowering People to Make Healthy Choices:

o

Eliminating Health Disparities:

Definitions

Health Disparity- A type of difference in health that is closely linked with

social or economic disadvantage. Health disparities negatively affect
groups of people who have systematically experienced greater social or
economic obstacles to health. These obstacles stem from characteristics
historically linked to discrimination or exclusion such as race or ethnicity,
religion, socioeconomic status, gender, mental health, sexual orientation,
or geographic location. Other characteristics include cognitive, sensory, or
physical disability.

Health Equity- When all people have "the opportunity to 'attain their full
health potential' and no one is 'disadvantaged from achieving this
potential because of their social position or other socially determined
circumstance'".

Social Determinants of Health- The complex, integrated, and

overlapping social structures and economic systems that are responsible
for most health inequities. These social structures and economic systems
include the social environment, physical environment, health services, and
structural and societal factors. Social determinants of health are shaped
by the distribution of money, power, and resources throughout local
communities, nations, and the world.

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Community Defined

A group of people, often living in a defined geographical area, who may

share a common, culture, values and norms, and are arranged in a social
structure according to relationships which the community has developed
over a period of time. Members of a community gain their personal and
social identity by sharing common beliefs, values and norms which have
been developed by the community in the past and may be modified in the
future (World Health Organization [WHO], 2004, p 16).

Traditionally thought of as people in a given geographical location, really

can refer to any group of people sharing something in common
o People in relationship with others

Bounded geographical setting and/or common values or interests

Emotional or functional relationships

Community specified
o People, place, and function dimensions

Population
o may or may not interact , typically share a geographic location

Aggregateo a mass of individuals considered as a whole

Community as Client

The community client

o Nursing practicecommunity oriented
o The community is client ONLY when the nursing focus is the
collective or common good of the population NOT individual health

Relevance of the community client to nursing practice

o Nursing goalimproved health of the collective

A community practice setting is insufficient reason for saying that practice

is oriented toward the community client

o When the location of the practice is in the community but the focus
of practice is the individual or family, the nursing client remains the
individual or family, not the whole community

Nursing focus is on the collective or common good of the population

instead of on individual health

Nurse may work with individuals; families; other interacting groups,

aggregates, or institutions; or within a population but the resulting
changes are intended to affect the whole community

Community Assessment

One of the core functions of public health

The process of thinking critically about the community

A logical, systematic approach to identify community needs, clarify

problems, identify strengths and resources

Is an ongoing process

The primary goal of community assessment is to identify the health needs

of a community

Community Assessments are used to:

o Document needs and gaps in service
o

Identify potential resource

Help to establish a vision, goals and strategies to meet community

needs

Build consensus and buy-in to change

Increase a communitys readiness and ability to change by

promoting collaboration among partners

Identify benchmarks to measure progress in meeting goals

Provide information for problem and asset identification and policy

formulation, implementation, and evaluation.

Involves getting to know and understand the community as client and

partner

Steps to assessing community health:

o Gathering relevant existing data and generating missing data
o Developing a composite database
o

Interpreting the composite database to identify community

problems and strengths

Analyzing the problem

The process of community assessment will help you

o Understand the context in which people live and issues they want
addressed
o

Locate strengths or underutilized resources that could be developed

Help you design effective, collaborative strategies to engage people

Empower people by giving them a role in designing and

implementing the strategies that improve their health

Community Health Needs Assessments and the Affordable Care Act

Community health needs assessments (CHNA) and implementation

strategies are newly required of tax-exempt hospitals as a result of the
Patient Protection and Affordable Care Act.

CHNA must be done every 3 years, include an in depth analysis of the

communitys needs and an implementation strategy outlining how you
propose to address those needs in the coming years.

By statute, the CHNAs must take into account input from persons who
represent the broad interests of the community served by the hospital
facility, including those with special knowledge of or expertise in public
health.

Define the Community

What are the boundaries for the assessment?

1. County

2. City

3. Neighborhood

4. Day Care Center

5. School

6. Worksite

7. Specific population group

8. Other?

Data Collection

Acquire usable information about community health problems and health

strengths

Community Assessment Data

Data collection and interpretation

Data gathering

Data generation
o Informant interviews
o Community forum

Focus groups

Participant observation

Windshield surveys

Collection of reported data

o Secondary analysis
o

Surveys

Profile of the Community

Brief history including a health-related history

Natural physical characteristics

Population per square mile

Existing form of government

Traditions, values, and beliefs

Cultural traditions and norms

Strengths and liabilities

Data about the People

Age and sex distribution

Ethnic and religious composition

Education and socioeconomic status

Income, occupation, unemployment

Environmental Data

Geography

Climate

Purity of air and water

Toxins, pollutants

Adequacy of housing

Police, fire and civil defense

Waste disposal

Transportation systems and patterns

Channels of Communication

Formal and Informal

Key community leaders

Service, religious, and voluntary health organizations

Newspapers, TV, radio, postal services

Centers for congregating

Resources and services

Health and Illness Patterns

Vital statistics

Disease incidence and prevalence

Leading causes of death

Rate of births

Health Facilities

Facilities, resources, and personnel

Current and adequately equipped?

Accessibility

Health-related planning groups

Analysis of Community Assessment Data

Gather all your collected data

Identify and generate any missing data

Synthesize data and identify themes

Identify community needs and problems

Identify community strengths and resources

Next, state your identified problems as nursing diagnoses

Community Nursing Diagnosis

Developing the community health diagnosis helps clarify the problem and
is an important first step to planning.

Community diagnoses clarify who receives the care, provide a statement

identifying problems faced by who is receiving the care, and identify the
factors contributing to the identified problem.
o Risk of
o

Among

Related to

* You do not need to use your NANDA DX book for this*

Nursing Diagnosis

Risk for or actual

o identifies the specific problem or risk faced by the community

Among
o The specific population that is affected by the problem or risk

Related to
o identifies factors/strengths/weaknesses influencing the problem or
risk

Examples of Nursing Diagnosis

Risk of violent crime among African-American youth in Orange Mound

related to poverty and high levels of unemployment

Risk of increased infant mortality among residents of North Memphis

related to high levels of teen pregnancy

Planning for Community Health

The planning phase

o analyzes the community health problems identified in the
community nursing diagnoses

establishes priorities among them

establishes goals and objectives

identifies intervention activities that will accomplish the objectives

Community Health Planning Process

1. Problem analysis and prioritization

o Clarify nature of the problem

Rank- start with highest priority

Priority given to problem that has greatest impact on health of all

Criteria for ranking problem:

Community awareness of the problem

Community motivation to solve the problem

Availability of expertise to solve problem

Severity of outcomes if problem not resolved

Speed with which the problem can be solved

2. Establish goals and objectives

o Goal- global statement of the desired

outcome
o Objective- more specific, precise, behaviorally stated, incremental
and measurable.

o *SMART* objectives- specific, measurable, achievable, realistic,

timetable

3. Identify intervention activities

o The means by which the objectives are met

Implementing in the Community

Involves the work and activities aimed at achieving the goals and
objectives

May be made by the person or group who established the goals and
objectives, or they may be shared with, or even delegated to, others

Nurse as content expert and as process expert

o Change agent
o Change partner

Evaluating Community Health Intervention

The appraisal of the effects of some organized activity or program

Begins at the planning stage when goals and objectives are established

Must decide whether the costs in money and time are worth the resulting
benefits

Role of outcomes

Personal Safety in Community Practice

Personal safety is a prerequisite for effective community-oriented practice

Awareness of the community and common sense

Three clear sources of information that will help answer personal safety
questions
o Other nurses, social workers, or health care providers who are
familiar with the dynamics of a given community

Community members

Nurses own observations

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Program management consists of assessing, planning, implementing,

and evaluating a program

The program management process is parallel to the nursing process:

o when to make a decision to develop a program (through needs
assessment and defining a problem)
o

where they want to be at the end of the program (goal setting)

how to decide what to do to have a successful program (planning)

how to develop a plan to go from where they are so they will know
where they want to be (implementing)

how to know that they are getting there (formative evaluation)

and what to measure to know that the program has successful

outcomes (summative evaluation)

Definitions

A Program is an organized approach designed to meet the assessed

needs of individuals, families, groups, or communities by reducing or
eliminating one or more health problems. Community health programs
are planned to meet the needs of designated populations or
subpopulations.

Programs are ongoing organizational activities as compared with

projects, which are organizational activities with a limited time frame.

Planning is defined as selecting and carrying out a series of actions

designed to achieve desired improvements

Evaluation is an ongoing process of accountability and is defined as

determining whether a service is needed and can be used, whether it is
conducted as planned, and whether the service actually helps people in
need.

Program evaluation is used to make judgments about improving,

managing, and continuing programs. It addresses such areas as
relevance, adequacy, progress, efficacy, effectiveness, impact, and
sustainability of program activities.

Goals

Program planning: Ensure that health care services are acceptable,

equal, efficient, and effective.

Program evaluation: Determine the relevance, adequacy, progress,

efficiency, effectiveness, impact, and sustainability of program activities.

Benefits of Program Planning

Ensures that available resources are used to address the actual needs of
people

Focuses attention on what the organization and health provider are

attempting to do for patients

Assists in identifying the resources and activities that are needed

Reduces role ambiguity

Reduces uncertainty within the program environment

Increases the abilities of the provider and the agency to cope with the
external environment.

Allows for quality decision making and better control over the actual
program results by setting specific goals

Assessment of Need

Planning for effective and efficient programs must be based on identifying

the needs of populations within the community and is often essential if
funding is sought for implementation
o Community assessment
o

Population needs assessment

Planning Process

Formulating is the initial and most critical step

o It includes defining the problem
o

the target population

the target population boundaries

assessing the need for, availability of, accessibility of, and

acceptability of the program (needs assessment)

determining the availability of program resources

Conceptualizing
o creates options for solving the problem
o considers several solutions along with their risks, consequences,
and potential outcomes.

o Involves reviewing the literature and synthesizing the evidencebased practice available.

Detailing involves both the provider and client in a consideration of the

possibilities to solve the problem as it relates to costs, resources, and
program activities.

Evaluating each possible solution allows for each alternative to be

weighed (cost, benefits, and acceptance) and ranked for choice with
emphasis on the desired outcome.

Implementing requires obtaining and managing the resources to

operationalize the program in a way that is consistent with the plan and
also requires accountability and responsibility.

Planning

Formulating written objectives is critical to both the program planning and

evaluation process
o providing direction for conducting the program
o mechanism for evaluating the specific activities and total program

Goal- global statement of the desired outcome

Objective- more specific, precise, behaviorally stated, incremental and
measurable.

*SMART* objectives- specific, measurable, achievable, realistic,

timetable

Benefits of Program Evaluation

Ensuring that a program has met its goals

Documenting accountability by the program managers to the patients and

the funding sources

Shows whether the program is fulfilling its purpose

Used to make judgments about a program and may be used to justify

sustaining the program, making adjustments in the program, expanding
or reducing the program, or even discontinuing it

Sources of Program Evaluation

Both quantitative and qualitative methods may be used.

Qualitative methods
o Site visits, structured observations of interventions, open-ended
interviews

Quantitative methods
o Program records
o

Epidemiological data

Aspects of Evaluation

RelevanceNeed for the program

AdequacyProgram addresses the extent of the need
ProgressTracking of program activities to meet program objectives
EfficiencyRelationship between program outcomes and the resources
spent

EffectivenessAbility to meet program objectives and the results of

program efforts

ImpactLong-term changes in the patient population

SustainabilityEnough resources to continue the program

Cost Studies Applied to Program Management

Cost Accounting: Cost-accounting studies are performed to find the

actual budgetary cost of a program, procedure, or technique.

Cost-Benefit: Cost-benefit studies are a way of assessing the desirability

of a program, procedure, or technique by placing a specific quantifiable
value on all costs and all benefits of the variables to be evaluated.

Cost-Effectiveness: Cost-effectiveness analysis is a measure of the

quality of a program, procedure, or technique as it relates to costs.

Cost Efficiency: Cost-efficiency analysis involves the analysis of actual

costs to perform a number of services at different volumes if the same
standards are applied.

Program Funding

Can be a challenge to obtain adequate funding

Gifts

Contracts

Grants
o A grant proposal is a means of documenting plans for establishing,
managing, and evaluating a program and including specific
components (target population, problem definition, program
description, evaluation plan, operating budget).

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Introduction

Evidence based practice (EBP) is an approach to providing the highest

quality of health care in all settings to improve health outcomes

The Institute of Medicine has set a goal that by 2020, the best available
evidence will be used to make 90% of all health care decisions, yet most
nurses continue to be inconsistent in implementing EBP.

Definitions of EBP

Evidence-based practice (EBP)

o the conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual clients

Evidence-based public health

o a public health endeavor in which there is an informed, explicit, and
judicious use of evidence that has been derived from any of a
variety of science and social science research and evaluation
methods

Evidence-based nursing

o an integration of the best evidence available, nursing

expertise, and the values and preferences of the individuals,
families, and communities who are served. (Sigma Theta Tau,
2005)

External evidence
o Research and other evidence

Internal evidence
o Includes the nurses clinical experiences and the clients preferences

Factors Leading to Change or Barriers to EBP

Knowledge of research and current evidence

Ability to interpret the meaning of the evidence

Individual professionals characteristics

Time needed to implement EBP and to engage in education and directed

practice

Hierarchy of the practice environment, level of support of managers, and

ability to engage in autonomous practice

Philosophy of the practice environment and the willingness to embrace

EBP

Resources available to engage in EBP

Practice characteristics

Links to outside supports, such as teaching facilities

Political constraints and the lack of relevant and timely public health
practice research

Steps in the EBP Process

Cultivating a spirit of inquiry

Asking clinical questions

Searching for the best evidence

Critically appraising the evidence

Integrating the evidence with clinical expertise, client preferences, and

values

Evaluating the outcomes of the practice decisions or changes based on

evidence

Disseminating EBP results

Approaches to Evaluating Evidence

Grading the strength of evidence

o Quality

Sample selection, randomization, blinding, sample size,

description of intervention, outcomes, length of followup,
attrition, confounding variables, statistical analysis

Quantity

Consistency

Approaches to Implementing EBP

First step is recognizing the current status of ones own practice

EBP is new concept for many practicing nurses

Will only be successful when practicing in an environment that supports

evidence-based care

Current Perspectives

Cost versus quality

Individual differences

Appropriate EBP methods for population-centered nursing practice

Healthy People 2020

Objectives offer a systematic approach to health improvement.

Several objectives are devoted to improving clients understanding of EBP

and how they can contribute to health care decisions.

Examples

The Intervention Wheel

o Originally developed using a qualitative, grounded theory process
but did not include a systematic review of evidence to support the
interventions or their application to practice

Systematic review done later to examine the evidence

underlying the interventions and levels of practice

The 17 interventions grew out of an extensive analysis of the actual

work of 200 practicing public health nurses in a variety of work
settings.

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The Intervention Wheel: Origins and Evolution

Original version resulted from a grounded theory process carried out by

public health nurse consultants at the Minnesota Department of Health in
the mid-1990s

A wheel-shaped graphic was developed to illustrate the set of

interventions and the levels of practice

Since first published in 1998, adoption of the model has been rapid and
worldwide

The 17 Interventions

Surveillance

Disease and health event investigation

Outreach

Screening

Case finding

Referral and follow up

Case management

Delegated functions

Health teaching

Counseling

Consultation

Collaboration

Coalition building

Community organizing

Advocacy

Social marketing

Policy development and enforcement

Assumptions Underlying the Intervention Wheel

Defining public health nursing practice

Public health nursing practice focuses on populations

Public health nursing practice considers the determinants of health

Public health nursing practice is guided by priorities identified through an

assessment of community health

Public health nursing practice emphasizes prevention

Public health nurses intervene at all levels of practice

Public health nursing utilizes the nursing process at all levels of practice

Public health nursing uses a common set of interventions regardless of

practice setting

Public health nursing practice contributes to the achievement of the ten

essential services

Public health nursing values and beliefs

Using the Intervention Wheel in Public Health Nursing Practice

Component 1: Population based

o The upper portion of the Wheel illustrates that all levels of practice
are population based.

Component 2: Levels of practice

o Community level

You want to change community norms, attitudes, awareness,

practices and behaviors

Systems level

You want to change organizations, laws, policies, and power

structures

Individual/Family level

You want to change behaviors, knowledge, attitudes,

practices, and beliefs

Component 3: Public health interventions

o The Intervention Wheel encompasses 17 interventions
o All interventions except case finding, coalition building, and
community organizing are applicable at all three levels of practice.
o

Community organizing and coalition building cannot occur at the

individual level. Case finding is the individual level of surveillance,
disease and other health event investigation, and outreach and
screening.

Adoption of Intervention Wheel

In practice

In education

In management

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Colonial Period

Household members (usually women) tend to the sick

o Urbanization in the early 1800s causes this system to became
insufficient

Englands Elizabethan Poor Law of 1601

o 1751 Pennsylvania Hospital founded

Early colonial PH efforts

After American Revolution

o First PH committee was established

After American Revolution

Public Health Service (PHS)

o Established in 1798 as the Marine Hospital Service

Early experiments in providing nursing care at home

o Ladies Benevolent Society of Charleston (1813)
o Philadelphia lay nurses
o

Roman Catholic Sisters of Charity (1854)

Shattuck Report (1850) by the Massachusetts Sanitary Commission

Nightingale and the Origins of Trained Nursing

Need for nurses

Origins of organized nursing

o Pastor Theodor Fliedner
o

Crimean War

Principles of nursing
o Health of the unity is the health of the community
o Differentiated sick nursing for health nursing
o

Improved soldiers health using a population-based approach

Proper nutrition, rest, sanitation, and hygiene necessary

William Rathbone
o Founded first district nursing association in Liverpool, England
o Rathbone and Nightingale recommended steps to provide nursing in
the home, and district nursing was organized throughout England

Florence Sarah Lees Craven

o Guide to District Nurses

America Needs Trained Nurses

Need for PH nursing

o Increase of women in workforce
o More economical to have home-visiting nurses

Origins of organized nursing

o 1870s First Nightingale model nursing schools started
o 1877 Womens Board of the New York City Mission hired Frances
Root
o

1878 Ethical Culture Society of New York hired four nurses to

work in dispensaries

1885-1886 Visiting nurse associations were established

District Nursing and Settlement Houses

Deplorable environmental conditions in immigrant tenement housing and

sweatshops

District nursing and settlement houses established

Rural Nursing Service

Occupational Health

School Nursing in America

Grew out of school absences caused by the prevalence of infections and

communicable diseases

Lina Rogersfirst United States school nurse

o Worked with children in New York City schools
o

She and her other school nurses found illness was often not the
reason for absence.

Significant and positive impact

o More nurses hired
o

School nursing soon implemented in Los Angeles, Philadelphia,

Baltimore, Boston, Chicago, and San Francisco

The Profession Comes of Age in the United States in the Twentieth Century

National Organization for PHN (NOPHN)

o Sought to standardize PHN education
o

1914 First post-training school course in PHN offered at Teachers

College in New York City

1920s to 1930s Many newly hired PHNs had to verify completion

in a certificate program in PHN,

American Public Health Association (APHA)

o Established in 1872
o

Sought to facilitate interprofessional efforts and promote the

practical application of public hygiene

PHN in Official Health Agencies and in WWI

Late 1800s local health departments formed

Federal role in PH gradually expanded

o 1912 U.S. Public Health Service role defined
o NOPHN loaned a nurse to the U.S. Public Health Service

First federal government sponsorship of nurses

WWI depleted the ranks of PHNs

1918 worldwide influenza pandemic

Paying the Bill for PHNs

Metropolitan Life Insurance Company

Sheppard-Towner Act

Individual commitment and private financial support

o Frontier Nursing Service

African-American Nurses in PHN

1919: National Health Circle for Colored People

o Bessie M. Hawes

1936: PHN certificate program for African-American nurses

Wage discrimination in the South

Nursing education segregated until 1960s

Between the Two World Wars

Economic depression
o Agencies and communities not prepared to address the increased
needs and numbers of impoverished

Decreased funding

Agencies that helped to support nurse employment

Federal Emergency Relief Administration (FERA)

Works Progress Administration (WPA)

Relief Nursing Service

Civil Works Administration (CWA) programs

1932 survey found only 7% of nurses working in PH were adequately

prepared

Increasing Federal Action for the Publics Health

Social Security Act of 1935

o Funded opportunities for education and employment of PHNs
o Funded assistance to states, counties, and medical districts in
establishing adequate health services
o

Provided funds for research and investigation of disease

World War II

Accelerated need for nurses, both for war effort and at home

Nursing Council on National Defense

Many nurses joined the Army and Navy Nurse Corps.

Bolton Act of 1943 established Cadet Nurses Corps

Some expansion of PHN scope of practice

o Emergency Maternity and Infant Care Act of 1943

Job opportunities

Rise in Chronic Illness

National crude mortality rate decreased by 47%

Change in leading cause of death from communicable diseases to chronic

diseases

Aged population grew as did prevalence of chronic disease

Some visiting nurse associations provide home-care programs

o Reimbursable by commercial health insurance and later by
Medicare and Medicaid

Resurgance in combination agencies

Declining Financial Support for Practice and Professional Organizations

Hospitals preferred for illness and childbirth

Funding stopped for visiting nurse services

Consolidation of national nursing organizations

o National League for Nursing
o

American Nurses Association

Professional Nursing Education for PHN

National League for Nursing adopted Esther Lucile Browns Nursing for the
Future (1948)
o Recommended to establish basic nursing preparation colleges and
universities

Included PHN concepts in all baccalaureate programs;

however, these were very brief components of the curricula

1950s PHN practice increased focus on the psychological elements of

client, family, and community care

1960s

Medicare and Medicaid

o Did not include coverage for preventive services
o Home health care only reimbursed if ordered by a physician

Increase in for-profit home health agencies

Reduction in health promotion and disease prevention by local and state

health departments

Community Organization and Professional Change

Civil Rights Movement

Funding increases in certain areas

Economic Opportunity Act

1970s

Nurses made significant contributions to:

o The hospice movement
o

The development of birthing centers

Day care for older adults and disabled persons

Drug abuse programs

Rehabilitation services in long-term care

1990s

Health care debate focused on cost, quality, and access to direct care
services
o Nursing organizations joined to support health care reform

2000s

Health Care Reform finally passed in 2010 with the federal Patient
Protection and Affordable Care Act

PHN organizations develop position papers on:

o Graduate education for advanced practice PHN
o Faculty qualifications for community/public health nursing
educators
o

Importance of PHN within PH systems

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The Role of Federal Public Health Agencies

Federal: develop regulations that implement policies formulated by

Congress and provide a significant amount of funding to state and
territorial health agencies to:
o Provide public health services

Survey the nations health status and health needs

Set practice and standards

Provide expertise that facilitates evidence-based practices

Coordinate public health activities that cross state lines

Support health services research

Role of State Public Health Agencies

State: responsible for monitoring health status and enforcing laws and
regulations that protect and improve the publics health
o Distribute federal and state funds to local public health agencies to
implement programs at the community level

Examples of programs: communicable disease programs,

maternal and child health programs; chronic disease
prevention programs; injury prevention programs

Provide oversight and consultation for local public health agencies

State Health System

Tennessee Department of Health

Office of Minority Health

Office of Rural Health

License and Regulate Professionals

Health Care Facilities Regulation

Division of Vital Records

Alcohol, drug, and mental health services

Maternal and Child Health

Immunization

Communicable Diseases

BT/ Emergency Preparedness

Roles of Local Public Health Agencies

Local: responsibilities vary depending on the locality and are responsible

for implementing and enforcing local, state, and federal public health
codes and ordinances and providing essential public health programs to a
community

o Goal: to safeguard the publics health and to improve the

communitys health status

Roles of Local, State, and Federal Public Health Agencies

The majority of local, state, and federal agencies are involved in the
following functions:
o Collecting and analyzing vital statistics
o Providing health education and information to the population served
o Receiving reports about and investigating and controlling
communicable diseases
o

Protecting the environment to reduce the risk to health

Providing some health services to particular populations at risk or

with limited access to care

Identifying public health problems for at-risk and high-risk

populations

Partnering with other organizations to develop and implement

responses to identified public health concerns

Factors influencing Public Health Nurses Role

1) health reform and the impact upon public health

2) budget cuts

3) new definition of competencies

4) recommendations from the Institute of Medicine 2010 report, The

Future of Nursing: Leading Change, Advancing Health, including that 80
percent of nurses achieve bachelor-level degrees by 2020

5) public health agency accreditation and adoption of quality improvement

measures

6) emphasis on chronic disease prevention

7) interventions targeted at improvement of conditions in the community

that are conducive to health for all populations

8) Multiple determinants of health

Tennessees Big Three

Tobacco Use

Physical Inactivity

Obesity

Determinants of health

Health care is not the primary driver of an individuals overall health and
well-being

Improving Health requires comprehensive focus: a public health approach

RWJF Forum on the Future of Public Health Nursing Summary Report January

2013

Public health nurses constitute the largest professional segment of the

public health workforce, and they assume a wide variety of roles in health
departments, including providing clinical care to individuals, health
planning, surveillance, management, and serving as directors at the local
and state levels.

PHN Roles in Tennessee Health Departments

Clinic managers

State/Regional program managers

Regional and local county directors

Direct patient care providers

Home visitors

Care Coordinators

Disease investigators

Educators

Nurses in Communities

Nurses are considered the most trustworthy professionals in the US

(2014 Gallup Poll)
o Schools

Parish Nurses

Educators

Worksite Wellness

Care Coordinators

Current Challenges and Future Needs

Knowledge
o Quad Council-Public Health Nursing Core Competencies
o Population health focus
o

Applied epidemiology

Public Health accreditation

Social and environmental health determinants

Legislation- process and laws affecting both nursing practice and

population health

Skills
o Leadership skills to engage internal and external community
partners
o

Tech Savvy-statistical software, EMR, Health Information exchange

Public speaking skills

Emergency preparedness- local disaster shelters and global health

issues

Enhanced Preceptor training for nurses working with students in PH

clinics

Abilities
o Assess the needs of the community served
o Identification and elimination of health inequality and disparity in
the population and in the workforce
o

Develop and utilize population specific and evidence based health

strategies

Recruitment and Retention

60% of PHNs in Tennessee eligible for retirement in the next 10 years

Generate interest in Public Health

o Affiliation Agreements- precept student nurses
o County and Regional PHN leader presentations
o

Inform key stakeholders of population health needs

Attend job fairs- share application process

Educational Needs

BSN preferred entry level into PHN in Tennessee Health Department

Clinics

Masters level preparation preferred for administrative leadership positions

and for Advanced Practice Nurses in clinic settings

Explore MSN and MPH dual programs

Doctoral level programs for nurse epidemiologists, researchers, and

advanced clinical practice

PHN Education

Programs to incorporate public health concepts throughout each course in

addition to traditional community health courses

Enhanced instruction of population health concepts at all levels of nursing

education

Encourage nurses to apply prevention and public health concepts in all

settings to improve the health of individuals, families and communities.

Next Step Strategies

Explore strategies to demonstrate value PHN practice

Promote educational resources supporting changing PHN role and

disseminate broadly

PHN engagement in strategic local, state and national partnerships

Promote leadership development opportunities

Support attainment of BSN and advanced degrees by PHNs

Support academic-practice partnerships

Lillian Wald

Nursing is love in action, and there is no finer manifestation of it than the

care of the poor and disabled in their own homes.

Florence Nightingale

"It is cheaper to promote health than to maintain people in sickness."

(1894)

"The work we are speaking of has nothing to do with nursing disease, but
with maintaining health by removing the things which disturb it . . . dirt,
drink, diet, damp, draughts, and drains.

Key Findings of Workforce Survey

There is significant need to strengthen the education and training of public

health nurses.

Provision of clinical services continues to be a major activity of RNs in

state and local health departments.

The national public health nurse workforce in state and local health
departments is not as racially and

ethnically diverse as the countrys

population. Further, few minority public health nurses serve in leadership

positions.

The public health nurse workforce is aging; however, most RNs do not
intend to retire within the next 5 years.

Recruitment and hiring of RNs into public health nurse positions can be
challenging, particularly for state health departments.

Lack of promotion opportunities is a concern to both health departments

and RNs.

Public health nurses report high levels of job satisfaction, despite

reporting high levels of dissatisfaction with salary compensation.

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Current Health Care System

Indicators which demonstrate continued disparities within our current

health care system
o Cost

The United States spends more money on health care than

any other country in the world.

Access to care

The 2003 US Census reported 45 million people without

health insurance.

Quality

In 1998 IOM estimated 98,000 deaths / year from

preventable medical errors

Cost

Aging Baby Boomer population

o Will increase Medicare expenditures

Medicaid recipients can be expected to decline as jobs are added to the

economy.

Percentage of workers covered by employer-sponsored insurance should

rise.
o
o

Premiums increase
Higher co-pay and deductible expenses

Costs will rise

o Rise in percentage of uninsured-

Access

48.9 million uninsured in 2009 , 42.0 million in 2014 ( ACA has started!)

In 2013, 34.3 percent of the population was covered by government

health insurance ( Medicare, Medicaid,Tricare, etc)

Government programs play significant role in meeting the needs of the

uninsured

Increasing demands leave some states struggling with budget

Strong relationship between health insurance coverage and access to

health care services

Groups who face greatest barriers to access:

o Poor
o

Minority group members

Non-English speakers

Medically underserved
o 56 million in the United States lack adequate access to primary
health care (2007)

Safety net
o Community health centers

Quality

To Err is Human: Building a Safer Health System (IOM, 2000)

o 98,000 deaths a year attributed to preventable medical errors

7,000 of which are due to preventable medication errors

Keeping Patients Safe: Transforming the Work Environment of Nurses

(IOM, 2003)
o Long work hours pose most serious threat

Cultivating a culture of safety

o Look at the system- stop blaming individuals
o Sentinel events reporting (unexpected occurrences)
o

Hospital Compare: website for consumers thru CMS website

Trends Affecting the Health Care System

Demographics

Technology

Global Influences

Demographics

Aging Baby Boomer generation

o Cost of Medicare expected to rise

Rise in foreign-born population

o The U.S. is more diverse than ever

Lack of diversity in health care workforce

o Minorities are underrepresented
o Pew Commission- we need more minority health care providers.
Health professionals who have the same culture and language with
patients they serve can provide more effective care.

Technology

Examples:
o Telehealth: use of electronic communication networks to transmit
patient-related information
o

Electronic medical records

Personal Health Record (PHR)

Health Information Exchanges (HIEs):regional network of

integrated data incorporating patient information from local
hospitals as well as clinics or provider practices within one
database.

Benefits:
o Cost-effective
o

Improved care

Reduce medical errors

Pitfalls:
o Concerns about privacy and security
o Unclear reimbursement for services provided at distance

Global Influences

Globalization
o process of change and development across national boundaries and
oceans, involving economics, trade, politics, technology, and social
welfare.

Infectious disease outbreaks

o With immigration, trade, and air travel, no country on earth is
completely safe from infectious disease

World Health Organization (WHO)

o comprised of 192 member countries, provides leadership on global

health, shapes worldwide research and policy agendas, and
monitors trends and responses to disease threats on a global level.

Organization of the Health Care System

Primary health care system

o Comprehensive range of services
o Encourages self-care and self-management
o

Emphasis on prevention

Care provided at the community level that is accessible and

acceptable to the community and invites community participation

Community or population focused

1977: Declaration of Alma Ata: Basis for global efforts in public

health

Primary care

Public health system

The federal system

The state system

The local system

Primary Care Versus Primary Health Care

Primary Care
o Component of the private health care system
o Care provided by health care professional
o Care provided at the individual level

Primary Health Care (PHC)

o Focus of the public health system in the U.S.
o Broad range of services
o

Emphasis is on prevention

Care provided at the community level

Accessible, acceptable to the community

Invites community participation

PHC Workforce

Multidisciplinary team of health care providers.

Team members include:

o Primary care generalists
and public health physicians
o

Nurses

Dentists

Pharmacists

Optometrists

Nutritionists

Community outreach workers

Mental health counselors

Translators

Other allied health professionals

Community members also important to the team

PHC Initiative

Declaration of Alma Ata (1978)

o Basis for the PHC initiative. Goal of attaining a level of health that
permitted all citizens of the world to live socially and economically
productive lives

Healthy People 2020

o National health objectives which serve as a roadmap for improving
the health of all people in the U.S.

Organization of the Health Care System

Primary care system

o Strategy of choice
o

Provides first contact, continual, comprehensive, and coordinated

care

Addresses most needs of clients

Focus is on pathophysiological process

Variety of community settings

Focus on the individual

Emphasizes cost containment

Primary Care

First level of the private health care system

Delivered in a variety of community settings

Americans access it through insurance programs

Managed care
o defined as a system in which care is delivered by a specified
network of providers who agree to comply with the care approaches
established through a case management process, was a strategy
chosen by the federal government as a means to control the rising
costs of traditional fee-for-service health care.

Managed Care Act of 1973

HMOs, PPOs, and POS

Medicare Advantage Program

Primary Care Workforce

Primary care developed in the 1960s

o Needed to reexamine role of general practitioner

Primary care generalists include:

o Family physicians
o

General internists

General pediatricians

Nurse practitioners (NPs)

Clinical nurse specialists (CNSs)

Physician assistants (PAs)

Certified nurse-midwives (CNMs)

Doctorate in Nursing Practice (DNP)

Public Health System

Mandated through laws that are developed at the national, state, or local
level

Organized into many levels in the federal, state, and local systems

At the local level, health departments provide care that is mandated by

state and federal regulations.

Organization of the Health Care System

Public health systemmandated through laws

Federal system
o U.S. Department of Health and Human Services (HHS)
o Office of Global Health Affairs

U.S. Public Health Service (PHS)

Health Resources and Services Administration (HRSA)

National Institutes of Health (NIH)

Agency for Health Care Research and Quality (AHRQ)

Food and Drug Administration (FDA)

Centers for Disease Control and Prevention (CDC)

Centers for Medicare and Medicaid Services (CMS)

Departnent of Homeland Security (DHS)

State Health Department

o Stand ready for disaster prevention or response
o Health care financing and administration
o

Direct assistance to local health departments

Ongoing assessment of health needs

Board of examiners of nurses

Local Health Department

o Direct responsibility to the citizens on its community or jurisdictions
o Variety of services and programs offered depending on the state
and local health codes that must be followed, the needs of the
community, and available funding and other resources

28/09/2015 15:20:00

Population Health

Population health is defined as the health outcomes of a group of

individuals, including the distribution of such outcomes within the group
(Kindig and Stoddart,2003)

These groups are often geographic populations such as nations or

communities, but can also be other groups such as employees, ethnic
groups, disabled persons, prisoners, or any other defined group.

Kindig and Stoddart propose that population health is concerned with both
the definition of measurement of health outcomes and the pattern of
determinants. Determinants include medical care, public health
interventions, genetics, and individual behavior, along with components of
the social (e.g., income, education, employment, culture) and physical
(e.g., urban design, clean air, water) environments

Population Health versus Public Health

Traditionally, public health has been understood by many to be the critical

functions of state and local public health departments such as preventing
epidemics, containing environmental hazards, and encouraging healthy
behaviors.

Public health, can be defined as what we as a society do collectively to

assure the conditions in which people can be healthy (Institute of
Medicine, 1988). Federal and state public health policies and programs
play an important role in the health of the overall population of a nation
and its states; however, as noted in the definition above public health is
not the same as population health. Population health tends to be more
concerned with outcomes.

IHI Triple Aim

Starting in October 2007, IHI developed an innovative approach to

improving health and health care called the Triple Aim. The three
simultaneous goals of the Triple Aim are:
o Improve the health of the population

o Enhance the patient experience of care (including quality, access,

and reliability)
o

Reduce, or at least control, the per capita cost of care

ACA and Population Health

The ACA addresses population health in four ways

o 1. Provisions to expand insurance coverage

Individual mandate, Medicaid expansions, state insurance

exchanges, support for community health centers

2. Provisions aimed at improving the quality of care offered

National Strategy for Quality Improvement, CMS Center for

Medicare and Medicaid Innovation, Patient-Centered
Outcomes Research Institute

3. Provisions which seek to enhance prevention and health

promotion measures within the health care delivery system

Accountable Care Organizations (ACOs ) to incentivize

providers to take responsibility for population health
outcomes, requirements that private health plans, Medicare,
and Medicaid provide specific preventive services (USPSTF
recs) without cost sharing, expansion of preventive services

4. Provisions aimed at promoting community and population-based

activities

National Prevention Health promotion and Public Health

Council, which produced National Prevention Strategy,
funding for Community Transformation Grants, incentives for
workplace wellness programs in the form of small grants for
use in developing comprehensive workplace wellness
programs

National Prevention Strategy

Called for under the Patient Protection and Affordable Care Act

Developed by the National Prevention Council

Four Strategic Directions:

o Building Healthy and Safe Community Environments: .

o

Expanding Quality Preventive Services in Both Clinical and

Community Settings

o Empowering People to Make Healthy Choices:

o Eliminating Health Disparities