JoAnne Carrick, RN, MSN Penn State University State College, Pennsylvania Deborah Chaulk, MS, APRN, BC Univerza Massachusetts, Lowell Lowell, Massachusetts. Bobbie Reddick, EdD, MSN, PhD Winston Salem State University Winston Salem, Severna Karolina Jerelyn Resnick, RN, PhD Univerza Washington Bothell, Washington Will Anne Ricer.
ABOUT THE SEVENTH EDITION
This book is designed to provide students with a basic grounding in the principles of public health care and introduce them to key populations they can engage with while working in the community setting. The nexus of public health care lies in the use of public health principles along with nursing science and skills to promote health, prevent disease, and protect vulnerable populations.
ORGANIZATION OF THE TEXT
Unit 4, Society as Client, examines the theoretical basis for public health care (Chapter 14). The current topics of disaster and terrorism are covered in Chapter 17, with an emphasis on the role of the local health care provider in emergency response, both personally and professionally.
NEW AND REVISED CHAPTERS
The community health nurse is an advocate for clients, and a basic knowledge of policy making, political advocacy and client empowerment strategies is needed (Chapter 13). Finally, the important roles of home health and hospice nursing are discussed in Chapter 32.
KEY FEATURES
Unit 8, Community Nursing Settings, examines public (Chapter 30) and private (Chapter 31) settings in more detail. The critical thinking activities at the end of each chapter are designed to challenge students, promote critical thinking skills, and encourage active involvement in solving community health problems.
FEATURES NEW TO THIS EDITION
Levels of prevention Pyramid boxes increase the understanding of the levels of the concept of prevention, fundamental to health care in the local community. Each box addresses a chapter topic, describes nursing actions at each of the three levels of prevention, and is unique to this text in its complexity and comprehensiveness.
RESOURCES FOR INSTRUCTORS
When the Client is a Community: Characteristics of Community Health Nursing Practice 375 Theories and Models for Community Health. History of Urban Health Care Issues 819 Urban Populations and Health Disparities 820 Social Justice and Community Health Nursing 822 Rural and Urban Community Health Nursing.
FOUNDATIONS OF COMMUNITY HEALTH
A generation that acquires knowledge without ever understanding how that knowledge can benefit the community is a generation that does not learn what it means to be citizens of a democracy.—Elizabeth L.
LEARNING OBJECTIVES
KEY TERMS
This chapter provides an overview of the basic concepts of community and health, the components of community health practice, and the most important features of modern times.
COMMUNITY HEALTH
In most states, it is now unusual to see smoking in public places, and smokers are often moved to outside smoking areas. With our current focus on bioterrorism, it is interesting to note the findings of a recent study showing that the worldwide mortality burden from tobacco is on average 5,700 times greater than that of international terrorism; in the United States, smoking-related mortality is 1,700 times greater than terrorism-related mortality, and in Russia it is 12,900 times greater (Thomson & Wilson, 2005).
PERSPECTIVES
However, tobacco remains the leading cause of preventable disease and death in the United States (Public Health Milestones, 2006). Through a master settlement agreement negotiated by attorneys general and the tobacco industry, billions were awarded to states to promote smoking cessation; create a smoke-free environment in the workplace, restaurants and bars; and develop anti-smoking public information campaigns (Public Health Milestones, 2006).
STUDENT VOICES
It combines all the basic elements of professional clinical nursing with public health and community practice. One of the challenges facing community health is continuing to respond to community health needs.
THE CONCEPT OF COMMUNITY
A population can be defined geographically, such as the population of the United States or the population of a city. What are the characteristics of the people in terms of age, gender, race, socio-economic level and health status.
What Do You Think?
A holistic focus, or a concern for groups of people as opposed to individual health care, becomes a hallmark of community health practice. In fact, some say it validates the focus of community health nursing as practiced over many decades (Porter-O'Grady, 2001).
THE CONCEPT OF HEALTH
Top ten health concerns were also identified as key health indicators (Healthy People) and these are used in measuring the health of US Healthy People in Healthy Communities is a result of the Healthy People 2010 movement (Healthy People.
ISSUES IN COMMUNITY HEALTH NURSING
Obesity Education Initiative, National Heart, Lung, and Blood Institute Information Center http://www.nhlbi.nih.gov/about/oei/index.htm. National Institute on Alcohol Abuse and Alcoholism, NIH http://www.niaaa.nih.gov Responsible Sexual Behavior.
RESOURCES FOR THE LEADING HEALTH INDICATORS
Leading health indicators will be used to measure the nation's health over the next 10 years. One example is the situation in the Gulf Coast region after Hurricane Katrina made landfall in August 2005.
WHAT ARE THE QUALITIES OF A HEALTHY CITY?
In assessing the health of individuals and communities, the community health nurse can observe people's ability to function, but must also know their values, which may contrast sharply with those of the professional. Complex situations like this can be positively influenced by the interaction with and services of the community health nurse.
COMPONENTS OF COMMUNITY HEALTH PRACTICE
The community health nurse has the skills to work at the individual, family and group level to meet these needs. On any given day, the community health nurse may interact with clients who have either ongoing or episodic health care needs, or both.
VOICES FROM THE COMMUNITY
It is practiced at three levels in community health: primary prevention, secondary prevention, and tertiary prevention (Neuman, 2001). In wider community health practice, tertiary prevention is used to minimize the effects of an existing unhealthy community condition.
LEVELS OF PREVENTION PYRAMID
It also encourages community nurses to look out for early signs of child abuse in the family, emotional disturbances among widows, or alcohol and drug abuse among adolescents. To this end, medical practice directs many of its efforts to ensure safe and satisfactory living and working conditions, nutritious food, and clean air and water.
CHARACTERISTICS OF COMMUNITY HEALTH NURSING
PARABLE OF THE DANGEROUS CLIFF
In the first 70 years of the 20th century, nursing in the community was known as public nursing. Public health nurses link community engagement and population-wide knowledge with a personal, clinical understanding of the health and illness experiences of individuals and families within the population.
THE ROLE OF PUBLIC HEALTH NURSES
The later title community health nursing was adopted to better describe where the nurse practices. Further discussion of ethical principles in community health nursing can be found in Chapter 4.
PARABLE OF THE TREES: POPULATION-FOCUSED PRACTICE
Community nurses focus on the wellness portion of the health continuum in a variety of ways. Community health practice includes the elements of health promotion and prevention of health problems.
ACTIVITIES TO PROMOTE CRITICAL THINKING
Recognize the contributions of selected nursing leaders throughout history to the advancement of community health nursing. Analyze the impact of societal influences on the development and practice of community health nursing.
HISTORICAL DEVELOPMENT OF COMMUNITY HEALTH NURSING
Much of the foundation for modern community health nursing practice was laid through the remarkable achievements of Florence Nightingale (Figure 2.1). Miss Nightingale's concern for populations at risk included a continuing interest in the sick population in
TWENTY YEARS IN HISTORY: 1873–1893
Her books, The House on Henry Street (1915) and The Windows of Henry Street (1934), portray her work and views on public health nursing. The Public Health Service establishes the Division of Public Health Nursing to aid the war effort for the World War I Armistice.
TWENTY YEARS IN HISTORY: 1909–1929
By the 1920s, nursing in public health was gaining a more professional meaning, in contrast to its previous association with charity. Previously, only postgraduate courses in public nursing were available to nurses. 32 ❂ UNIT 1 Foundations of community nursing.
TWENTY YEARS IN HISTORY: 1933–1953
During this phase, the institutional basis for much of public health nursing shifted to the government. Other community health professionals took on responsibilities that had traditionally been the domain of public health nursing.
SOCIETAL INFLUENCES ON THE DEVELOPMENT OF COMMUNITY
This movement prompted some fundamental changes in the philosophy of community nursing. Other economic forces affecting community health care are changing patterns of health care financing (including prospective payments and diagnosis-related groups).
NURSES RANK HIGH IN HONESTY AND ETHICAL STANDARDS
Increasing racial and ethnic representation in community health care is essential and remains one of the greatest challenges facing the profession in the coming years. The women's movement has contributed to community nursing's gains in taking on leadership roles, but there remains a need for greater influence and involvement for all nurses.
PREPARATION FOR COMMUNITY HEALTH NURSING
Select one social influence on the development of community health nursing and explore its continuing impact. Perhaps you may discover a specialist area of community health nursing that you never even considered.
CORE PUBLIC HEALTH FUNCTIONS
Although practice environments may have differed, the essential goal of the community nurse has always been a healthier community. In addition, it will increase awareness of the many existing and future opportunities for community nurses to improve public health.
TEN ESSENTIAL SERVICES OF PUBLIC HEALTH
At the community level, the assessment is made both formally and informally, as nurses identify and interact with key community leaders. At the local level, the nurse provides leadership in convening and facilitating community groups to evaluate health problems and develop a plan to address those concerns.
STANDARDS OF PRACTICE
HEALTHY PEOPLE 2010—OBJECTIVE 23 PUBLIC HEALTH INFRASTRUCTURE
The community nurse provides nursing services based on other standards developed by the American Nurses Association (ANA), such as the Code of Ethics for Nurses with Interpretive Statements (2001), the Social Policy Statement of Nursing (2003), and Nursing : scope and standards of practice (2004). Combined with Public Nursing: Scope and Standards of Practice (2007c) provides the community nurse with a clear understanding of accepted practice in this nursing specialty.
ROLES OF COMMUNITY HEALTH NURSES
Another important role for the health nurse is pedagogue or health teacher. What types of skills and competences does the health nurse need in the leadership role.
SETTINGS FOR COMMUNITY HEALTH NURSING PRACTICE
Schools of all levels constitute a major group of settings for community nursing practice. Specialized schools, such as those for persons with developmental disabilities, are another setting for community nursing practice.
A Graduating Student Viewpoint on Postgraduation Employment
In each ambulatory setting, all of the community health nursing roles are used to varying degrees (see Student Voices). Any facility where clients live can be a setting in which community health nursing is practiced.
INNOVATIVE COMMUNITY HEALTH NURSING PRACTICE
Describe the nature of values and value systems and their influence on local health care. This chapter discusses current research as it relates to and affects community health care.
EVIDENCE-BASED PRACTICE
Other researchers have noted the benefits of community nurse visits in nurse-family partnerships in California for Spanish-speaking adolescent mothers and infants (Nguyen, Carson, Parris, & Place, 2003). For example, a community nurse working with a group of adults with diabetes might be interested in the systematic review on the importance of exercise for type 2 diabetes patients.
ASKING THE QUESTION
The Cochrane Collaboration (www.cochrane.org) lists systematic reviews on various topics of interest to both physicians and nurses. A clear understanding of basic research principles is necessary to systematically review and integrate research into the practice of community medicine.
QUANTITATIVE AND QUALITATIVE RESEARCH
More than 93% of nurses believed that using the fact sheets improved their level of knowledge. This led to other questions, such as the perceived quality of the fact sheets and the perceived areas in need of improvement.
STEPS IN THE RESEARCH PROCESS
Identifying the problem or area of interest is often one of the most difficult tasks in the research process. Valid tools or instruments and appropriately applied statistical methods lead to greater confidence in the results of the study.
IMPACT OF RESEARCH ON COMMUNITY HEALTH AND NURSING PRACTICE
Do not share the bed with baby - put baby in a separate crib or cradle with parents in the same room. This research strengthened nursing's role in the community by connecting with community members in their field and demonstrating nurses' roles in research.
THE COMMUNITY HEALTH NURSE’S ROLE IN RESEARCH
After the first intervention year, there was a 27% increase in the number of children tested for lead in the intervention census tracts and only a 10% increase in the control census tracts. Community nurses must provide empirical evidence of their worth as professionals, as well as serving the needs of their clients.
VALUES AND ETHICS IN COMMUNITY HEALTH NURSING
Similarly, the nurse may experience a conflict between two nonmoral values, such as whether to plan logically (designing a traditional group intervention for mental health clients) or plan creatively (designing an innovative field experience). It is this persistence of some values (e.g., individualism versus community) that makes universal coverage and other issues so controversial in health care reform (Axtell-Thompson, 2005).
ETHICS
These strategies also help the nurse to help community health clients become clearer about their own values. The nurse participates in the advancement of the profession through contributions to practice, education, administration and knowledge development.
From the Case Files I
Several ethical decision-making frameworks have been proposed to resolve ethical dilemmas or conflicts between moral values in community nursing practice and to ensure morally responsible nursing service. Iserson (1999) advocates the use of three tests: an impartiality test (e.g., would you be willing to have this done to you? – the “golden rule”), a universality test (e.g., if every nurse in similar circumstances would do the same as you, would this "universal rule" suit you?) and an interpersonal test of justification (e.g. Can you give a reason for your choice and justify your actions to your peers, superiors and society? ).
A FRAMEWORK FOR ETHICAL DECISION-MAKING
When self-determination lapses into self-interest, it poses a major roadblock to equitable health care. When providing health care, self-determination and taking personal responsibility for health care decisions should be fostered.
From the Case Files II
In healthcare contexts, the desire for self-determination has been of such high ethical importance in the US. Equitable access to health care requires that all citizens can secure an adequate level of care without excessive burdens.
SOCIETY AND INDIVIDUAL RESPONSIBILITY IN HEALTH CARE
How community health nurses balance these values may even conflict with their own personal values or the professional values of nursing as a whole. In public health, the nurse applies the principle of benefits.
From the Case Files III
It is useful to identify a problem or a CHAPTER 4 Evidence-Based Practice and Ethics in Community Health Nursing ❂ 85. More community health nurses should also conduct research studies on their own or in collaboration with others.
ACTIVITIES TO PROMOTECRITICAL THINKING
Retrieved August 2, 2008, from http://www.nursefamilypartnership.org/. content/index.cfm?fuseaction=showContent&contentID=. Long-term effects of home visiting on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. Patient support and education for promoting adherence to highly active antiretroviral therapy for HIV/AIDS. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/- article/CD001442/frame.html.
THE MEANING OF CULTURE
The early settlers came mainly from European countries in the 19th century, but they reached their peak only after the turn of the 20th century, receiving almost 9 million immigrants in the first decade. From the United States population by race and Hispanic/Hispanic origin, 2000 census and July 1, 2005.
HISPANIC POPULATION TREND IN THE UNITED
Regional microcultures, such as those of the White Appalachian people living in the hills and hollows of Kentucky or West Virginia, also have distinctive ways of defining the world and interacting with life. The left side of the continuum represents the most extreme response to cross-cultural differences: refusal or denial.
CHARACTERISTICS OF CULTURE
For example, Hmong teenagers from Southeast Asian refugee families in the United States are among the first generations to be raised in America. Immersion in a culture over time and learning a new culture are the main remedies.
CULTURE SHOCK
As adaptation occurs, old beliefs and practices that are still functional in the new environment may be retained, but others that are not functional must be replaced. Second, cultures change as their members see greater benefits in adopting “new ways.” Discussions about these benefits should be conducted in a language understood by members and in the context of their own cultural value system.
ETHNOCULTURAL HEALTH CARE PRACTICES
This is an important reason for nurses to develop an understanding of their clients' culture and provide culturally competent care (Callister, 2001; Giger & Davidhizar, 2002; Leininger, 2006). These key people can adapt the change process so that "new" practices are culturally consistent and fit the values of the group.
VOICES FROM THE COMMUNITY
When working with diverse cultural groups in health care practice, the community health nurse can be an effective advocate for the client. Preparation of the community health nurse In order to be effective in working with clients in cultural health care and spirituality, the nurse must be prepared.
SELECTED CULTURAL COMMUNITIES
When you start working with a group or family, it's important to get to know them as much as possible. As you know from your studies and preparation, teaching is the most important role in nursing, both in acute care settings and in the home.
DEVELOPING CULTURAL COMPETENCE
Native American and Alaska Native populations are mainly concentrated in 26 states in the United States, including Alaska and the Aleutian Islands (Spector, 2009). The Census Bureau estimates that there will be approximately 4.5 million Native Americans living in the United States, nearly double the number in 2000 (US Department of Commerce, 2001).
SIMILARITIES AMONG NATIVE AMERICAN
Although African Americans make up only 13% of the population, more than 50% of prison inmates are black. Although African Americans assimilated into the more dominant European American culture in the United States,.
ASIAN-PACIFIC POPULATIONS
The subgroups of Hispanics vary depending on their patterns of geographic distribution in the United States. However, remnants of the macho man and the self-sacrificing woman are still visible in Spanish culture and continue to shape behavior (see From the Files IV).
From the Case Files IV
Popular home remedies include holding the baby upside down over a pot of water, applying a poultice to the sunken area of the head, or putting a finger in the baby's mouth and pushing up on the palate. It should also be noted that the Middle East has one of the slowest growing levels of personal income in the world and the highest unemployment among developing countries (Naim, 2005).
TRANSCULTURAL COMMUNITY HEALTH NURSING PRINCIPLES
Some aspects of both the nurse's and the client's culture can and likely will change. Norms of the client's own culture (e.g., the client's diet compared to cultural norms). Norms of nurse culture.
INTERPRETER GUIDELINES
Unless the community nurse is highly effective and fluent in the client's language, an interpreter should be used. Confidentiality must be guaranteed by the interpreter, who will not disclose anything without the full consent of the client and the community nurse.
From the Case Files V
Examine Culturally Derived Health Practices The final transcultural nursing principle involves closely examining the cultural practices of the client group as they influence the health status of the group. Ensuring Language Access in Healthcare: Legal Rights and Responsibilities: http://www.kff.org.
PUBLIC HEALTH ESSENTIALS FOR
Explain the philosophical implications of health care financing patterns on the mission and values of health care. It also provides an overview of the economics of healthcare and the ever-changing landscape of financial incentives and disincentives to improve public health.
HISTORICAL INFLUENCES ON HEALTH CARE
Nurses preparing for population-based practice must be familiar with how the health care delivery system is organized and operates because it is through this system that we are able to provide health services to the community (see Chapter 3). The goal of health care economics, like public health, is to overcome scarcity by making good choices and providing essential services.
PUBLIC HEALTH CARE SYSTEM
During the 16th and 17th centuries, London was one of the largest cities in the world, and by the end of the 17th century the population had tripled (Cockayne, 2007, p. 9). At the turn of the 19th century, English leaders became increasingly concerned with social and sanitary reform.
DEVELOPMENT IN THE UNITED STATES
In 2002, the Institute published a new publication, The Future of Public Health in the 21st Century. To impoverish or empower: Public health nursing at the turn of the 20th and 21st centuries.
HEALTH ORGANIZATIONS IN THE UNITED STATES
State public health agencies are challenged to address the health-related issues they face. The contribution of the private, non-profit health agency then becomes complementary to public health services.
INTERNATIONAL HEALTH ORGANIZATIONS
The blurring of the private and public healthcare sectors has opened the door to emerging creative healthcare services. This incident brought tuberculosis to the fore and reinforced the concept of the world as a global community.
SIGNIFICANT LEGISLATION
It is “an independent agency that provides economic, development, and humanitarian assistance worldwide in support of United States foreign policy objectives” (USAID, 2006, ¶1).
THE ECONOMICS OF HEALTH CARE
The act lapsed in 1929, but it set a pattern for maternal and child health programs that were later revived and strengthened by the successful and far-reaching efforts of the Children's Bureau (now known as the Maternal and Child Health Bureau), housed in the Department of Labour. In addition to its revolutionary welfare insurance and assistance programs, which especially benefited high-risk mothers and children, Title VI of the law assisted states and territories financially to provide public health services.
LANDMARK HEALTH CARE LEGISLATION
It established the National Institute for Occupational Safety and Health (NIOSH) and OSHA – the Occupational Safety and Health Administration (US Environmental Protection Agency, 2007). The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 is commonly known as the "Welfare Reform Act." He amended the Social Security Act to reform the federal welfare system and institute a 5-year lifetime cap on welfare benefits.
DATA COLLECTION SYSTEMS
However, as a healthcare consumer, you can be a truly efficient and successful buyer of healthcare services and goods. They do not know the quality of health care goods and services – hence the need for state regulations (eg, licensing, certification) and malpractice lawsuits.
SOURCES OF HEALTH CARE FINANCING
See Figure 6.5 for trends in health insurance premium costs compared to wages and overall inflation. The number of small companies offering health plans continues to decline, and state efforts to reform small group health insurance have been relatively unsuccessful in increasing the number of employers offering coverage (Gabel et al., 2004; RAND Health, 2005).
PUBLIC AND PRIVATE
Medicare pays the majority of health care costs (56%) for citizens age 65 and older, while private insurance pays 54% of health care costs for people younger than 65 (Goldman & McGlynn, 2005). Medicare is administered by the US Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration – HCFA).
TRENDS AND ISSUES INFLUENCING HEALTH CARE ECONOMICS
More than half of healthcare dollars go to hospital and physician costs (31% and 22%, respectively) (Goldman & McGlynn, 2005). Managed care is a cost containment strategy used in both the public and private healthcare sectors.
HEALTH CARE REFORM POSSIBILITIES
Some believe that the overall performance of the health care system will improve once everyone has access to care. Today, consumers and professionals agree that health care reform is needed in the United States.
EFFECTS OF HEALTH ECONOMICS ON COMMUNITY HEALTH PRACTICE
Nursing's Agenda for Health Care Reform (American Nurses Association [ANA], 2002) supports this emphasis by promoting nurses as primary providers of health care. Tax-deductible employer contributions for health care coverage and non-taxable employee health benefits encourage unnecessary use of services and lead to cost increases.
HOW FOUR OTHER COUNTRIES APPROACH UNIVERSAL HEALTH CARE
If the community health approach is embraced by MCOs, conflict with public health can be minimized and perhaps eliminated. Angeles County reflects the potential benefits of public health care services for clients of MCOs and other private health care plans.
IMPLICATIONS FOR COMMUNITY HEALTH NURSING
Interview two consumers about their perceptions of the problems and strengths of our health care system. Find the latest articles and legislation on health care reform, public health system pros and cons, and the uninsured population.
