Along with increasing complexity and professional social networks, among the grow- ing contexts for health care, is population-based care. Population-based care, or care of aggregates and populations, crosses a vast array of disciplines in health and social sciences, with a focus toward optimum well-being and health care for all (Weinstein, Hermalin, & Soto, 2001). Our language, processes, and models of care are moving away from traditional categories of medical diagnosis and body systems of the individual
toward population-based models and ways of thinking about health care. The increas- ing complexity of care managed by healthcare providers requires attention to patient aggregates.
An aggregate or patient population is simply a collection of people within some discrete unit which may be defined by a number of distinguishing factors such as demographics, geography, interest, illness experience, or many others. Sometimes, the terms population health, public health, community health, and population-focused (or population-based) health care are used interchangeably (Radzyminski, 2007). They can be distinguished by their overall goals. The goal of population health is to “maximize the health of the population,”
with a management view toward health promotion, disease prevention, and emphasis on risk reduction related to the mental, behavioral, and social factors of health. The goal of public health is generally considered to be organized governmental or community ef- forts to promote and improve health among its citizens. Public health management also includes health promotion, risk reduction, and disease prevention, focusing on public safety and environmental issues. Community health includes health care for individu- als in a context of families or other social groups at the community level. Thus, com- munity health management includes health promotion and disease prevention among specific social groups who share common interests or characteristics within a community (Radzyminski, 2007, p. 42).
Rising costs and renewed emphasis on quality and outcome measurement have forced expansion of the paradigm of individual episodic patient care encounters to care along the entire spectrum of patients within a defined population. Such attention must now include all aspects of care: prevention, treatment, and chronic disease management.
Healthcare leaders, specifically advanced practice nurses, must be able to lead the man- agement of patients at the individual, organization, and population care level. This is a challenge for healthcare providers, especially physicians and nurse practitioners who have been prepared to diagnosis and treat conditions in individual patients. Advanced practice professionals have a history of pride in their distinction to provide direct patient care. However, such a focus on primary care often does not address population-based care any further than by applying the results of aggregate patient data to individual patients. Furthermore, population-based care has not been adequately defined or articu- lated into the practices of many individual primary care providers (Dalzell, 1998). That is the challenge for clinical leaders of the future.
According to the Association of American Medical Colleges (1999, p. 130), a popula- tion health perspective “encompasses the ability to assess the health needs of a specific population; implement and evaluate interventions to improve the health of that popula- tion; and provide care for individual patients in the context of the culture, health status, and health needs of the populations of which that patient is a member.” Population- focused health is influenced by physical, social cultural, and economic environmental factors. Leadership in population-focused health care requires the ability to conceptual- ize and analyze health and care from the larger community, or “macro” perspective, that includes environment, behavior, social attitudes and lifestyle, and values along with policy issues all linked with health (DeSouza, Williams & Meyerson, 2003; Radzyminski, 2007). The Healthy People 2010 campaign (U.S. Department of Health & Human Services, 2007) and other sources of clinical guidelines also provide definitions, data, and other information from a population-based perspective to guide care for aggregates.
A focus on population health includes aspects of behavior, lifestyle, culture, environ- ment, and society. It also includes the following:
Health care based on assessment of relationships derived from the population’s (a) genetic predisposition; (b) behaviors . . . and lifestyle; and (c) societal and environmental factors. . . . Healthcare activities based on an assessment of the ecosystem and its subsystems [including]
the healthcare system. . . . Healthcare activities based on assessment of the population’s (1) knowledge, attitudes, beliefs, values, and perceptions that facilitate or hinder motivation for change; (2) rewards or feedback following the adoption of a health behavior; and (3) skills, resources, or barriers that help or hinder desired behavioral or environmental changes (Green
& Kreuter, 2005; Radzyminski, 2007, p. 39).
As nurses and other providers continue to recognize and serve aggregate populations, there will be shifts from resource-based to population-based planning and evaluation.
Furthermore, some leaders have proposed the development of new specialists in health lifestyle and behavioral health to include the role of environment and societal factors that influence health (Radzyminski, 2007).
Even the primary care provider may take a perspective of care of aggregates by pro- viding population-focused care: “When caring for a population, you should measure outcomes for all your patients with the targeted condition, not just those who come to your office. This is largely what differentiates population-based care from traditional, individual-centered care” (Rivo, 1998).
Radzyminski (2007, pp. 41–42) provided a specific hypothetical example of population- based care in contrast to “population-focused” individual primary care:
Clinical Nurse Specialists (CNS) or Nurse Practitioners (NP) in pediatric nursing typically include infants and children as their specialty population for which they deliver expert care services. This does not mean that they deliver care based on the population health frame- work. Take, for example, the common childhood problem of otitis media. . . . If the nurse examines the infant, diagnoses otitis media, prescribes treatment (usually under protocol), provides discharge instructions, and arranges for follow-up, the nurse is operating in the advanced practice nursing model. . . . If the nurse uses his or her experience with all other patients in this population and takes into consideration the cost and the efficacy of one antibiotic over another, success rates of therapies, availability of services for the family . . . and so on, then the nurse can be said to be providing population-focused care. For the nurse to work in the population health model, the antibiotic treatment for the disease would be a secondary care provision. The primary goal would be to investigate why the children [in the community] contract the disease, why children continue to contract the disease in spite of treatment options, and what contributes to the large number of children who contract that disease, often repeatedly, year after year. Perhaps, in this example, the nurse would identify the mode of infant feeding as being associated with the high incidence of otitis media. . . . The nurse would have to investigate the culture, beliefs, values . . . not only of the parents of the infants but also of the whole community in which they live. . . . The population health nurse would then approach the problem of otitis media by implementing health care strategies that change infant feeding practices. . . . As nurses providing popula- tion-focused care continue to treat infants with otitis media with the best available therapy, population health nurse experts will work to . . . support healthy infant feeding practices, develop programs aimed at addressing the cultural components involved in infant feeding practices, and so on.
Obviously, effective patient care must focus on the care of both individuals and aggre- gates in the broadest sense. The transformational leader must be able to balance, vision, and navigate across both arenas. He or she must direct individual care within the frame- work and vision of care for entire communities.
To lead effectively in health care for aggregates and populations requires a different model than those that focus on traditional primary or acute care. One well-worn ap- proach is the Precede-Proceed model by Green and Kreuter (2005). This model emerged from health education and epidemiology. It promotes the idea of predisposing, enabling, and reinforcing factors of human behavior, demographic factors, beliefs, attitudes, val- ues, knowledge and perceptions, skills, resources, barriers, risk conditions, and environ- ment as they contribute to disease prevention, health promotion, risk reduction, and optimum well-being. It allows for interventions at the individual and population level.
The focus on health care for aggregates and populations will continue to grow. Thus, leadership in this arena is critical, especially for practitioners who are accustomed to the traditional model of individual care. As the aggregate focus becomes more effective, the movement will continue to benefit individual patients as well as populations. Some have called the aggregate focus “denominator medicine” (Halpern & Boulter, 2000). The de- nominators (or populations) represent groups with similar demographics, or with simi- lar disease conditions, with the numerator being the individual within the group. Such a model allows data tracking for screening, treatment, or other factors toward goals to identify quality metrics, patterns of utilization of services, or other outcomes.
Population-based care promotes a community perspective. It is complementary to in- dividual care. It promotes the development of effective protocols and sharing of best practices. At the same time, it invites ethical considerations to meet the needs of under- served populations as well as attention to idiosyncratic needs of individual patients and families. More important from a leadership perspective, population-based practice calls for planning, teamwork, interdisciplinary collaboration, and creative transformational leadership.
Context of care will continue to be a critical factor in healthcare leadership. Chaos, complexity, and change will continue to be predominant themes of context. Healthcare practice will expand its focus on aggregates and patient populations. Context is more than setting or backdrop for practice. It is the very circumstance of service that surrounds the work of the leader.
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5
Leading Among Leaders
Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.
— Margaret Mead
A
s you advance in clinical preparation, formal education, and leadership develop- ment, you become more than an expert clinician. You become a citizen of the larger discipline of healthcare leadership and a leader among leaders. Assume your role as leader. Take up the banner of your citizenship among leaders. The world awaits your ideas, skills, and the unique contribution you will make. You claim membership among thoughtful, committed people who can make a difference. Doors open, opportunities appear for you to make transformational change in ways you could not imagine before you entered the society of leaders. The challenges are too complex to be overcome by a sole creativ.e person, or even by representatives of a single discipline. Transformational change happens only by the collaborative choreography of groups and teams of leaders.You must prepare to be a leader among leaders.
There are others who struggle with similar issues and who may share your concerns but who have different perspectives, complementary skills, and new ideas that amplify your abilities. We have so much to learn from leaders in other disciplines to transform our vision of practice to improve lives. Just as this work focuses on the talents and skills for leadership among nurses, the need for effective leadership in health care is recog- nized and promoted among a variety of professions, each with ideas, advice, and ratio- nale for why each discipline is best poised to be the leaders of the future (see Falcone &
Satiani, 2008; Schwartz & Pogge, 2000). For example, some have proclaimed that “most physicians possess the traits essential for leadership” (Falcone & Satiani, 2008, p. 187).
Others claim that this is the time for nurses to take the helm as the leaders to transform health care. Still others propose that the best leadership can come only from a business model. The truth is that we are working together. Success in the next century can come only from a community of leaders to understand the values, theories, and approaches of each other to finally invent the true interprofessional leadership. You will be a leader among those leaders.