Read chapter 1, 2 & 6 of the class textbook and review the attached PowerPoint presentations once done answer the following questions.
1. Compare and contrast definitions of health from a public health nursing perspective.
2. Explain the difference between public/community health nursing practice and community-based nursing practice.
3. Discuss major contemporary issues facing community/public health nursing and trace the historical roots to the present.
4. Discuss and explain the steps to identified/diagnosed community health problems.
Chapter 1
Health: A Community View
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
Community/Public Health Nursing …
… is the synthesis of nursing practice and
public health practice.
… has the major goal to preserve the health
of the community and surrounding
populations.
… focuses on health promotion and health
maintenance.
… is associated with health and identification
of populations at risk rather than an episodic
response to patient demand.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
2
The mission of public health is …
… social justice, which entitles all people to
basic necessities such as adequate income
and health protection and accepts collective
burdens to make this possible.
http://www.health.gov/phfunctions/public.htm
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3
How Do We Define Health?
A state of complete well-being, physical, social, and
mental, and not merely the absence of disease or
infirmity.
– World Health Organization, 1958
The extent to which an individual or group is able, on
the one hand, to realize aspirations and satisfy
needs; and, on the other hand, to change or cope
with the environment. Health is, therefore, seen as a
resource for everyday life, not the objective of living;
it is a positive concept emphasizing social and
personal resources, and physical capacities.
– World Health Organization, 1986
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4
Community …
… a group or collection of locality-based
individuals, interacting in social units and
sharing common interests, characteristics,
values, and/or goals.
Nies and McEwen, 2013
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5
Figure 1-2
From U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Federal
Interagency Workgroup: The vision, mission, and goals of Healthy People 2020.
http://www.healthypeople.gov/2020/Consortium/HP2020Framework.pdf. Accessed July 2013.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
6
Healthy People 2020 Leading
Health Indicators
Access to Health
Services
Clinical Preventive
Services
Environmental
Quality
Injury and Violence
Maternal, Infant, and
Child Health
Mental Health
Nutrition, Physical
Activity, and Obesity
Oral Health
Reproductive and
Sexual Health
Social Determinants
Substance Abuse
Tobacco Use
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7
Public and Community Health
Public health is the Science and Art of …
(1) preventing disease,
(2) prolonging life, and
(3) promoting health and efficiency through organized
community effort…
C.E. Winslow…
Community health extends the realm of public
health …
…to include organized health efforts at the
community level through both government and
private efforts.
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8
Core Public Health Functions
Assessment: Regular collection, analysis, and
information sharing about health conditions, risks,
and resources in a community.
Policy development: Use of information gathered
during assessment to develop local and state health
policies and to direct resources toward those policies.
Assurance: Focuses on the availability of necessary
heath services throughout the community. It includes
maintaining the ability of both public health agencies
and private providers to manage day-to-day
operations and the capacity to respond to critical
situations and emergencies.
– Institute of Medicine (1988)
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9
10 Essential Services
Assessment
➢
➢
➢
Monitor health status to identify community health
problems.
Diagnose and investigate health problems and
health hazards in the community.
Research for new insights and innovative
solutions to health problems.
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10
10 Essential Services (Cont.)
Policy Development
➢
➢
➢
➢
Inform, educate, and empower people about
health issues.
Mobilize community partnerships to identify and
solve health problems.
Develop policies and plans that support individual
and community health efforts.
Research for new insights and innovative
solutions to health problems.
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11
10 Essential Services (Cont.)
Assurance
➢
➢
➢
➢
➢
Enforce laws and regulations that protect health
and ensure safety.
Link people to needed personal health services
and ensure the provision of health care when
otherwise unavailable.
Ensure a competent public health and personal
health care workforce.
Evaluate effectiveness, accessibility, and quality of
personal and population-based health services.
Research for new insights and innovative
solutions to health problems.
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12
The Three Levels of Prevention
Primary prevention
➢
➢
Secondary prevention
➢
➢
Prevention of problems before they occur
Health promotion and health protection
Early detection and intervention
Early diagnosis and treatment
Tertiary prevention
➢
➢
Correction and prevention of deterioration of a
disease state
Limitation of disability and rehabilitation
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13
The Three Levels of Prevention
(Cont.)
Figure 1-2
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14
Level of Prevention—Individual
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15
Level of Prevention—Family
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Level of Prevention—Group
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17
Level of Prevention—Community
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Healthy People 2020
Vision
➢
A society in which all people live long, healthy lives.
Overarching Goals
➢
➢
➢
➢
Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death.
Achieve health equity, eliminate disparities, and improve the
health of all groups.
Create social and physical environments that promote good
health for all.
Promote quality of life, healthy development, and healthy
behaviors across all life stages.
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Healthy People 2020
(Cont.)
HP2020 has 42 focus areas
➢
The objectives and related information and
materials can help guide health promotion
activities and can be used to aid in communitywide initiatives.
(USDHHS, 2013)
➢
All health care practitioners…
• should focus on the relevant areas in their practice
• incorporate objectives into programs, events, and
publications whenever possible
• use them as a framework to promote healthy cities and
communities
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20
Healthy People 2020 Topic
Areas
1.
2.
3.
4.
5.
6.
7.
8.
Access to Quality Health
Services
Adolescent Health New
Arthritis, Osteoporosis and
Chronic Back Conditions
Blood Disorders and Blood
Safety New
Cancer
Chronic Kidney Disease
Dementias, including
Alzheimer’s Disease New
Diabetes
9.
10.
11.
12.
13.
14.
15.
16.
Disability and Secondary
Conditions
Early and Middle Childhood
Educational and
Community-based
Programs
Environmental Health
Family Planning
Food Safety
Genomics New
Global Health New
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Healthy People 2020 Topic
Areas (Cont.)
17. Health Communication and
18.
19.
20.
21.
Health Information
Technology
Healthcare-Associated
Infections New
Health-Related Quality of
Life and Well-Being New
Hearing and Other Sensory
or Communication Disorders
Heart Disease and Stroke
22. HIV
23. Immunization and Infectious
24.
25.
26.
27.
28.
Diseases
Injury and Violence
Prevention
Lesbian, Gay, Bisexual, and
Transgender
Health New
Maternal, Infant, and Child
Health
Medical Product Safety
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Healthy People 2020 Topic
Areas (Cont.)
29. Mental Health and Mental
30.
31.
32.
33.
34.
35.
36.
37.
Disorders
Nutrition and Weight Status
Occupational Safety and
Health
Older Health New
Oral Health
Physical Activity
Preparedness New
Public Health Infrastructure
Respiratory Disease
38. Sexually Transmitted
39.
40.
41.
42.
43.
Diseases
Sleep Health New
Social Determinants of
Health New
Substance Abuse
Tobacco Use
Vision
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23
Public Health Nursing
ANA definition (2007)
➢
➢
➢
The practice of promoting and protecting the
health of populations
Uses knowledge from nursing, as well as social
and public health sciences, to promote and protect
the health of populations.
Is population focused, with the goals of promoting
health and preventing disease and disability for all
people
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24
Community Health Nursing
ANA definition (1980)
➢
Synthesis of nursing practice and public health to
promote and preserve the health of populations
➢ Care is directed to individuals, families, groups
➢ Contributes to health of the total population
*The terms Public Health Nursing and Community Health Nursing are used interchangeably
in Nies and McEwen, 6th edition.
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Community-Based Nursing
“Application of the nursing process in caring for
individuals, families and groups where they live, work
or go to school or as they move through the health
care system”
–McEwen and Pullis, 2009
Setting-specific
Emphasis is on acute and chronic care
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Community and Public Health
Nursing Practice
Nurses practice disease prevention and
health promotion
Practice is collaborative
Practice is based on research and theory
Applies the nursing process to the care of…
➢
Individuals
➢ Families
➢ Aggregates
➢ The community
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Population-Focused Nursing
Focuses on the entire population
Is based on assessment of the population’s
health status
Considers the broad determinants of health
Emphasizes all levels of prevention
Intervenes with communities, systems,
individuals, and families
– Minnesota Department of Health, 2003
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28
PHN Intervention Wheel
✓ Is population based
✓ Contains three levels
of practice
(individual,
community, and
system)
✓ Identifies 17 public
health interventions
Figure 1-3
Illustration from Minnesota Dept. of Health
Center for Public Health Nursing.
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29
Public Health Interventions
(purple section)
Surveillance: Describes and monitors health events
through ongoing and systematic collection, analysis,
and interpretation of health data for the purpose of
planning, implementing, and evaluating public health
interventions.
Disease and other health event investigation:
Systematically gathers and analyzes data regarding
threats to the health of populations, ascertains the
source of the threat, identifies cases and others at
risk, and determines control measures.
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30
Public Health Interventions
(purple section) (Cont.)
Outreach: Locates populations of interest or
populations at risk and provides information about the
nature of the concern, what can be done about it, and
how services can be obtained.
Screening: Identifies individuals with unrecognized
health risk factors or asymptomatic disease
conditions in populations.
Case finding: Locates individuals and families with
identified risk factors and connects them with
resources.
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31
Public Health Interventions
(green section)
Referral and follow-up: Helps individuals, families,
groups, organizations, and/or communities identify
and access necessary resources to prevent or
resolve problems or concerns.
Case management: Optimizes self-care capabilities
of individuals and families and the capacity of
systems and communities to coordinate and provide
services.
Delegated functions: Direct care tasks a registered
professional nurse carries out under the authority of a
health care practitioner as allowed by law.
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32
Public Health Interventions
(blue section)
Health teaching: Communicates facts, ideas, and
skills that change knowledge, attitudes, values,
beliefs, behaviors, and practices of individuals,
families, systems, and/or communities.
Counseling: Establishes an interpersonal relationship
intended to increase or enhance capacity for selfcare and coping with a community, system, and
family or individual.
Consultation: Seeks information and generates
optional solutions to perceived problems or issues
through interactive problem-solving with a
community, system, and family or individual.
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33
Public Health Interventions
(red section)
Collaboration: Commits two or more persons or
organizations to achieve a common goal through
enhancing the capacity of one or more of the
members to promote and protect health.
Coalition building: Promotes and develops alliances
among organizations or constituencies for a common
purpose.
Community organizing: Helps community groups
identify common problems or goals, mobilize
resources, and develop and implement strategies for
reaching the goals they collectively have set.
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34
Public Health Interventions
(yellow section)
Advocacy: Plead someone’s cause or act on someone’s behalf,
with focus on developing the capacity of the community, system,
and individual or family to plead their own cause or act on their
own behalf.
Social marketing: Uses commercial marketing principles and
technologies for programs designed to influence the knowledge,
attitudes, values, beliefs, behaviors, and practices of the
population of interest.
Policy development and enforcement: Places health issues on
decision-makers’ agendas, acquires a plan of resolution, and
determines needed resources, resulting in laws, rules,
regulations, ordinances, and policies. Policy enforcement
compels others to comply with laws, rules, regulations,
ordinances, and policies.
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35
Providing population-based care… a
shift in thinking
Populations are not homogeneous; must address
the needs of special subpopulations.
2. High-risk and vulnerable subpopulations must be
identified early in the care delivery cycle.
3. Nonusers of services often become high-cost users;
essential to develop outreach strategies.
4. Quality and cost of all health care services are
linked together across the health care continuum.
1.
(Kaiser Family Foundation, 2013)
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36
Chapter 2
Historical Factors:
Community Health Nursing in Context
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Stages* in the Disease History of
Humankind
Hunting and gathering (before 10,000 B.C.)
Settled villages (10,000 to 6000 B.C.)
Preindustrial cities (6000 B.C. to 1800 A.D.)
Industrial cities (1700 to 1800 A.D.)
Present period (1900 to 2000 A.D.)
*Stages overlap and time periods are widely debated in the field of
anthropology. Some form of each stage remains evident in the
world today.
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2
Aggregate Impact on Health
Increased population
Increased population density
Imbalanced human ecology
➢
Resulted in changes in cultural
adaptation
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3
Evolution of Early Public Health
Efforts
Prerecorded historic times (before 5000 B.C.)
➢
➢
Practices based on superstition or sanitation
Health practices evolved to ensure survival
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4
Evolution of Early Public Health
Efforts (Cont.)
Classical times (3000 to 200 B.C.)
➢
Devised ways to flush water; constructed drainage
systems
➢ Developed pharmaceutical preparations
➢ Embalmed the dead
➢ Dealt with pollution
➢ Hygienic code to protect food and water
➢ Greek and Roman impact public health
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5
Evolution of Early Public Health
Efforts (Cont.)
Greeks
➢
Literature contains accounts of communicable
diseases
• Endemic, epidemic, and pandemic
➢ Hippocratic book on Airs, Waters and Places
➢ Hygeia, goddess of health, or good living
➢ Panacea, goddess of curative medicine
➢ Balance of human life with environmental
demands
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6
Disease Definitions
Disease
Definitions
Endemic
Diseases that are always
present in a population (e.g.,
colds and pneumonia).
Epidemic
Diseases that are not always
present in a population but flare
up on occasion (e.g., diphtheria
and measles).
Pandemic
The existence of disease in a
large proportion of the
population—a global epidemic
(e.g., HIV, AIDS, and annual
outbreaks of influenza type A).
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7
Evolution of Early Public Health
Efforts (Cont.)
Romans
➢
Surpassed Greek engineering
• Massive aqueducts, bathhouses, and sewer systems
➢ Addressed occupational health threats
➢ Priests mediated diseases and dispensed
medicine
➢ Public physicians worked in designated towns
• Worked in groups much like today’s HMOs
• Eared money to care for the poor
➢ Hospital for sick poor established by Fabiola, a
Christian woman
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8
Evolution of Early Public Health
Efforts (Cont.)
Middle Ages (500 to 1500 A.D.)
➢
Monasteries promoted collective
activity to protect public health.
➢ Churches enforced hygienic codes.
➢ A pandemic ravaged the world in the
14th century.
➢ Modern public health practices (e.g.,
isolation, disinfection, quarantines)
emerged.
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9
Evolution of Early Public Health
Efforts (Cont.)
Renaissance (15th, 16th, 17th centuries)
➢
➢
➢
A theory about the cause of infection evolved.
Leeuwenhoek described microscopic organisms.
Elizabethan Poor Laws were enacted.
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10
Evolution of Early Public Health
Efforts (Cont.)
18th century
➢
The Industrial Revolution occurred.
➢ Poor children were forced into labor.
➢ Vaccination was discovered by Edward Jenner.
➢ Sanitary Revolution’s public health
reforms were taking place.
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11
Evolution of Early Public Health
Efforts (Cont.)
19th century
➢
➢
➢
Communicable diseases ravaged the population
that lived in unsanitary conditions.
Edwin Chadwick examined death rates by
occupation and class in England.
The General Board of Health for England was
established in 1848.
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12
Evolution of Early Public Health
Efforts (Cont.)
19th century (Cont.)
➢
➢
Public health laws were enacted in 1849:
• Healthy mental and physical development of citizens
• Prevention of all dangers to health
• Control of disease
John Snow demonstrated the transmission
of cholera via the public water source.
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13
Evolution of Early Public Health
Efforts (Cont.)
19th century (Cont.)
➢
Waves of epidemics occurred in the United States.
➢ Lemuel Shattuck published vital statistics in
Massachusetts; he called for child health reform.
➢ The first Board of Health was formed in response.
➢ The AMA was asked to collected vital statistics.
➢ Efforts focused on determinants of health.
➢ The advent of “modern” health care occurred.
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14
Florence Nightingale (1820-1910)
Credited with establishing
“modern nursing”
Concern for environmental
determinants of health
Emphasis on sanitation,
community assessment, and
analysis
Use of graphically depicted
statistics and comparable census
data
Political advocate
Education reform for nurses
Figure 2-2
Public domain; courtesy University of Chicago
Library.
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15
Impact of Important Scientists
Louis Pasteur
➢
➢
Robert Koch
➢
Theory of existence of germs
Discovered immunizations in 1881 and
the rabies vaccine in 1885
Discovered causative agent for cholera
and the tubercle bacillus in 1882
Joseph Lister
➢
Surgical success with wound care
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16
“Modern” Medical Care
Emergence of germ theory focused diagnosis
and treatment on individual organism and
individual disease.
Community outcry for social reforms forced
governments to take action.
Boards of health and health departments
began in 1866.
TB surveillance began in 1889.
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17
“Modern” Medical Care (Cont.)
Flexner Report (1910) outlined shortcomings
of U.S. medical schools.
Philanthropic foundations influenced health
care efforts.
1916: Rockefeller Foundation
established first school of
public health at Johns Hopkins.
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18
Community Caregiver
Traditional healer common in non-Western,
ancient, and primitive societies.
Societies retain folk practices because of their
success.
Folk healing practices are socially cohesive
and involve support systems.
Although often overlooked, cultural
practices affect health.
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19
Establishment of Public Health
Nursing
In England
➢
District Nursing in England, 1850s
➢ Rathbone worked with Nightingale to educate
“health nurses,” 1859
➢ Health Visiting in Manchester, England, 1862
In the United States
➢
➢
Visiting Nurses, 1877
Henry Street Settlement, 1893
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20
Lillian Wald (1867-1940)
Established Henry Street Settlement in 1893 (along
with Mary Brewster)
Played an important role in establishing public health
nursing in the United States—later called “Visiting
Nurses Association of NYC”
Role of Henry Street Settlement was “one of helping
people to help themselves” (Wald, 1871)
The Children’s Bureau and the
Social Security Act Legislation
formed as a result of these efforts
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21
Other Key Dates in the
Establishment of PH Nursing
First School Nurse, Linda Rogers, 1902
Metropolitan Life Insurance Company provided home
nurses for policyholders, 1909
Department of Nursing and Health at Teachers’
College of Columbia University in NYC, 1910
National Organization of Public Health Nurses
formed, 1912 (Lillian Wald was first president)
Public Health Service appointed its first public health
nurse, 1913
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22
Changing Perspectives on Mortality
in the 20th Century and Beyond
Change from infectious diseases to
chronic conditions
Modern medical advances (vaccination
programs and antibiotics)
Holistic approach to health
Better sanitation and nutrition
Grecian Hygeia (i.e., healthful living)
vs. Panacea (i.e., cure) dichotomy
Multi-causal, not uni-causal,
view of disease
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23
Challenges for Community Health
Nursing
Promote the health of populations
Need a broadened focus on the multiple
causes of morbidity and mortality
Aware of increased technological advances
Understand the community need for a focus
on prevention, health promotion, and home
care
Focus on holistic care
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24
Challenges for Community Health
Nursing (Cont.)
Emphasis on population-based focus nursing
➢
➢
➢
➢
➢
➢
Work on behalf of aggregates
Understand social determinants of health
Gather information and statistics to make
decisions
Be part of the solution to find ways to solve
persistent health problems
Emphasize society’s responsibility for health
Empower people to help themselves
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25
Chapter 6
Community Assessment
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Defining the Community
Aggregate of people
➢
➢
Location in space and time
➢
➢
The “who”
Share personal characteristics and risks
The “where” and “when”
Physical location frequently delineated by boundaries and
influenced by the passage of time
Social system
➢
➢
The “why” and “how”
Interrelationships of aggregates fulfilling community
functions
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2
Diagram of Assessment Parameters
Figure 6-1
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3
Community Assessment Parameters
Geography
Population
Environment
Industry
Education
Recreations
Religion
Communication
Transportation
Public services
Political organization
Community development
or planning
Disaster programs
Health statistics
Social problems
Health manpower
Health professional
organizations
Community services
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4
Healthy Communities
A movement to help
community members bring
about positive health
changes
Interconnectedness between
people and the public and
private sectors is essential to
make changes.
Each community has its
unique perspective.
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5
Assessing the Community
Windshield survey
➢
➢
➢
Gain an understanding of environmental layout
Locate possible areas of environmental concern
through “sight, sense, and sound”
Gives nurse an opportunity to observe people and
their role in the community
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6
Windshield Survey
Community vitality
Indicators of social
and economic
conditions
Health resources
Environmental
conditions related
to health
Social functioning
Attitudes toward
health and health
care
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Assessing the Community (Cont.)
Sources of data:
➢
Census data and other census reports
➢ Vital statistics
➢ NCHS survey data
➢ Local, regional, and state government reports
➢ Locally generated data collection
Analysis of demographic information provides
descriptive information about the population
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Assessing the Community (Cont.)
Needs assessment
Used to understand the community’s perspective
➢ Interview key community informants
➢ Use community forums, focus groups, or surveys
➢ 12 Steps in a Needs Assessment
➢
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
9
Steps in the Needs Assessment
Process
1.
2.
3.
4.
5.
6.
Identify aggregate for assessment
Engage the community in planning the assessment
Identify required information
Select method of data gathering
Develop questionnaires or interview questions
Develop procedures for data collection
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Steps in the Needs Assessment
Process (Cont.)
7. Train data collectors
8. Arrange for a sample representative of the
aggregate
9. Conduct needs assessment
10. Tabulate and analyze data
11. Identify needs suggested by data
12. Develop an action plan
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Nursing Process
● The nursing process can be applied to the
community as a client.
➢ Needs assessment
➢ Diagnosing health
problems (actual and
potential)
➢ Planning
➢ Intervention
➢ Evaluation
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
12
Format for Community Health
Diagnosis
Figure 6-3 Redrawn from Muecke MA: Community health diagnosis in
nursing, Public Health Nurs 1:23-35, 1984. Used with permission of Blackwell
Scientific Publications.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
13
Epidemiological Studies Used
Throughout the Nursing Process
Support planning by establishing
effectiveness of certain interventions in
specific aggregates
Construct benchmarks to gauge achievement
of program objectives
Compare data with other rates
Identify objectives of successful programs
Document effectiveness with epidemiological
data
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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