PART IIEntry-Level Population-Based
Public Health Nursing Competencies
3 COMPETENCY1: Applies the Public Health Nursing Process to Communities, Systems, Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4 COMPETENCY2:Utilizes Basic Epidemiological (The Incidence, Distribution, and Control of Disease in a Population) Principles in Public Health Nursing Practice . . . . . . . . . . . . . . . 75
5 COMPETENCY3:Utilizes the Principles and Science of Environmental Health to Promote Safe and Sustainable Environments for Individuals/Families, Systems, and Communities . . . . . . . 95
6 COMPETENCY4:Practices Within the Auspices of the Nurse Practice Act . . . . . . . . . . . . . . . . . . . . 127 7 COMPETENCY5:Works Within the Responsibility and Authority of the Governmental
Public Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 8 COMPETENCY6:Utilizes Collaboration to Achieve Public Health Goals . . . . . . . . . . . . . . . . . . . . . 167 9 COMPETENCY7:Effectively Communicates With Communities, Systems, Individuals,
Families, and Colleagues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 10 COMPETENCY8:Establishes and Maintains Caring Relationships With Communities,
Systems, Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 11 COMPETENCY9:Incorporates Mental, Physical, Emotional, Social, and Spiritual Aspects
of Health Into Assessment, Planning, Implementation, and Evaluation . . . . . . . . . . . . . . . . . . . . . . . 221 12 COMPETENCY10:Demonstrates Nonjudgmental/ Unconditional Acceptance of People
Different From Self . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 13 COMPETENCY11:Shows Evidence of Commitment to Social Justice, the Greater Good,
and the Public Health Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 14 COMPETENCY12:Demonstrates Leadership in Public Health Nursing With Communities,
Systems, Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 15 Putting It All Together: What It Means to Be a Public Health Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . 301
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47
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CHAPTER
3COMPETENCY #1Applies the Public Health Nursing Process to Communities, Systems, Individuals, and Families
n PatriciaM.Schoonwith Karen S. Martin, Kelly Krumwiede, and Noreen Kleinfehn-Wald
Kristi is listening to Beth, her public health nurse (PHN) preceptor, tell her about the client they are about to visit for the first time. The local public health agency received a maternal child health visit referral from a local OB/GYN for a 16-year-old, 20-weeks-gestation primipara. The client, Sara, has been diag-nosed with anemia and is underweight with poor weight gain. Sara is single and living with her mother, mother’s boyfriend, and two younger siblings. Sara and her family are uncomfortable with the idea of a public health nurse who works for the government visiting them in their home.
Beth says, “Well, I think the first thing we do is go and visit them. We need to get them to trust us if we are to help them.”
Kristi responds, “I have never visited a pregnant teenager or her family in their home. I don’t think I will feel comfortable. Will the family be okay with me there?”
Beth responds, “I asked Sara’s mother if you could covisit with me and she was okay with that. We will ask Sara and her mother what their health concerns and goals are and talk with them about how to arrange our visits and what we can do to help Sara. We will open a case file on Sara and begin to do a family assessment. You can observe and listen on this visit and take a more active part in future visits.”
Kristi says, “That sounds good to me!”As they walk to Beth’s car she mentions, “We can start to do a windshield survey on our way to Sara’s
home as part of the community assessment that you and your student work group are going to do of the local community.”
Kristi responds, “Great. I just happen to have my camera with me.”
KRISTI’S NOTEBOOKCOMPETENCY #1 AppliesthePublicHealthNursingProcesstoCommunities,Systems,Individuals,andFamilies
(continues)
A. Identifiesthepopulation(s)forwhichthePHNisaccountable
B. Assessesthehealthstatusofcommunities,systems,individuals,andfamilies
1) Usesahealthandsocialdeterminantsframeworktodetermineriskfactorsandprotectivefactorsthatleadtohealthandillnessincommunities,systems,individuals,andfamilies
2) IdentifiesrelevantandappropriatedataandinformationsourcesforthepopulationstowhichthePHNisaccountable
a. Familiarwithdatausedinthehealthdepartment
b. FamiliarwithdataintheprogramsinwhichthePHNworks
3) Worksinpartnershipwithcommunities,systems,individuals,orfamiliestoattachmeaningtocollectedquantitativeandqualitativedata
4) Worksinpartnershipwithcommunities,systems,individuals,andfamiliestoestablishpriorities
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48 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
KRISTI’S NOTEBOOKCOMPETENCY #1 (continued)
C. Createspublichealthstrength,riskandasset-baseddiagnosesforcommunities,systems,individuals,andfamilies
D. Inpartnershipwithcommunities,systems,individuals,andfamilies,developsaplanbasedonpriorities(includingnursingcareplansforindividuals/families)
1) Selectsdesiredoutcomesthataremeasurable,meaningful,andmanageable
2) Selectspublichealthinterventionsthat
a. Aresupportedbycurrentliteratureasevidence-based
b. Reducehealthdeterminantriskfactorsandstrengthenhealthdeterminantprotectivefactors
c. Havethegreatestpotentialforimprovingthehealthofthepopulation
d. Respectandareconsistentwiththecultureandethnicbeliefsofthecommunity
e. Areconsistentwithprofessionalstandards,theNursePracticeAct,existinglaws,ordinances,andpolicies
3) Selectslevel(s)ofintervention(community,systems,individuals,andfamilies)
4) Selectslevel(s)ofprevention(primary,secondary,tertiary)
E. Implementstheplanwithcommunities,systems,individuals,andfamilies
1) Worksinpartnershipwithcommunities,systems,individuals,andfamiliestoimplementpublichealthinterventions
2) Utilizesbestpracticeswhenimplementingthepublichealthnursingintervention
F. Evaluates
1) Measuresoutcomesofpublichealthnursinginterventionsusingevidence-basedmethodsandtools
2) Documentspublichealthnursingprocessbycompletingforms,records,andchartsforcommunities,systems,individuals,andfamilies
3) Usesinformationtechnologytocollect,document,analyze,store,andretrievethehealthstatusofcommunities,systems,individuals,andfamilies
Source: Henry Street Consortium, 2017
USEFUL DEFINITIONS
Community:Refersto(a)agroupofpeopleorpopulationgroup;(b)aphysicalplaceandtimeinwhichthepopulationlivesandworks;or(c)aculturalgroupthathassharedbeliefs,values,institutions,andsocialsystems(Skemp,Dreher,&Asselin,2006,p.23).
CommunityAssessment:Theprocessofsystematicallycollectinginformationaboutacommunity’sstructure,processes,anddynamics,itsphysicalandsocialenvironment,itspopulations,anditslevelofhealthandwellnesstodetermineitsstrengths,itsresources,itspopulationsofinterestandpopulationsatrisk,itshealthneeds,anditshealthpriorities.
ElectronicHealthRecords(EHRs):“Longitudinalcollectionofclinicalanddemographicclient-specificdatathatarestoredinacomputer-readableformat”(Martin,2005,p.461).
Family:Afamilyisdefinedasasocialunitoftwoormorepeoplewhoidentifythemselvesasafamily,shareemotionalbonds,andcarryoutthefunctionsofafamilyincludingmanaginghealthcare(Clark,2008;Friedman,Bowden,&Jones,2003;Martin,2005),andfamilyis“agroupofindividualswhoareboundbystrongemotionalties,asenseofbelonging,andapassionforbeinginvolvedinoneanother’slives”(Wright&Bell,2009,p.46).
FamilyAssessment:Theprocessofsystematicallycollectinginformationaboutclients’familystructure,pro-cesses,anddynamics;theirphysicalandsocialenvironments;andtheirlevelsofhealthandillnesstodeterminetheirstrengths,resources,healthneeds,andhealthpriorities.
HealthStatusIndicators:Measuresofthelevelofhealthorillnessofanindividual/family,community,orpopu-lation,suchasincidenceorprevalenceofdisease,birthanddeathrates,levelofindependence,lifesatisfaction,andqualityoflife.
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49CHAPTER 3  n  Competency #1
of the students, a recent immigrant, said she thought these families were fairly well off—they had housing, food, and were safe in their homes . The country she had emigrated from was in turmoil . She had seen family members mur-dered, their cattle slaughtered, homes burned, and people without food or clothing . These people, she thought, had truly stressful lives . The other students reflected on her com-ments and came to realize that people view the world from their own experiences . Understanding and appreciating the lived experiences of people is important . Knowing about and understanding each other helps promote the oppor-tunity for people to work together in a mutually respectful manner that can build on each other’s strengths .
PHNs work in partnership with individuals, families, and communities . Partnerships are mutual relationships based on trust . PHNs establish trust with individuals, fam-ilies, and communities by respecting their rights to make their own health decisions and by adapting the nursing practice to fit the lived experiences and daily lives of those individuals, families, and communities . PHNs direct their efforts to meet the priority health needs their clients iden-tify . Public health nursing practice includes the “3 E’s”:
n Egalitarian (equal) relationships with individuals, families, and communities
n Enhancement of individual, family, and community strengths, resilience, and resources
n Empowerment of individuals, families, and com-munities to advocate for and manage their own healthcare needs
Thinking and Doing Population Health—Nursing Process Leads the WayPHNs work with individuals and families wherever they find them in the community and in whatever condition they find them . The priority for public health nursing is health promotion and disease prevention, but PHNs also work with individuals and families who have chronic health conditions to help them achieve their health potential and, whenever possible, manage their own lives and healthcare needs . They need to discover their clients’ potential for self-care and wellness to help them reach that potential . PHNs use a strengths-based approach when using the public health nursing process . Because their clients live in the commu-nity, PHNs need to find out as much as they can about the community’s support systems, resources, and resource gaps .
Partnering With Individuals, Families, and CommunitiesPHNs need to understand the story, the context of the lives of the people in the community in which they work . PHNs must know and understand the history, culture, and life-style of individuals, families, populations, and the entire community . For example, in a post-clinical seminar, stu-dents were discussing the stresses and crises of the families they were visiting . They stated that they did not understand how these families could function with so much stress . One
OmahaSystem:“Research-basedapproachtopractice,documentation,andinformationmanagementthatincorporatestheProblemClassificationScheme,InterventionScheme,andProblemRatingScaleforOutcomes”(Martin,2005,p.463).
Population:The“totalnumberofpeoplelivinginaspecificgeographicarea”;subpopulations(syn.groupsoraggregates)“consistingofpeopleexperiencingaspecifichealthcondition,engaginginbehaviorsthathavepotentialtonegativelyaffecthealth,sharingacommonriskfactororriskexposure,orexperiencinganemerginghealththreatorrisk”(AmericanNursesAssociation[ANA],2013,p.3).
PrioritySetting:Organizinghealthconcernsbyhazardlevelsothathealthrisksthatplaceindividuals/families,communities,orpopulationsatgreaterriskaredealtwithfirst.
PublicHealthInformatics:Publichealthinformaticsisthesystematicapplicationofinformation,computerscience,andtechnologytopublichealthpractice,research,andlearning(CentersforDiseaseControlandPrevention[CDC],n.d.-b).
PublicHealthNursingProcess:Integratesconceptsofpublichealth,community,andallthreelevelsofPHNpractice(i.e.,individual/family,community,system)intothenursingprocess(i.e.,assessment,diagnosis,planning,implementation,andevaluation)(MinnesotaDepartmentofHealth[MDH],CenterforPublicHealthNursingPractice,2003).
System:Anorganizationorinstitutionthatispartofthesocialenvironmentaldeterminantofhealth(i.e.,healthcare,education,commerce,religion,government).
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50 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
third-party payers and accreditors require health depart-ments to provide evidence that their programs result in improved client outcomes . Aggregate data are a powerful tool to demonstrate the value of agency programs and can be shared with the public, be used to obtain grants and other funds, and be incorporated into quality improvement and program evaluation reports . Examples of reports generated by various agencies are found at www .omahasystem .org/ links .html .
Data Collection, Data Management, and the Public Health Nursing ProcessData compose the engine that drives the problem-solving process in nursing practice . Data are used to determine the health of populations and sub-populations in order to influence health priorities, health policy, and programs that promote the health and safety of communities and their pop-ulations (Allen, Soderberg, Laventure, 2017; Nelson & Stag-gers, 2018) . A continuum of population data is used by public health agencies to improve the health of their communities (see Figure 3 .1) . Accurate and consistent population data can be transformed to information, which leads to population health knowledge, and then to wisdom in order to design public health interventions to create healthier communities .
Therefore, you need to have a system and process for data collection and management in place at the beginning of the nursing process . For this reason, we discuss data in this chapter before we discuss the components of the public health nursing process . Many public health and community agencies use electronic health records (EHRs) and auto-mated health information systems (HIS) . EHRs and HISs provide ways to collect, store, analyze, and share informa-tion . Community and population data can be gathered from a variety of primary (data collected by individuals carrying out assessment) and secondary (data collected and published by others) sources .
Although more than one HIS exists, a system created for public health nursing is useful as an example . The Omaha System, a standardized terminology initially developed for use in the community, provides a problem-solving approach based on the nursing process (see Figure 3 .2) . The Omaha System is the foundation of the HIS that interprofessional team members at many health departments and other community provider sites regularly use to collect, docu-ment, and analyze individual, family, and population clin-ical data . The Omaha System allows PHNs to collect and record their own evidence-based practice data, analyze the data, and generate meaningful information that can be used to improve the quality of the care they provide . By using this approach, PHNs operationalize the data-information-knowledge- wisdom continuum (Allen et al ., 2017; Martin, 2005; Nelson & Staggers, 2018) . They can tell their data- and evidence-driven stories about the individuals, families, and communities they serve . More than 22,000 interprofes-sional clinicians use the Omaha System globally (Omaha System, 2017) .
The adoption of EHRs by healthcare providers, includ-ing health departments, is increasing very rapidly (Amer-ican Nurses Association [ANA], 2015; Martin, Monsen, & Bowles, 2011; Office of the National Coordinator for Health Information Technology, 2017; Omaha System, 2017) .
When health departments use EHRs based on the Omaha System accurately and consistently, they can aggre-gate individual and family data into larger data sets so that patterns can be identified within populations . Increasingly,
FIGURE 3.1 Transforming Data to PracticeSource: Allenetal.,2017;adaptedbyLaVenture,2008
PUBLIC HEALTH PRACTICE
HEALTHIER C MMUNITIES
LEV
EL O
F V
ALU
E
DATA
INFORMATION
KNOWLEDGE
WISDOM
PRACTICE
FIGURE 3.2 Omaha System Model of the Problem-Solving ProcessSource:Martin,2005,p.7,usedwithpermission
INDIVIDUAL,FAMILY, OR
COMMUNITY
Evaluateproblemoutcome
Collectand assess
data
Planand
intervene
Identifyadmissionproblem
rating
Identifyinterim/dismissalproblem
rating
Stateproblem
PRACTITIONER–CLIENT RELATIONSHIP
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51CHAPTER 3  n  Competency #1
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communities)—The Problem Classification Scheme is a hierarchy of terms that includes domains; individual-, family-, and community-centered problems; modifiers; and signs/symptoms .
n Intervention Scheme (plans, pathways, care activities, and service delivery terms to improve safety, qual-ity, and effectiveness)—The Intervention Scheme is a hierarchy of terms that includes categories, targets, and client-specific information .
n Problem Rating Scale for Outcomes (evaluation that pro-vides usable information for measuring and reporting client progress and change across time)—The Problem Rating Scale for Outcomes consists of Knowledge, Behavior, and Status concepts and Likert-type rating scales . Evidence Example 3 .2 showcases a case study of the Omaha System used to tell the story of a nurse-client interaction .
See Appendix B for additional Omaha System resources .
Kristi has just finished reading about the Omaha System. Her PHN preceptor, Beth, tells her that the public health nursing agency uses the Omaha System, and Beth wants Kristi to have a basic understanding of the Omaha System before she and Beth chart on any of the clients they visit. Beth gives Kristi the case study about Anna to read to help her understand the system. Beth asks Kristi if what she read made sense.
Kristi reflects: “I expected to be confused about the Omaha System, but the case study helped a lot. I could see the how the nurse assessed Anna and provided nursing services to her. She could use the Problem Rating Scale for Outcomes to evaluate Anna’s progress when she returns for another visit. I can see that using this system helps nurses measure the impact of their care and report how nursing care makes a difference. The one concern I have is that my instructor stresses the importance of using a strengths-based approach and the Omaha System always uses the term ‘problems.’”
Beth comments: “I had the same concern when I started using the Omaha System, but my supervisor pointed me to the literature on how ‘problem’ is actually defined in the Omaha System. Here is the definition of problem that I found: ‘Unique client concerns, needs, strengths, issues, foci, or conditions that affect any aspect of the client’s well- being; nursing diagnosis stated from the client’s perspective’* Also, I found that the term ‘problem’ can be considered neutral, not negative, so a problem in the Omaha System can also be used as part of a strengths-based approach.**
Kristi responds: “That makes me more comfortable. I am going to share with my classmates that the Omaha System term ‘problem’ can be used from a strengths-based perspective.” * Source: Martin, 2005, p . 465** Source: Monsen, Vanderboom et al ., 2017
Omaha System terms are used in documentation at the point of care (i .e ., the time and place that care occurs) . Because the terms of the Omaha System are not complex and the structure is relatively simple, nonhealthcare pro-fessionals can understand it . Clinicians see and use point-of-care terminologies in their EHRs . In 2014, Minnesota became the first state to recommend that American Nurses Association recognized point-of-care terminologies be included in all EHRs (ANA, 2015; Minnesota Department of Health [MDH], 2015) . Prior to that, Minnesota Department of Health staff conducted a survey and found that 96 .5% of community agencies in all counties used the Omaha System (Omaha System, 2017) .
The Omaha System enables healthcare providers to ana-lyze and exchange client-centered coded data that can be transformed to information, the first two stages of the data-to-wisdom continuum . The Omaha System was designed to be used by interprofessional clinicians to guide their prac-tice and document and communicate information about clients from admission to discharge . It exists in the public domain (no fee or license) and is intended for use across the continuum of care nationally and globally . It is based on a conceptual model that reflects the pivotal position of the individual, family, and community as client; interpro-fessional partnerships; and the value of the problem-solving approach . The Omaha System encourages critical thinking, enhances communication, and operationalizes the nursing process . The problem-solving approach complements the strengths-based approach that focuses on building devel-opmental assets and increasing the health of youth and communities (Martin, 2005; Monsen, Vanderboom, Olson, Larson, & Holland, 2017; Omaha System, 2017) . The Omaha System consists of three components: n Problem Classification Scheme (client-centered
assessment that engages individuals, families, and
EVIDENCE EXAMPLE 3.1TheOmahaSystem
The Omaha System was developed by the Visiting NurseAssociationofOmaha(Nebraska)andseventestsitestoenhance practice, documentation, and information man-agement. Four federally funded research studies wereconducted between 1975 and 1993 that validated appro-priatenessandeffectivenessoftheterminology.DeLanneSimmons, chief executive officer, envisioned a computer-izedmanagementinformationsystemthatincorporatedanintegrated, valid, and reliable clinical information systemfocusedonclientswhoreceivedservices,notonthenursesand other interprofessional team members who providedtheservices(Martin,2005;Martinetal.,2011;OmahaSys-tem, 2017). More than 400 articles, chapters, and bookshavebeenpublishedabouttheOmahaSystem;theListservhasmorethan3,000memberslocatedintheU.S.and22othercountries(OmahaSystem,2017).
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52 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
EVIDENCE EXAMPLE 3.2OmahaSystemCaseStudy
AnnaK.:Older woman who had a chronic cardiac condition and attended a screening clinic
First Visit/Encounter DataPublic health nurses at the Dakota County Public HealthDepartment (Minnesota) developed health clinics for seniorcitizens.Theclinicsofferedscreeningforhealthconcerns,par-ticularlyhypertension,heartdisease,anddepression;accuratehealthinformationforpreventionandtreatment;andoutreachandreferralcoordination forhomecare,equipment,medicalassistance, and other community services. Because inter-action time was limited, the nurses developed standardizedprotocolsandformsbasedontheOmahaSystemtoincreasetheefficiencyandeffectivenessofassessment,interventions,anddocumentation.Whennewclientsvisitedtheclinics,thenursesconsideredfourproblems,Communicationwithcom-munityresources,Mentalhealth,Circulation,andMedicationregimen. If thoseproblemsdidnotreflectclients’presentingdata, the nurses selected and documented other pertinentproblems,interventions,andoutcomeratings. WhenAnnaK.cametotheseniorclinicforthefirsttime,shereportedthatshehadahistoryofdizzinessandhighbloodpressure, but could not recall previous readings. When thenursecheckedhervitalsigns,herbloodpressurewas152/86sittingand154/82standing;herpulsewas60andregular.Herweightwas 138pounds,appropriate forher reportedheight.They talked about hypertension, blood pressure guidelines,theCirculationprotocol,andAnna’sdata.ThenursesuggestedstrategiestoincreaseAnna’ssafetywhenshewasdizzy.Thenurse recorded Anna’s vital signs on a health card, gave thecard toher,andsuggested thatshehaveherbloodpressurere-checkedmonthlyandrecordedonthecard.Sheaskedhertoshowthecardtoherdoctorduringfutureappointments. Anna said she took two “heart” pills fairly regularly. SheagreedtobringthemwithherwhenshereturnedtotheSeniorClinicthefollowingweeksosheandthenursecoulddiscussthem.ThenurseplannedtousetheMedicationregimenpro-tocolifappropriate,andrecordthemonAnna’shealthcard.
Anna’sAnswers:TransformingtheStoryintotheOmahaSystemassessment,services,andevaluationterms
Domain:Physiological
Problem:Circulation(highpriorityproblem)
Problem Classification SchemeModifiers:IndividualandActualSigns/SymptomsofActual:
n syncopal-faintingepisodes/dizziness
n abnormalbloodpressurereading
Intervention SchemeCategory:Teaching,Guidance,andCounselingTargetsandclientspecificinformation:
n anatomy/physiology(circulatorysystem)
n mobility/transfers(avoidfalls)
n signs/symptoms-physical(importanceofvitalsigns,whentonotifyphysician,dizziness)
Category:CaseManagementTargetsandclientspecificinformation:
n continuityofcare(showdoctorherhealthcardwithmonthlybloodpressurechecks)
Category:SurveillanceTargetsandclientspecificinformation:
n medical/dentalcare(scheduleandgotoappointments)
n signs/symptoms-physical(vitalsigns,circulatorystatus,weight,bloodpressure)
Problem Rating Scale for OutcomesKnowledge:2—minimalknowledge(someinformationaboutnormal/abnormalbloodpressurereadingsbutnotimpactonhealth;didnotknowpreviousreadings)
Behavior:4—usuallyappropriatebehavior(usuallytookmedications,hasbloodpressurecheckedperiodically,seekshealthcare)
Status:3—moderatesymptoms(bloodpressureexceededexpectedrangefornon-diabeticclient)
ElizabethA.Vance,BSN,RN,PHNRNPrimaryCareAllinaHealthClinicsDivisionMinneapolis,Minnesota
CarolA.Fish,MS,RN,PHNSupervisor,SocialServicesDepartmentDakotaCountyPublicHealthDepartmentWestSt.Paul,Minnesota
Source: Vance & Fish, 2017 Omaha System case study . Personal correspondence from Karen S . Martin, Martin Associates, Omaha, NE . December 8, 2017 .
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53CHAPTER 3  n  Competency #1
Home Visiting and the Nursing ProcessPHNs carry out assessments as part of the nursing process most often in a community setting, such as a home, a school, or a clinic . Most of the information is gathered through observation and listening . When in the home setting, PHNs are guests of the family members and need to follow their lead regarding communication methods; timing, length, and place of visit; and roles of the nurse and family mem-bers . To assess the family, PHNs must first establish a trust-ing relationship with family members based on mutual respect and understanding (Eriksson & Nilsson, 2008; Martin, 2005; McCann & Baker, 2001) . Answering ques-tions about personal family matters and health situations requires families to disclose information they generally do not share with strangers, so the development of a trusting relationship needs to precede or occur simultaneously with the interviewing process . Andrew Gardner (2010) found that one way to engage clients and help them feel comfort-able was to start by being open and friendly; this approach
seems obvious but can be challenging for nurses who are learning to be professional while maintaining boundaries and creating an environment conducive to effective nurs-ing practice . An appropriate level of openness certainly can facilitate a connection and mutual understanding, but this is sometimes a difficult balancing act, as friendship often occurs within the professional context of the nurse-client relationship . The initial visit to a family is critical in estab-lishing the nurse-client trust relationship (see Evidence Example 3 .3) .
Home visiting programs may include one or more vis-its to a client . PHNs follow some families for months and years, depending on their health risks and needs . So you should not feel as though you have to get everything done in one visit . Table 3 .1 demonstrates how a PHN would use the nursing process in making a series of home visits . The orientation phase takes one to three visits on average . The working phase might require multiple visits over a period of months or years .
EVIDENCE EXAMPLE 3.3PublicHealthNurses’ViewsofaGoodFirstMeeting
Swedish researchers used focus groups to determine whatpublic health nurses believed constituted a good first homevisitwithparentsofnewborns (Jansson,Petersson,&Uden,2001). A good first visit is considered key to developing aneffectiverelationshipwithparents.Threecriteriawereidenti-fied(Janssonetal.,2001):
1. Creatingtrustthroughgoodcontact/reciprocalrelation-ships;listening;beingaguest;havinganequalrolewithparents;andhavingtime,privacy,andpeaceandquiet
2. Creatingapictureofthefamily’slifesituationbygettingaholisticimpressionofthefamily,seeingthemintheirhomeenvironment,gettingapictureofwhattheclientsarelike,andtakingin,consciouslyandunconsciously,themoodandavarietyofinformationaboutthefamily
3. Creatingasupportiveclimatebyconfirmingandaffirmingparents’feelings,abilities,andresponsibilitiesandincreas-ingtheirresponsibilitieswhileprovidingasafetynetofservicesuntilfamilyisabletomanageonitsown
TABLE 3.1 How the Nursing Process Occurs in Home Visits
Home-Visiting Components Nursing Process
Orientation Phasen Introduction n Determine purpose of visit and visit activities with clientn Engage in social conversationn Assessmentn Identify and state client’s problems
Assessment and Diagnosisn Individual/family and community assessmentn Strengths-based assessment—protective factors identifiedn Resources identifiedn Health risks and active health problems identified n Unmet health needs identified
Working Phase: Identificationn Client asks questions and identifies nurse as someone who
can help .n Client identifies problems . n Nurse provides health teaching, support and counseling,
follow-up assessment, referral, and advocacy .
Planning and Implementationn Mutual planning, priority-setting, goal-settingn Interventions often used include teaching, guidance, and
counseling; treatments and procedures; case management; surveillance, advocacy, referral, and follow-up .
(continues)
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54 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
Home-Visiting Components Nursing Process
Working Phase: Mutual Relationshipn Client uses nurse as resource and accesses community
resources .n Nurse engages client in mutual problem solving .
Implementationn Interventions often used are teaching, guidance, and
counseling; treatments and procedures; case management; surveillance; collaboration; and consultation .
Resolution and Terminationn Problems are solved or ongoing but stable .n Client becomes independent of nurse or continues to
need support .n Relationship ends when client no longer needs nurse or no
longer participates in plan (moves or refuses participation in plan or visits) .
Evaluationn Evaluation of Knowledge, Behavior, and Status outcomes:
outcomes met, partially met, or not metn Replan—change in goals, outcomes, or interventionsn New priorities or emerging problems identified and nursing
process continued
Sources: Phases adapted from McNaughton, 2005; Omaha System terms from Martin, 2005; and interventions from Minnesota Department of Health, 2001
TABLE 3.1 How the Nursing Process Occurs in Home Visits (continued)
PHNs carry equipment they need to complete assess-ments on individual family members . For example, common equipment used on maternal/child health visits includes a baby scale, blood pressure cuffs, a stethoscope, paper tape measures, disposable thermometers, developmental screen-ing tools, growth grids, and a thermometer for determining the temperature of bath water .
PHNs carry smartphones, laptops, and other electronic devices to stay in contact with others, access information, and enter family data into EHRs during their home visits . Many PHNs use automated guidelines or clinical path-ways specific to individual client and family situations . For example, public health agencies have screening, assessment, and monitoring databases for newborns, infants, children, antepartum, postpartum, and family clients . PHNs collect admitting data on each client during their initial visits to their clients . They monitor and record health changes at each visit .
Public Health Nursing Assessment Public health nursing assessment is a systematic, deliber-ative, and holistic process of collecting data about a client (individual, family, community, or system) that leads to an understanding of the client’s health determinants, health status, and priority health concerns and needs, as shown in Figure 3 .3 . PHNs also need to carry out strengths-based assessments so that intervention plans for health concerns and problems are based on the clients’ abilities to manage their own healthcare needs . Strengths-based assessments identify clients’ abilities, resources, and resilience as well as health needs (Monsen, Vanderboom et al ., 2017) .
FIGURE 3.3 How PHNs Collect Data About Individuals, Communities, and Systems
Individual/Family• Family assessment• Family health goals
Community• Strength-based assessment• Health assessment and intervention process
• MAP-IT• Windshield survey
System• Community health priorities• Community action plan• Community intervention plan
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55CHAPTER 3  n  Competency #1
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Individual/FamilyLevelofPracticeThe family is the focus of care when PHNs work at the individual/family level of practice . The family is the pri-mary unit of society and is responsible for carrying out the functions that allow family members to survive and thrive . In a health sense, the family is a unit of care allowing the nurse to simultaneously focus on the individual, the family, and the health issue (Hunt, 2013) . Families come in many shapes and sizes and in different stages of development . Family composition is varied and changeable in contempo-rary society (Kaakinen, Coehlo, Steele, & Robinson, 2018) . A family is “a group of individuals who are bound by strong emotional ties, a sense of belonging, and a passion for being involved in one another’s lives” (Wright & Bell, 2009, p . 46) .
The experience of illness or a health concern is felt by not just the individual but also by larger systems including fam-ily members and the community (Marshall, Bell, & Moules, 2010) . Family-focused care has the potential to empower vulnerable and at-risk families (Rossiter, Fowler, Hopwood, Lee, & Dunston, 2011) . Family assessment is a holistic pro-cess in which all the factors that influence a family’s level of health and wellness are considered . Specifically, a family unit assessment includes collecting data on the individual, family, household, and community to identify resources, strengths, and risks (Meiers, 2016; Meiers, Krumwiede, Denham, & Bell, 2016) . In addition to considering individ-ual human development stages, PHNs consider the family’s stage of development . Transitions between the stages involve rearrangement of relationships . Although it is important to note that this is a very traditional model for married fam-ilies with children and would need to be adapted to a vari-ety of diverse family structures, Carter and McGoldrick’s (2005) Family Life Cycle model highlights the development of the family system over time: n Leaving home as single young adultsn Joining of families through marriage: the new couplen Families with young childrenn Families with adolescentsn Launching children and moving onn Families in later life
Each stage is associated with tasks that will foster each member’s development . Sara’s family falls in the “families with adolescents” stage . One unique aspect to this stage is that the parents face a transition with both the adolescent in terms of growing independence and the adolescent’s aging grandparents . This stage requires the family to alter its parent-child relationship to accommodate the adolescent’s growing independence and autonomy . This awareness of the family’s stage of development can be helpful for PHNs in understanding potential family conflict as they are work-ing through the stages . Table 3 .2 outlines the components of family assessment typically included in a comprehensive family assessment using the Healthy People 2020 Health Determinants Framework .
Beth and Kristi make their first visit to Sara. Her mother, Patricia, introduces herself at the beginning of the visit and states that she hopes the public health nurse can straighten out her daughter and help her daughter understand the poor choice she made in getting pregnant at such a young age. She is concerned because Sara is missing so much school. Sara has poor eye contact with Beth and her mother. Beth focuses on Sara and asks her what she would like help with for the rest of her pregnancy. Sara responds that she is very tired and feels uncomfortable with all of her body changes that are now becoming visible. She is afraid of how the other students at school will treat her.
Beth tells Sara and Patricia that she would like to get a good sense of the family before she begins any work with Sara. Beth asks if she can visit again next week to finish the family assessment she was able to start today. Before Beth and Kristi leave, Beth collects information from Sara so a case file can be opened. Beth then asks Sara if Kristi can check her height and weight to get some basic information. Sara agrees. Kristi finds that Sara weighs 100 lb. and her height is 5’3″.
After the visit, Kristi writes in her public health nursing clinical journal. She thinks about what phases of the home visiting occurred during this first visit. She also analyzes the visit and asks herself the question, “Was this a good first visit?” Kristi also reviews the holistic family assess-ment framework that she and Sara will be using during the second home visit.
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56 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
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‘‘During the second home visit, Kristi works with Beth to complete the family assessment. She constructs a genogram with Sara and her mother and they notice that Patricia and Sara’s grandmother have a history of preterm labor. During the visit, Jimmy, Patricia’s boyfriend, comes home early from work and Sara’s sisters, Tara and Kara, 9-year old twins, come home from school. The home becomes loud and there are lots of interruptions during the early part of
the visit. Beth asks Patricia if they can continue the visit in the kitchen and asks the twins to stay in the living room. Jimmy decides he will take a nap. The visit continues unin-terrupted. By the end of the visit, information about the family health determinants of biology and behaviors have been collected. When Kristi completes her weekly clinical journal, she organizes the family data by health determi-nant categories.
Table 3 .3 is what Kristi recorded .
TABLE 3.2 Holistic Family Assessment Framework
Framework Factors
Family Biological and Genetic Factors
n Agen Sex or gender identifyn Three-generation genogramn Family-identified ethnicityn Health status
Family Behavioral Factors n Lifestyle and daily patterns including nutrition, sleep, exercise, and recreationn Housing and living arrangementsn Social support/ecomapn Family and community rolesn Education, employment n Socioeconomic status (income, poverty)n Cultural patterns, religious affiliations n Language and health literacyn Health-seeking and health-limiting behaviorsn Patterns of coping and resiliencen Patterns of conformity and nonconformity
Physical Environment Factors
n Home environment (use a home safety checklist appropriate to family members’ age, development, and physical and cognitive abilities)
n Immediate neighborhood (observations, walkability, windshield surveys)n Natural physical environment and weathern Built environment, including safetyn Maintenance of sidewalks, roads, pedestrian crossingn Transportationn Adequate recreational resourcesn Access to shopping centersn Accessible healthcare—see the 5 A’s of accessible healthcare in the community-assessment guiden Potential or actual environmental hazards such as pollution of air, water, food, or soil
Social Environment Factors (i.e., social actions, patterns, systems, healthcare access)
n Availability of health and social services resources n Availability of quality schools and daycaren Availability of fire and policen Employment opportunitiesn Mass media and library availabilityn Cultural and social patterns of community, including potential exposure to violencen Governmental servicesn Business community and working conditions
Data Analysis Summary of the family assessment including: n Major family protective factors, major family risk factors n Statement of family resilience and ability to manage own healthcaren Family’s priority health problems or concerns and health goals
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57CHAPTER 3  n  Competency #1
TABLE 3.3 Sara’s Family Assessment: Individual/Family Health Determinants
Biological and Genetic Health Determinant Factors
Sara: is 16 years old, 20 weeks gestation, primipara, on a prenatal vitamin, diagnosed with anemia, and underweight with poor weight gain . She and her family are Caucasian .
Patricia: mother, is 34 years old taking hydrochlorothiazide 12 .5 mg daily for hypertension .
Jimmy: mother’s live-in boyfriend, is 37 years old and has no health conditions .
Siblings: Tara and Kara are 9-year-old twins; both females have attention deficit hyperactivity disorder (ADHD) and take Adderall XR 1 .25 mg daily . Immunizations are up to date .
Extended family: Sara’s grandparents, Patricia’s parents, live on a farm house 30 miles away . Grandmother, 55 years old, has hypertension . Grandfather, 57 years old, has type II diabetes .
Samuel: Sara’s boyfriend, is 17 years old, Hispanic, and has no known health conditions .
Behavioral Factors
Socioeconomic Status: Sara is a full-time high school student in 10th grade, unemployed, and with no income . Patricia is a full-time factory worker and Jimmy is a full-time welder . Both have high school diplomas . Tara and Kara are full-time elementary school students . Samuel, Sara’s boyfriend, is a full-time 11th-grade student and works part time at a restaurant . Although the family does not live in poverty, their income is low and they struggle to pay their monthly bills . Patricia has family health insurance and Jimmy has his own insurance .
Cultural and Religious Affiliation: All family members were born in the United States and are Catholic . The family attends church most Sundays .
Family Developmental Stage: families with adolescents’ developmental stage (Carter & McGoldrick, 2005)
Family Roles and Function: Patricia takes on leadership and organizer role in the home and schedules Sara’s prenatal check-ups . Patricia makes the decisions and Jimmy pays the bills and fixes the house . Sara babysits the twins but lacks knowledge of the difference between being an older sibling and being a parent . Patricia is tired, stressed, guilty for not being available for the family, and upset that Jimmy is not helping more at home . Samuel doesn’t come over much anymore because Patricia and Jimmy are not very welcoming .
Family Lifestyle Patterns (disrupted by health concerns): The family is struggling to manage schedules . Sara has been missing school due to fatigue and does not want anyone to know she is pregnant . Patricia and Jimmy leave for work at 6:00 a .m ., so Sara routinely takes care of the twins in the morning . Lately, Sara hasn’t been helping the twins get ready for school or to the bus on time . Patricia has been contacted by both schools due to Sara’s multiple absences and Tara and Kara’s tardiness . Patricia has been working overtime to pay for Sara’s prenatal care costs . Due to the stress of Sara’s pregnancy and working overtime, the house is messy, meals are not being made or eaten together, and the twins are not taking their ADHD medication as prescribed .
Ecomap Summary: The family has close relationships with their neighbors and church . The twins’ relationship with their school is strained due to tardiness . Sara also has a strained relationship with her school and misses Samuel and her friends . She would like to find a peer support group for pregnant and parenting teens but cannot find one .
Health seeking behaviors: Prior to the recent family disruptions, the family had healthy eating patterns, including eating supper together . They enjoyed weekly family bike riding . The twins and sometimes Sara got at least 8 hours of sleep most nights . No one in the family smokes; Sara does not use alcohol or other drugs .
Health Limiting Behaviors: The family lacks time to prepare and share meals and to go bike-riding . The twins often miss their daily ADHD medications . Sara feels like she is getting fat due to pregnancy, so she eats only one meal a day, typically a peanut butter and jelly sandwich, chips, and a soda and ice cream as a bedtime snack .
Family Resilience and Coping Patterns: Patricia stated she and her girls are strong and that Jimmy makes the family even stron-ger . Patricia went through a difficult divorce and feels her family is stronger because of the experience . Patricia and the girls talked through the experience; they “stuck together .” They have a positive outlook and pray together . Sara’s pregnancy has been stressful for the family . Sara is scared to give birth and depends on her mom being strong . “She has always been my rock and now I am scared because my mom is so disappointed in me . We don’t talk anymore; she just yells at me all the time .”
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58 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
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Beth and Kristi decide that Kristi could return for a third family visit to complete the home and neighborhood por-tions of the family assessment if Sara and her mother are okay with this. Beth phones Patricia and gets permission for Kristi to visit. After the visit, Kristi records the data on the physical and social environmental health determinants in her clinical journal. Kristi believes that she and Beth have now completed the Orientation Phase of family visit-ing. She will confirm this with Beth.
Table 3 .4 shows the notes that Kristi wrote after her visit .
Kristi goes to meet with Beth at the office before their next scheduled home visit with Sara and her family. Beth and Kristi review the data analysis of the family assessment and the summary of the family strengths and risk factors and identifies what she thinks are the family’s health problems and priorities.
Beth comments, “It is difficult to focus on the family as a whole when we opened the case on Sara and now we are assessing and planning on intervening with the family as a whole. You did a good job focusing on the family as a unit and putting Sara in the center of that family.”
EstablishingFamilyHealthGoalsThe PHN continues the nursing process by moving into iden-tification of the individual’s or family’s health priorities and mutual goal-setting . PHNs employ mutual problem-solving strategies with clients to foster self- efficacy . When working with families in the community, the PHN partners with the families in determining priorities, establishing goals, and developing an intervention plan . The plan should be con-gruent with and integrated into the family’s culture, life-style, and daily routine and be within the family’s potential to achieve . The plan should enhance the family’s potential for self-care and autonomy . The family care plan should be realistic, understandable, measurable, behavioral, achiev-able, and time-limited so that the effectiveness of the plan and the nursing interventions can be determined . It is pos-sible to develop and measure Knowledge, Behavior, and Status outcomes for a family using the Omaha System Prob-lem Classification Scheme .
TABLE 3.4 Sara’s Family Assessment: Physical and Social Environmental Health Determinants
Physical Environment Health Determinant Factors (Natural and Built Environment)
The family lives together in a 3-bedroom, 1-bath rambler in need of repairs in a low-income neighborhood . The twins share a room . The home safety checklist findings included: presence of smoke detectors, carbon monoxide detectors, and good lighting through-out . Cleaning products are in an unlocked cupboard under the sink . This will present a safety hazard for the new baby . Their neighborhood has sidewalks and is well lit . Traffic is light . There is a grocery store, a farmer’s market, and a park nearby . The family medical clinic is 5 miles from their home .
Social Environment Health Determinant Factors
The family feels that they live in a good neighborhood and good community . The neighborhood has a neighborhood watch commit-tee and a few retired neighbors have a Safe Home sign in their window, which means that any child who needs help can go to those homes . The local schools have good teachers and are safe . Patricia and Sara are relieved that a PHN can come to see Sara at home . The PHN is working with the school nurse and social worker to plan for Sara’s return to school once she has the baby . There is no peer support program for pregnant and parenting teens at the school . The City Council has recently started a marketing program to attract new businesses, which will give Patricia and Jimmy opportunities for better jobs .
Data Analysis—Summary of Family Assessment
Family Strengths (Protective Factors): The family has a good history of resilience and healthy family roles and functions . The family has good community support systems . Patricia and Jimmy expressed the desire to support Sara in her pregnancy . Sara plans to complete high school and go to college; she does not use substances such as tobacco, drugs, or alcohol . The family is working with the PHN, school nurse, and social worker to help Sara achieve her goals .
Family Risk Factors: Sara’s unexpected pregnancy has placed a stress on the family functions that has resulted in interruptions in some family processes . Key areas for improvement are meal preparation, Sara’s difficulty with caretaking the twins in the morning, and Sara’s poor eating habits . The family history of preterm labor is an added risk factor for Sara’s pregnancy . Sara has experience caring for her younger siblings and has a desire to learn about prenatal care; however, she has a lack of knowledge about pregnancy and caring for an infant . The relationship between Patricia and Sara is strained, and Sara does not feel she is receiving the support she needs from her mother . The relationship between Samuel and the family is strained . The twins are not receiving their daily ADHD medications and are often tardy at school, while Sara has frequent absences from her school .
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59CHAPTER 3  n  Competency #1
TABLE 3.5 Sara’s Pregnancy and Family Stress in the Omaha System
DOMAIN: Physiological DOMAIN: Psychosocial
PROBLEM: Pregnancy (high-priority problem)Modifiers: Individual and Actual
Signs/Symptoms of Actual n Difficulty with prenatal exercise/rest/diet/behaviorsn Difficulty coping with body changesn Inadequate social support
Problem Rating Scale for Outcomes
Knowledge: 2—Minimal knowledge (interested in information about appropriate rest, exercise, and diet patterns)Behavior: 1—Not appropriate behavior (no prenatal care; high-risk behaviors) Status: 1—Extreme signs/symptoms (anemia and is underweight with poor weight gain)
PROBLEM: Interpersonal Relationship Modifiers: Family and Actual
Signs/Symptoms of Actual: n Difficulty establishing/maintaining relationshipsn Incongruent values/goals/expectations/schedules n Prolonged, unrelieved tension
Knowledge: 3—Basic knowledge (describes importance of positive communication but not methods)Behavior: 3—Inconsistently appropriate behavior (great decrease in number and increase in length of relationships, increase in repairing relationship) Status: 2—Severe symptoms (limited, brief communication and interaction, often tense)
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Kristi and Beth carry out a home visit with Sara and her family to identify the family’s priority health goals. During the visit, they work collaboratively with the family to iden-tify two family health goals and then translate them into the Omaha System Problems.
• Goal One: Have a healthy baby to add to the family → Problem: Pregnancy.
• Goal Two: Work on supporting each other by improving their relationships and communications and get back into a scheduled routine → Problem: Interpersonal Relationship.
Kristi and Beth return to the office to input the family data for their family health goals using the Omaha System Problem Classification Scheme. In order to measure health outcome improvements over the time of the home visiting, Beth assigns a Knowledge, Behavior, and Status (KBS) rat-ing starting for the primary family health problems.
Kristi’s KBS rating for Sara and her family is shown in Table 3 .5 .
Beth says, “The next step will be to develop care plans.” Kristi states, “I just reviewed Anna’s case study and the Intervention Scheme. Was that a care plan?”
Beth suggests, “The Omaha System Intervention Scheme is used to describe care plans and services. For simplic-ity, Anna’s case study documents services so readers can ‘match’ the services to the text in Anna’s story. Why don’t you take the next half hour and go online to the Omaha Sys-tem Community of Practice (http://omahasystemmn.org/ data.php)? Watch ‘An Introduction to the Omaha System’
and ‘How to Read an Omaha System Pathway.’ You will see that the term ‘pathway’ is used to suggest various Interven-tion Scheme categories, targets, and client-specific infor-mation for specific problems. Then we can work together to develop pathways for the Pregnancy and Interpersonal relationship problems.”
Kristi responds, “That sounds like a great idea. I am concerned though that Sara has a lot of other health prob-lems related to her pregnancy: her eating habits and not gaining any weight, anxiety, isolation from her friends and her boyfriend, Samuel. The list goes on and on! When will we deal with those issues?”
Beth responds, “With home visiting, we take things one small step at a time. We are still in the Identification Phase of the Home Visiting Process. As we work with Sara and her family, we will deal with all of these issues using many interventions. Once we have developed a working relationship with the family we will move into the Mutual Relationship Phase. Then we will be able to have more of a consultative relationship and help them connect with com-munity resources and decide how they want to manage the challenges of the birth of Sara’s baby.”
Health teaching, counseling, consultation, and case management are interventions commonly used to build on and enhance the families’ strengths and encourage them to manage their healthcare . PHNs use advocacy to facilitate the individual’s and family’s ability to access health and social resources . They also use advocacy when populations are found to be at risk for a specific health hazard .
Whether individuals live alone or with others, the same family functions are relevant . If you are working with an individual who lives alone or whose extended family lives
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60 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
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elsewhere, you still need to use the same family assess-ment approach . Sometimes a complete family assessment is not needed or impossible to collect . In that case, the PHN would select the assessment components that relate to the specific family health problem or priority concern . It would be important to include the following components in this focused family assessment: the health problem or issue and the related risk factors and protective factors, the family goal related to the health problem or concern, necessary access to health and social services, and the family’s ability to manage healthcare needs and resources .
Community Level of PracticePHNs assess communities to determine their levels of health and wellness . These assessments are carried out in partner-ship with the community . Many geographic communities, such as cities, counties, and states, conduct a community assessment on a periodic basis . They do this to monitor changing health conditions of the populations in their com-munities and to establish community priorities for health goals, funding, and actions . The governmental agencies conducting the assessment partner with other community organizations and members to ensure that the diversity of the community and all points of view are reflected in the assessment . PHNs are part of the team that collects and analyzes the community data .
It is important to conduct a strengths-based assessment as part of the community-assessment process . PHNs work to enhance community strengths so that communities can be as independent as possible in solving their own health-care problems and managing their own healthcare needs . See Chapter 8 for a discussion of the formation of com-munity partnerships and building on community assets to strengthen the community’s ability to manage its own healthcare needs .
The population data collected in public health includes population health status, health differences or health status gaps between populations (health disparities), and health determinants (causes of health and illness within the popu-lation) . Population health status data, also known as global health status measures, are the “vital signs” of the popula-tion . These global health measures include: n Mortality (death rates) datan Life Expectancy (average years lived for someone born
in a specific year)n Years of Potential Life Lost (life expectancy–age of
death = YPLL)
n Morbidity (illness rates) datan Health behaviors data (e .g ., smoking, exercise, obesity,
use of seatbelts)n Health and life satisfaction data (how satisfied one is
with current health and lifestyle) n Functional health data (ability to live independently
and manage own healthcare needs)
Kristi is just starting her community-assessment proj-ect with three of her classmates. They are conducting an aggregate assessment (focusing on a specific portion of the population). Because of the home visits to Sara and her family, Kristi is interested in looking at the needs of preg-nant and parenting teens and identifying existing resources and resource gaps. She finds out that Sara’s mother’s church is considering starting an outreach program for pregnant and parenting teens. She asks Beth what information the health department might have to help her and the church members decide what to do. Did the PHNs have any data that would help?
Beth responds, “The public health department carries out a community assessment every five years to determine the priority health problems of the people living in the com-munity. We want to know what the major health needs are and which needs are met and which are unmet. We also look at the assets or resources of the community to deter-mine the community’s capacity to manage its own health-care needs and solve its own problems. Then we prioritize and decide which services to offer, what the funding should be, and how to allocate resources to our different programs. During the last community-assessment process, we found out that while our teen pregnancy rate had decreased, we still did not have the outreach and health promotion services to meet their needs. One area we identified as a priority was peer support groups for pregnant and parent-ing teens. Many of our public health nurses provide health teaching and case management interventions for pregnant and parenting teens in the home, and they found that until the teens return to school, they are quite isolated. We aren’t sure if this is affecting their ability to parent their newborns. So, we are in the process of using Omaha System data to see if there are services we need to provide. When you organize your aggregate assessment, you should con-sider looking at what other churches and community orga-nizations are doing or if they have the resources to develop new programs.”
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61CHAPTER 3  n  Competency #1
CommunityHealthAssessmentandInterventionProcessCommunity assessment and intervention is an inclusive process that involves all relevant stakeholders such as health and social services providers, spokespeople for the commu-nity and its sub-populations, and key decision-makers in the community . The MAP-IT 5-step process (see Figure 3 .4) is a Healthy People 2020 tool that helps people unite to improve the health of their communities (CDC, n .d .-a) . It may be
used as a community-assessment tool and as a commu-nity planning process tool . MAP-IT resources are found at http://www .healthypeople .gov/2020/implement/MapIt .aspx .
Before starting the data-collection process, an assess-ment tool must be selected or developed . The community- assessment tool presented in Table 3 .6 is based on the determinants of health (see Chapter 1) . The community- assessment project you participate in as a student may include many of these components . Remember that all data sources, both primary and secondary, must be documented .
TABLE 3.6 Community-Assessment Guide
Part I: Defining Target Population
n Entire Population of a Geographic Area: Population by census track, community, county, state, countryn Sub-Population or Aggregate: Population who share common character (i .e ., ethnic, cultural or religious group, age or
developmental stage, common health risk [potential or actual])n Population of Interest: Population who is essentially healthy but could improve factors that promote or protect health
(MDH, 2001)n Population at Risk: Population with a common identified risk factor or risk exposure that poses a threat to health (MDH, 2001)
Part II: Identifying Population Health Status
Levels of Health and Illnessn Birth and Death (Mortality) Ratesn Accidents and Injuries: accidental, intentional, homicide, and suiciden Communicable and Infectious Disease Incidence and Prevalence Ratesn Acute and Chronic Disease Rates (physical, mental)
Health Risk Behaviors (may also be listed under Behavioral Health Determinants)n Rates of smoking or chewing, drinking, drug use, obesity, drinking and driving, sexual behaviors and unprotected sex, use of
seatbelts and helmets, interpersonal abuse, participation in antisocial or illegal behaviors
Levels of Independence by age, gender, health status, socioeconomic status
Levels of Life Satisfaction by age, gender, health status, socioeconomic status
(continues)
FIGURE 3.4 Community Planning Process: MAP-ITSource: AdaptedfromMAP-IT(CDC,n.d.-a)
Mobilize key people& organizations
Identify roles& responsibilities
Form coalition
MOBILIZE
Assess needsand assets
Start collectingcommunity data
Work togetheras coalition toset priorities
ASSESS
Develop goalsand objectives
Decide how tomeasure progress
& success
Considerintervention points
where & whenchange can occur
PLAN
Create detailedwork plan
Develop acommunication
plan
Identify a singlepoint of contact to
manage project
IMPLEMENT
Plan regularevaluations tomeasure and
track progressover time
Share progressand success
TRACK
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62 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
Part III: Assessing Population Determinants of Health
Population Biological and Genetic Factorsn Population at last census and population changes in last decaden Demographics: Age, gender, race, and ethnicity (may use population pyramids)n Physical characteristicsn Genetic factorsn Health conditions: Acute and chronic
Physical Environment Factorsn Natural Environment: Geography, climate, weather, air and water and other natural resources, agriculture, animal life, urban,
rural, suburban n Built Environment: Infrastructure of community (roads, bridges, transportation, public spaces, and recreational areas), public,
and governmental buildings; housing stock and density; industries and workplaces; educational and religious facilities; health-care facilities; shopping and entertainment; accessibility; and environmental adaptation
Social Environmental Factors: Social Actions and Social Patterns
Population Behavioral Patternsn History of the communityn Social, economic, and political
patternsn Socioeconomic status (income,
poverty), education, employment, and work patterns
n Housing and living arrangementsn Lifestyle patterns n Cultural patterns, diversity, and
religious affiliationsn Community roles and engagement n Language n Health insurancen Health literacyn Health-seeking behaviors n Health-limiting behaviorsn Patterns of coping and resiliencen Patterns of conformity and
nonconformity
Community Systems (Institutions)n Cultural and ethnic organizationsn Education (public, private, religious)n Commerce and job opportunitiesn Media and forms of communication
including mail delivery, phone, radio, television, and Internet
n Libraries and public informationn Governmental systems and services:
public health and social services; police and protective services; environmental services (water, air quality, sanitation, waste management, recycling services, vector control); emergency preparedness and response
n Laws, regulations, ordinancesn Community safety net programs
( public and private)n Community support systems
(formal and informal)n Community networks, coalitionsn Health services and health services
access (physical, mental, chemical, dental, pharmaceutical)
Access to Healthcare
Assessing the “7 A’s of Access”
(Truglio-Londrigan & Lewenson, 2013, p . 93)
1 . Is the individual, family, or population aware of its needs and the services available in the community?
2 . Can the individual, family, or pop-ulation gain access to the services it needs?
3 . Are services available and convenient for the individual, family, or popu-lation in terms of time, location, and place for use?
4 . How affordable are the services for the individual, family, or population?
5 . Are the services acceptable to the individual, family, or population in terms of choice, satisfaction, and congruency with cultural values and beliefs?
6 . How appropriate are the services for the individual, family, or population?
7 . Are the services adequate in terms of quantity or degree for the individual, family, or population?
Part IV: Analysis of Population Health Data
n Summarize the population demographics and health statusn Summarize the physical and social environmental factorsn Identify the major protective factors for population healthn Identify the major risk factors for population healthn Identify the key health disparities within the population as a whole and between sub-groups
TABLE 3.6 Community-Assessment Guide (continued)
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63CHAPTER 3  n  Competency #1
WindshieldSurveyThe windshield survey is a first look at a community through a car’s windshield . Observers are asked to use their senses (sight, hearing, and smell) to learn about a community as they drive, walk, or use public transportation to get around the community . They then make observations about the physical and social environments and the natural and built environments . The windshield survey is sometimes referred to as a familiarization survey because it helps establish the community context of care for PHNs . It can also be an initial
step to a more comprehensive community assessment by raising awareness of issues for further exploration . Table 3 .7 includes a list of questions you might ask yourself to help guide your windshield survey and analyze your findings .
Other types of windshield surveys may also be carried out, such as environmental hazard surveys (see Chapter 5) and walkability surveys to assess areas not accessible by car such as sidewalks, paths, parks, playgrounds, campuses, and malls .
TABLE 3.7 Windshield Survey—Snapshot of Community Assessment
Windshield Survey
The first steps of a windshield survey require identifying the community boundaries and determining whether you will conduct the survey by car, by public transportation, or partially on foot to determine feasibility of your possible travel routes . It is best to con-duct the survey in pairs or as a group . As you drive or ride through the community, pay careful attention to as many characteristics of the community as possible . You may wish to take photos or videotape your windshield survey . Make sure that you are only taking photos of people in public places . Be sensitive to the privacy of others; avoid taking pictures of people where they could be identified .
n Which resources/assets do you see available in the community? Resources may include libraries, clinics, thriving local businesses, and other features that may provide support to community members .
n Which types of services for families do you see in the community? n Are there other organizations, such as youth centers, churches, or Head Start programs that might provide activities for
children/families?n Where do people live in the community? Is the housing primarily single-family housing or apartments? What is the condition
of the housing?n What types of jobs are available in the community? Would these jobs likely be held by people in the area?n Where do people shop? Which types of stores are available: locally owned or chain stores?n How do people get around in the community? Is public transportation available?n What do you notice about ethnic diversity in the community? Which age range seems predominant?n What is the geographic environment? Which types of opportunities are available for exercise? Are parks available? Is there
green space?n Which options are available for eating out?n What did you learn about the health status of population groups in the community that augments published population
health data?n Where can people go for healthcare services?n Based on your observations, what would you identify as assets in this community?n Overall, how did you feel about being in the community (e .g ., safe, comfortable, uneasy)?
Reflection and Analysis Questionsn What is the story of each photo you have taken? What do the photos tell you about the life and health of the community?n What are the community’s outstanding assets? Is there a relationship between these assets and the health of the community?n What appear to be the community’s major challenges? Is there a relationship between these challenges and the health of
the community?n What do you see as the most striking characteristic about the community? Would this characteristic influence your approach
to providing care to the community?n What did you find to be the most unexpected? Would the unexpected be an asset or a challenge to providing care to the
community?
Source: Modified from Hargate, 2013
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64 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
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PHN Assessment at the Systems Level of PracticeSystems are part of the social environmental category of health determinants . Systems can be assessed to determine their ability to respond to public health priorities in the community . Systems that PHNs interact with on an ongo-ing basis include healthcare systems; public and govern-mental agencies; schools and school systems; community health and social service agencies; local and state govern-ments, including elected and appointed officials; insurance companies; and faith-based organizations . PHNs assess systems to identify the extent to which they can meet com-munity health needs and, if gaps exist, to identify the addi-tional resources that are needed . Kristi’s discussion about the local Catholic church, the Salvation Army, and county public health nurses working together demonstrates how public-private partnerships can often fill the gap when one organization cannot meet the need alone .
Kristi and her fellow students find that two organizations in the community are interested in developing some out-reach services to pregnant and parenting teens: a local Catholic church and the Salvation Army. She asks her PHN preceptor if two such different organizations might be able to work together.
Beth advises, “You might want to divide your group of four students into two and ask each pair to assess one of the organizations. You would want to look at their values, goals, resources, and willingness to work with each other.
If you find common ground based on an interest in help-ing pregnant and parenting teens, then you can arrange a meeting of the two organizations. You could let them know that the PHNs in our agency would be willing to help them.”
Kristi responds, “Wow! We might be able to do some-thing valuable for the community while we are carrying out our clinical assignment. I am going to call my classmates and set up a meeting to get started. Thanks.”
IdentifyingCommunityHealthPrioritiesPHNs employed in governmental public health agencies are accountable to the public for the health priorities they select, the populations they serve, and the services they pro-vide (see Chapter 7) . PHNs consciously make the connec-tion between the health needs of the community as a whole and the health needs of individuals and families within the community . The priority health needs identified through the community-assessment process help PHNs determine the most vulnerable and underserved populations in their communities and target those with greatest need for services .
PHNs also identify health priorities in the community by determining health and illness patterns among their individual clients and families by aggregating data on all the families whom their agency serves . PHNs look at mul-tiple interacting health determinants, including the social determinants of health, to identify population health pat-terns and causes when working with individual clients and community partners (Monsen, Swenson, & Kerr, 2016; Monsen, Brandt et al ., 2017; Monsen, Swenson, Klotzbach, Mathiason, & Johnson, 2017) . PHNs also conduct research to identify health concerns in known vulnerable popula-tions . For example, a study of early care and education pro-grams identified the following health needs of the centers and enrolled children: hygiene and hand-washing; sanita-tion and disinfection; supervision; and safety of indoor and outdoor equipment (Alkon, Rose, Wolff, Kotch, & Aronson, 2016) . PHNs can determine community health priorities by reviewing the community-assessment data to determine which health problems have the greatest potential for harm and have effective interventions . Questions to consider when establishing health priorities are listed in Table 3 .8 .
PHNs are ever-vigilant community watchers who are often the first to notice when a new health concern emerges or when a service gaps exists in the community . An exam-ple of a health concern identified by a PHN intake nurse, explored by agency staff, and taken to a group of commu-nity partners for a systems-level intervention is found in Evidence Example 3 .5 .
EVIDENCE EXAMPLE 3.4WindshieldSurvey
A total of 284 windshield surveys were carried out bynursing students in Mexico, New Zealand, Norway,Turkey, and the United States. The Omaha System Prob-lemClassificationSchemewasusedtoevaluatethewind-shield survey data. The students were able to input thecommunity-assessmentdataintoelectronicrecordsusingan online checklist of 11 Omaha System problems. Thisframework for collecting and analyzing community datawas found to be an effective teaching-learning tool forstudents.
Source: Kerr et al ., 2016
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65CHAPTER 3  n  Competency #1
TABLE 3.8 Determining Community Health Priorities
1 . What is the incidence and prevalence of major diseases, health risk behaviors, and health concerns in the com-munity (e .g ., heart disease, teen pregnancy, drinking and driving, smoking, depression, influenza)?
2 . What are the major causes of death and disability in the community (e .g ., heart attacks, stroke, cancer, demen-tia, car accidents, and homicide)?
3 . Which populations in the community are most affected by these health problems (health disparities)?
4 . What are the major health risks in the community (e .g ., obesity, air pollution, homes with lead-based paint, seasonal flooding, homelessness, lack of health insurance)? Consider level of risk and proportion of population affected . What are the key social determi-nants of health affecting vulnerable populations in the community?
5 . Which health needs are met by community resources?
6 . Which health needs are not met?
7 . Are affordable and effective interventions available for these health needs?
8 . Who is responsible for meeting these health needs?
9 . Rank order priorities by level of risk or hazard to community population or sub-populations .
DeclineinChildMortality
GOAL 3 Significantprogresshasbeenmadeinreducingchildmortality.In2015,themortalityrateforchildrenunderage5worldwidewas43deathsper1,000livebirths—a44%reductionsince2000.Thistranslatesto5.9millionunder-5deathsin2015,downfrom9.8millionin2000.Butdespiteprogressineveryregion,widedisparitiespersist.Sub-SaharanAfricacontinuestohavethehighestunder-5mortal-ityrate,with84deathsper1,000livebirthsin2015—abouttwicetheglobalaverage. Childrenaremostvulnerableinthefirst28daysoflife(theneonatalperiod).Toreducechilddeathsevenfurther,greaterattentionmustbefocusedonthiscrucialperiod,whereprogresshasnotbeenasrapid.In2015,theglobalneonatalmortalityratewas19deathsper1,000livebirths,a37%reduction
since2000.Thismeansthat,in2015,about2.7millionchildrendiedinthefirstmonthoflife.NeonatalmortalityremainshighestinCentralandSouthernAsiaandinsub-SaharanAfrica:29deathsper1,000livebirthsin2015inbothregions. Theshareofnewborndeathsinallunder-5deathsgrewfrom40%in2000to45%in2015,duetotheslowerpaceofprogressamongnewborns.Itisestimatedthat40%ofneonataldeathscouldbepreventedbyprovidinghigh-qualitycareforbothmotherandbabyaroundthetimeofbirth(UnitedNations,n.d.).
EVIDENCE EXAMPLE 3.5DeterminingPopulationNeedsinaRural/SuburbanCounty
Theintakenurseatthepublichealthagencywasrespon-sible for logging referralsandconversationsofsignificantpublichealthconcern.Theagencysheworkedatwassmalland lacked an on-site physician or walk-in clinic services.Itwasa50-miledrivetothelargermetropolitancommu-nity where low-cost clinics were available. An analysis ofthemonthlylogsincludedcallsfromuninsuredadultswitha variety of acute and chronic healthcare conditions. Theintakenursefoundatrendofincreasingnumbersofworkingadults lackingaccesstocare.Shecompiledabrief reportsummarizingtwomonthsoflogentriesandpresentedittoherpublichealthdirector.Atthenextcommunitypartnercommittee meeting with local medical clinics and hospi-tals, the director shared the intake nurse’s report. Afterconsultingwithothercommunitypartners,thecommitteeproposedestablishinganursingcenter.Thehospitalagreedtofundthepart-timecenterstaffedbyaPHNforoneafter-noonaweekfortwoyears.Servicesfocusedonscreening,referrals,andhealthpromotion.Areviewofclientdataafterseveralmonthsidentifiedaneedforlimitedphysicianser-vices.Alocalmedicalclinicofferedtoseepatientsreferredby the nursing center free of charge. Another healthcareprovider purchased a mobile health unit to do mammog-raphyoutreach.Thecommitteeworkedwiththisprovidertousethemobileunittovisitseveralcommunitysitesona monthly basis. These services were the direct result ofsystems-levelcollaborationandadvocacyforthoselackingaccesstohealthcare.
Source: Kleinfehn-Wald, 2010
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66 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
Public health diagnoses for populations are often written as population risk diagnoses . The traditional risk diagno-ses have four components: health risk, population at-risk, modifiable risk factors, and bio-statistical data . This tradi-tional population risk diagnosis has been modified to create an asset-based risk diagnosis by adding the component of modifiable protective factors (see Table 3 .9) . This approach helps to build on existing community resources and involve community members when creating an intervention plan .
If you wish to write an asset-based public health risk diagnosis using the Omaha System taxonomy, you would include Domain, Problem, and Signs/Symptoms in the health risk area and could use the KBS ratings as a way to measure outcomes . The category of Problem as discussed in Chapter 2 may also be used to identify strengths .
PublicHealthNursingCommunityActionPlanWhen the PHN is working with the community, the plan-ning process and intervention process involves an interpro-fessional team and key community members . After the team
has established priorities and formulated clear statements of the health priorities to be addressed, it is time to deter-mine goals . Community goals are based on community values, beliefs, and the willingness of community members and elected and appointed officials to make changes; the resources available; and a consensus of what is achievable in the given time frame . Specific outcomes are then estab-lished . An example of a goal and an outcome for a commu-nity follow (sometimes the words goal and outcome are used interchangeably):n Goal: Reduce obesity in our communityn Outcome: Reduce obesity in adults in our community
by 10% by 2020
PopulationHealthGoalsThe United States has established population health goals each decade since 1990 . The purpose of the goals is to encourage communities to work together to improve the health of their citizens and to empower individuals to make better health decisions (U .S . Department of Health and Human Services [U .S . DHHS], 2010) . These measurable out-comes, called health status indicators, are determined by reviewing existing population health outcomes, comparing specific population outcomes with outcomes from other populations, and analyzing evidence from the literature on acceptable outcomes . They are time-specific and stated as a percent . For example, scientific evidence suggests that obe-sity is a risk factor for many diseases, so reduction of obesity in adults within the U .S . population by 2020 would be a pos-itive health outcome . Healthy People 2020 was based in part on the level of achievement of Healthy People 2010 goals (Reinberg, 2010; U .S . Department of Health and Human Services [U .S . DHHS], 2010) . Healthy People 2030 will be based on the population progress toward achievement of Healthy People 2020 goals . Evidence Example 3 .6 illustrates the ongoing monitoring of level of achievement of Healthy People 2020 goals .
TABLE 3.9 Asset-Based Public Health Population Risk Diagnosis
Components Example
Health risk Increased risk of infection (pertussis)
Population at risk Among nonimmunized or partially immunized infants and children in (specify geographic area, community, or county)
Modifiable risk factors
Related to contact with non- immunized children and adults who may have pertussis, health beliefs opposing childhood immunizations, knowledge deficit about benefits of immunization, lack of access to health resources
Modifiable Protective Factors
Related to increased funding for outreach and immunizations to at-risk populations through the public health department, coalition with local religious organizations and safety net organizations to immunize children .
Bio-statistical data (for geographic area, community, city, county, state, national)
As evidenced by lack of herd immu-nity (80–90% immunization) in preschool population (state immuni-zation rate) in (geographic area or city, county, state, country) with (insert number of cases) reported cases of pertussis in the last month in infants and children ages (insert age range) .
EVIDENCE EXAMPLE 3.6HealthyPeople2020Goals
A mid-decade review of progress toward Healthy People2020 goals identified that Healthy People 2020 goalswouldbemoremodestthanthe2010goals.Only19%ofHealthy People 2010 goals were met, and progress wasmadeononly52%ofthem.Some,likeobesity,hadbecomeworsesince2000.U.S.obesityratesincreasedfrom25%to34%between2000and2010(Reinberg,2010),andtheprevalenceofobesityintheU.S.was35.6%between2011and2014(CDC,2015).
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67CHAPTER 3  n  Competency #1
n Systems Level: Consult with schools to increase the physical activities of students within the curriculum .
n Individual/family Level: Provide health education and counseling to children and families to empower them to develop healthier lifestyles .
ThePublicHealthNursingCommunityInterventionPlanPHNs work collaboratively with multiple community part-ners to establish population health goals and to develop intervention plans . These plans need to be consistent with the demography, culture, and health status of the target population and be in language that is clear to interprofes-sional partners and the community . It may be more appro-priate to label the plan a population health plan rather than a nursing care plan . However, the framework of the public health nursing process can be used effectively with interpro-fessional as well as lay groups . Public health interventions for population health:n Modify the health determinant risk factors that are
causing the population health problems or disparities by weakening or eliminating the risk factors
n Modify health determinant protective factors that will improve the ability of at-risk and vulnerable populations to better manage their own healthcare
Online Activity    Go to Healthy People 2020 and study a goal of interest  to you. 
n Identify an objective and then click “National Snapshots”  to see how progress has been made on that goal. 
n Go to the “Interventions & Resources” tab to find evidence  of interventions that have been effective in working to achieve this goal. 
Public health nurses and other public health profession-als use Healthy People goals as well as their community- assessment data to establish organizational and program goals for their communities and the clients they serve . The focus in Public Health is primary prevention; however, PHNs will include secondary and tertiary prevention goals when appropriate to meet unmet community needs . PHNs often work at more than one level of practice simultane-ously . For example, if there is a primary prevention goal to reduce childhood obesity, the PHNs might do the following .n Community Level: Collaborate with local television
stations to have a media campaign to increase commu-nity level of awareness for the need to increase children’s activity levels and to develop more afterschool sports and activity programs for children .
THEORY APPLICATIONPopulation-BasedModelsforPHNInterventionsandOutcomes
Twelveconceptualmodelsofpopulation-basedPHNinterven-tionsandoutcomespublishedbetween1981and2003wereidentified and compared (Bigbee & Issel, 2012). Four of thetwelvemodelsareveryconsistentwith thePHNcommunity
assessmentandinterventionmodelpresentedinthischapter.The following table demonstrates how these models reflectessential components of this book’s population-based PHNinterventionplan.
Model Major Components PHN Concepts
PHN Conceptual Model (White, 1982) Determinants of health impacted by nursing process at individual/family, and population levels
PHN process, levels of practice, deter-minants of health, PHN interventions, outcomes
Community as Partner Model (Anderson & McFarlane, 1988, 2011)
Based on Neuman’s systems model and includes assessment wheel and inter-ventions based on Intervention Wheel
PHN process, levels of prevention, PH interventions from the Intervention Wheel, outcomes
Public Health Intervention Model (Keller-Olson et al ., 1998)
Population-based model including 17 interventions at individual, commu-nity, and systems levels
Population focus, levels of practice, interventions, interprofessional aspects
LA Public Health Nursing Practice Model–LA Model (Smith & Bazini-Barakat, 2003)
Population-based model using nursing process to address health indicators using Intervention Wheel
PHN process, population focus, levels of practice, interventions from Intervention Wheel, outcomes, interprofessional aspects, client participation
Source: Abstracted from Bigbee & Issel, 2012
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68 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
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The Public Health Nursing Community Intervention Plan includes the following components:n Public health asset-based population risk diagnosisn Population health goal and level of prevention focusn Client focus: individual/family, community, systemn SMART behavioral outcomes that are measurable and
attainable and understandable to the family . SMART outcomes are:
l Specific: What needs to be accomplished? l Measurable: How will the nurse, client, and family
know the goal has been met? l Attainable: Can the goal be met with the resources
available? l Realistic: Does the client (and family) have the physi-
cal, emotional, and mental capacity to meet the goal? l Time-Bound: When will the goal be achieved? n Evidence-Based Public Health Interventions: Pub-
lic Health Intervention Wheel (Keller, Strohschein, Lia-Hoagberg, & Schaffer, 2004; refer to Chapter 2) or Omaha System (Omaha System, 2017) interventions may be used . Include the intervention, the strategy or process to be used, and the provider(s) of the intervention
n Evidence-Based Rationale for each intervention: Include the scientific rationale with citations as well as population preferences
n Evaluation of Outcomes: Use quantitative measures to determine the progress made toward achievement of the outcome . These measures to be used should be selected during the planning process .
EVIDENCE EXAMPLE 3.7EvaluationofaHomeVisitingProgramforPregnantandParentingTeens
Afterinterventionsareimplemented,itisnecessarytoassesstheeffectivenessoftheprogramandtheprogressofthetargetpopulationtowardgoalandoutcomeachievement. Four commonly used public health evaluation methodsidentifiedbySpiegelman(2016)are:
n Feasibilityevaluation:Assesswhethersomethingwillworkandbeeffectiveinthe“realworld”
n Impactevaluation:Assesstheefficacyandeffectivenessofaninterventiononhealthoutcomes
n Programevaluation:Assessaprogram’sprocessestoimprovethem(qualityimprovementapproach)
n Comparativeeffectiveness:Assessandcompareinterventionstoseewhichworkbestforwhom,inwhatsituations,andfromacost-effectivenessperspective
The Pregnant and Parenting Teen program, discussed inEvidence Example 3.8, demonstrates the effectiveness ofusingallfouroftheseevaluationmethods.
Implementing population-based interventions in a com-munity often includes collaborative efforts of many provid-ers, organizations, and community members . Usually, a core team develops the implementation plan timeline and selects or designs public health intervention strategies . For exam-ple, if social marketing is selected for a program to encour-age parents to have their children immunized, potential strategies could be billboards, development of online and printed media, and radio and television adds or other forms of media . It would be important to know when the best time (i .e ., window of opportunity) would be to start a social mar-keting campaign and where (before school starts in the fall, during spring preschool enrollment, etc .) .
Kristi and her classmates complete an assessment of the sub-population of pregnant and parenting teens in their community and identify an unmet need for a pregnant and parenting peer support group. They work with a group of local churches and the Salvation Army to plan a community-wide outreach effort with the Salvation Army for the meeting site. The church groups and local high school are ready to start recruiting teen participants. They work with Kristi’s preceptor, Beth, to identify the best time to recruit teens and start the program. They decide to recruit teens at the time the pregnancy is confirmed, and decide that the beginning of the next school year is a good time to launch the program.
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69CHAPTER 3  n  Competency #1
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Kristi asks her neighbor, a county commissioner, if she would help to find funds for the pregnant and parenting teen peer support group that will be held at the Salvation Army. The group needs funding for transportation for the teens and their babies to attend a support group meeting once a week for 6 months. The commissioner asked Kristi if she has data to support the need for transportation ser-vices. Kristi assures her that she does. There are 20 teens interested in joining such a group, and only two of them have transportation. Although the local bus service has a stop only a block away from the Salvation Army, only five of the girls are on a bus line. That leaves 13 teens without transportation. In addition, the PHNs have assessed all the teens and have data that support the need for socialization and peer group support for these pregnant and parenting teens. The commissioner is not sure if these teens can make a commitment to attend the group or if attending the group would really make a difference. Kristi tells the commis-sioner that PHNs from the county are going to be group facilitators and would be using the Problem Rating Scale for Outcomes to determine if the outreach and counseling efforts are effective. Of course, she has to explain to the commissioner what the Problem Rating Scale for Outcomes is! The commissioner asks Kristi and her classmates to come to a council meeting to present their proposal. Kristi says they can do that and she will also ask her PHN precep-tor to come to the meeting.
EVIDENCE EXAMPLE 3.8PHNHomeVisitingProgramforPregnantandParentingTeens
AvisitingnurseassociationcreatedandimplementedaPreg-nantandParentingTeenProgramtopromotefamilyandchildhealth and family self-sufficiency for teen moms 19 yearsof age or younger. The pillars of the program are: a trustingrelationship between the PHN and the teen; outreach andcoordination with schools, clinics, and human service agen-cies; a comprehensive and intensive maternal mental healthcurriculum; and community support and caring by provisionofneededresources.Acomprehensiveevaluationofthepro-gram’seffectivenessandclientoutcomes’ssuccesswascom-pletedaftertwoyears(Schaffer,Goodhue,Stennes,&Lanigan,2012).Keyoutcomespresentedbyfourpublichealthevalua-tionmethodsfollow.
n Feasibilityevaluation:78%oftheteensreferredtotheprogramacceptedtheservices.
n Impactevaluation:76%ofteenswith10ormorevisitscontinuedorgraduatedhighschoolcomparedto56%ofteenswhoreceived9visitsorless;97%wereup-to-dateonwell-childcheck-ups;95%wereup-to-dateonimmuni-zations;and96%hadhealthybirthweightbabies.
n Programevaluation:69%referredtocommunityresources;47%receivedneededresources.
n Comparativeeffectiveness:Teenswith10ormorevisitsweremoresuccessfulinachievingexpectedoutcomesthanteenswhohad9orfewervisits.
Ethical ApplicationCommunity assessment and program evaluation involves collecting data on individuals . These data are then aggre-gated to provide for confidentiality and anonymity . How-ever, when the group size is small or the members of the group are easily identified, ethical issues related to privacy rights can arise .
Kristi is concerned because there are only 20 teens who will be participating in the initial pregnant and parenting teen peer support program. Most of these teens are well known in the community. She is worried that when the program evaluation occurs, the teens will be evaluated as individu-als. Even though their outcome data will be aggregated, it will be difficult to provide for anonymity if there is a need to present program outcomes to the county commissioners.
Use the ethical framework in Table 3 .10 to determine how you would use ethical principles to make decisions about this ethical problem .
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70 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
TABLE 3.10 Ethical Application of the Nursing Process in Public Health Nursing
Ethical Perspective Application
Rule Ethics (principles)
n Respect the rights of individuals related to privacy, autonomy, and self-determination .n Critique selected actions and interventions for possible unintended harmful consequences that might
occur for diverse populations in a community .n Select interventions that promote justice through reducing health disparities .
Virtue Ethics (character)
n Maintain the dignity and confidentiality of individuals, families, populations, and communities when assessing their health needs .
n Be honest in communicating the purpose of selected interventions to individuals, families, populations, and communities .
n Be an advocate for assessing the public health needs of vulnerable populations .
Feminist Ethics (reducing oppression)
n Include voices of vulnerable populations in community assessments and in setting priorities for action .n Emphasize the contribution of the assets that communities and diverse populations bring to resolving
public health concerns .
Table based on work by Volbrecht (2002) and Racher (2007)
n PHNs use public health nursing interventions to provide nursing services to individuals, families, communities, and systems .
n PHNs use EHRs and HIS to assist them in assessing and monitoring their clients’ health status, evaluating their clients’ progress, and determining the effectiveness of interventions and programs . The Omaha System is the only ANA-recognized standardized terminology that has integrated those components .
KEY POINTS
n PHNs are accountable to the individuals and families they serve, and the communities in which they live and work, to take action to maintain or improve their health status .
n PHNs work in partnership with individuals, families, communities, and systems .
n The public health nursing process is used to assess and intervene with individuals, families, communities, and systems .
n PHNs collect demographic and health determinant data when carrying out family and community assessments .
REFLECTIVE PRACTICE
It is difficult for public health nursing students to adapt to providing nursing care in the unstructured environment of the home and community . When students are in family homes, they are visitors in someone else’s personal space . Visits often do not go as planned . It takes time to develop trust with family members who may initially be uncom-fortable with a nurse in their home . Think about Kristi’s co- visits with her PHN preceptor Beth to Sara, the pregnant teen, and her mother and then the individual visit Kristi made to complete the home environmental assessment . If you were making that visit alone as Kristi was, consider how you would carry out the home environmental assessment with Sara and her mother . n How would you prepare for the visit? What would you
wear? Do you think you should phone Patricia or Sara to confirm the visit?
n How would you introduce yourself to Sara and her mother and review the purpose of the visit?
n This is your first visit alone with Sara and her mother . Think about what makes a good first visit . What would you want to do to make your visit a good one?
n When you carry out the home environmental assess-ment, you will probably be going into some private areas of the home . What can you do to make Sara, her mother, and yourself comfortable in these private spaces?
n What will you do if you are told you cannot go into certain rooms?
n Will you share your assessment of the family home environment as you conduct the assessment, or will you wait until the end of the visit?
n How will you end the visit with Sara and her mother?
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71CHAPTER 3  n  Competency #1
Centers for Disease Control and Prevention . (n .d .-a) . MAP-IT: A guide to using Healthy People 2020 in your community. Retrieved from http://www .healthypeople .gov/2020/ implement/MapIt .aspx
Centers for Disease Control and Prevention . (n .d .-b) . Public health 101 series: Introduction to public health informatics. Retrieved from https://www .cdc .gov/publichealth101/documents/ introduction-to-public-health-informatics .pdf
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Clark, M . J . (2008) . Community health nursing. Upper Saddle River, NJ: Pearson/Prentice Hall .
Eriksson, I ., & Nilsson, K . (2008) . Preconditions needed for estab-lishing a trusting relationship during health counseling—An interview study . Journal of Clinical Nursing, 17(17), 2352–2359 .
Friedman, M . M ., Bowden, V . R ., & Jones, E . (2003) . Family nursing: Research, theory, and practice (5th ed .) . Hoboken, NJ: Pearson Education, Inc .
Gardner, A . (2010) . Therapeutic friendliness and the development of therapeutic leverage by mental health nurses in community rehabilitation settings . Contemporary Nurse, 34(2), 140–148 .
Hargate, C . (2013) . Survey. Unpublished manuscript, Bethel University, St . Paul, MN .
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APPLICATION OF EVIDENCE
Think about the community assessment you and your class-mates are going to complete . You are interested in deter-mining the need for and the resources for a teen pregnant and parenting peer support group . Your assessment is going to be assessing a sub-group of the community (i .e ., aggre-gate), so you need to think about whom you will want to work with and what data you need to collect .
Review Figure 3 .4 (Community Planning Process: MAP-IT):
1. How would you use this tool to plan a community assessment?
2. How would you carry out the community assessment?3. When you develop your intervention plan, you need
to consider your “window of opportunity” for imple-mentation . How would you find your “window of opportunity”?
4. The implementation phase requires a detailed work plan . What would you include in your work plan?
5. The tracking phase includes measuring the effective-ness of your intervention plan . How would you mea-sure the effectiveness of your plan?
6. Review Evidence Example 3 .7 . What type of evaluation would you want to include? What measures might you use?
Review the Community-Assessment Guide . This is an aggregate assessment . You do not have to collect all of the community data . Think about what you need:
1. What community demographic data would you want to collect?
2. What biological and genetic health determinant data would you want to collect?
3. What physical environmental health determinant data would you need?
4. What social environmental health determinant data would be most important?
5. How would you collect information about healthcare access?
6. Once you have all of your data collected, how would you analyze it?
7. What would be effective methods to communicate your community-assessment data to others?
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72 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
Minnesota Department of Health . (2001) . Public health interven-tions: Application for public health nursing practice. St . Paul, MN: Author . Retrieved from http://www .health .state .mn .us/divs/opi/cd/phn/docs/0301wheel_manual .pdf
Minnesota Department of Health, Center for Public Health Nursing Practice . (2003) . The nursing process applied to population-based public health nursing practice . Retrieved from http://www .health .state .mn .us/divs/opi/cd/phn/docs/ 0303phn_processapplication .pdf
Minnesota Department of Health . (2015) . Recommendations regarding the use of standard nursing terminologies in Minnesota, 2014 . Retrieved from http://www .health .state .mn .us/e-health/standards/docs/nursingterminology082114 .pdf
Monsen, K . A ., Brandt, J . K ., Brueshoff, B ., Chi, C . L ., Mathiason, M . A ., Swenson, S . M ., & Thorson, D . R . (2017) . Social determi-nants and health disparities associated with outcomes of women of childbearing age receiving public health nurse home visiting services . Journal of Obstetric and Gynecological Neonatal Nurs-ing, 46(2), 292–303 . doi:10 .1016/j .jogn .2016 .11 .014 .
Monsen, K . A ., Swenson, S . M ., & Kerr, M . J . (2016) . The percep-tions of public health nurses on using standardized care plans to translate evidence-based guidelines into family home visiting practice . Kontakt, 18(2), e75–e83 . doi:10 .1016/ j .kontakt .2016 .04 .001
Monsen, K . A ., Swenson, S . M ., Klotzbach, L ., Mathiason, M . A ., & Johnson, K . E . (2017) . Empirical evaluation of change in public health nursing practice after implementation of an evidence-based family home visiting guideline . Kontakt, 19(2), e75–e85 .
Monsen, K . A ., Vanderboom, C . E ., Olson, K . S ., Larson, M . E ., & Holland, D . E . (2017) . Care coordination from a strengths perspective: A practice-based evidence evaluation of evidence- based practice . Research and Theory for Nursing Practice, 31(1), 39–55 . doi:10 .1891/1541-6577 .31 .1 .39 .
Nelson, R ., & Staggers, N . (2018) . Health informatics: An interpro-fessional approach (2nd ed .) . St . Louis, MO: Elsevier .
Office of the National Coordinator for Health Information Technology . (2017) . Standard nursing terminologies: A landscape analysis . Washington, DC: Author . Retrieved from https:// www .healthit .gov/sites/default/files/snt_final_05302017 .pdf
Omaha System . (2017) . Omaha System website . Retrieved from http://www .omahasystem .org
Racher, F . (2007) . The evolution of ethics for community practice . Journal of Community Health Nursing, 24(1), 65–76 .
Reinberg, S . (2010) . U .S . government sets new health goals for 2020 . Retrieved from http://consumer .healthday .com/ Article .asp?AID=646932
Rossiter, C ., Fowler, C ., Hopwood, N ., Lee, A ., & Dunston, R . (2011) . Working in partnership with vulnerable families: The experience of child and family health practitioners . Australian Journal of Primary Health, 17(4), 378–383 . doi:10 .1071/PY11056
Schaffer, M . A ., Goodhue, A ., Stennes, K ., & Lanigan, C . (2012) . Evaluation of a public health nurse visiting program for preg-nant and parenting teens . Public Health Nursing, 29(4), 218–231 . doi:10 .1111/j .1525-1446 .2011 .01005 .x
Skemp, L . E ., Dreher, M . C ., & Asselin, M . (2006) . Healthy places, healthy people. Indianapolis, IN: Sigma Theta Tau International .
Henry Street Consortium . (2017) . Entry-level population-based public health nursing competencies . St . Paul, MN: Author . Retrieved from www .henrystreetconsortium .org
Hunt, R . (2013) . Introduction to community-based nursing. Phila-delphia, PA: Wolters Kluwer Health/Lippincott Williams and Williams .
Jansson, A ., Petersson, K ., & Uden, G . (2001) . Nurses’ first encoun-ters with parents of new-born children—Public health nurses’ views of a good meeting . Journal of Clinical Nursing, 10, 140–151 .
Kaakinen, J . R ., Coehlo, D . P ., Steele, R ., & Robinson, M . (2018) . Family health care nursing: Theory, practice, and research (6th ed .) . Philadelphia, PA: F . A . Davis .
Keller, L . O ., Strohschein, S ., Lia-Hoagberg, B ., & Schaffer, M . A . (2004) . Population-based public health interventions: Practice-based and evidence-supported . Part I . Public Health Nursing, 21(5), 453–468 .
Kerr, M . J ., Flaten, C ., Honey, M . L ., Gargantua‐Aguila, S . D . R ., Nahcivan, N . O ., Martin, K . S ., & Monsen, K . A . (2016) . Feasibility of using the Omaha System for community‐level observations . Public Health Nursing, 33(3), 256–263 . doi:10 .1111/phn .12231
Kleinfehn-Wald, N . (2010) . Determining population needs in a rural/suburban county. Unpublished manuscript, Scott County Public Health, Shakopee, MN .
LaVenture, M . (2008) . Building public health/clinical health infor-mation exchanges: The Minnesota experience. PHDHC, HRSA Panel [PowerPoint] . Minnesota Department of Health, St . Paul, MN . Retrieved from http://www .google .com/url?sa=t&rct= j&q=&esrc=s&source=web&cd=8&ved=0ahUKEwiPq_ TSwvvXAhXszIMKHRv_CVwQFghWMAc&url= http%3A%2F%2Fwww .phdsc .org%2Fabout%2Fcommittees %2Fpresentations%2FPHDSC_HRSA_Panel_%2520Marty_LaVenture .ppt&usg=AOvVaw23pM-1bJ1ZQ96G_krsLMNx
Marshall, A ., Bell, J ., & Moules, N . (2010) . Beliefs, suffering, and healing: A clinical practice model for families experiencing mental illness . Perspectives in Psychiatric Care, 46(3), 197–208 . doi:10 .1111/j .1744-6163 .2010 .00259x
Martin, K . S . (2005) . The Omaha System: A key to practice, docu-mentation, and information management (2nd ed .) . Omaha, NE: Health Connections Press .
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McCann, T . V ., & Baker, H . (2001) . Mutual relating: Develop-ing interpersonal relationships in the community . Journal of Advanced Nursing, 34(4), 530–537 .
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73CHAPTER 3  n  Competency #1
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75
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CHAPTER
4COMPETENCY #2Utilizes Basic Epidemiological (The Incidence, Distribution, and Control of Disease in a Population) Principles in Public Health Nursing Practice
n   Carolyn M. Porta with Noreen Kleinfehn-Wald, Linda J. W. Anderson, and Madeleine Kerr
Elizabeth has worked as a public health nurse (PHN) doing home visits on the maternal child health team for approximately a year. One day as she is having lunch with her co-workers, someone mentions that an outbreak of pertussis had occurred in an adjacent county. In fact, there are 42 cases! Two days later, Elizabeth’s supervisor asks whether she can help the Disease Prevention & Control (DP & C) team investigate 10 probable cases of pertussis.
DP & C nurses operate the immunization clinic and work with infectious disease issues, such as tuber-culosis. Other than these activities, Elizabeth knows very little of what their day-to-day work is like. Her supervisor explains that disease investigation is case management work. She will most likely not be required to do any additional home visits. (Sometimes follow-up visits are necessary when it is difficult to locate people.) She will need to plan on a limited amount of time to place phone calls, review records, and work with community partners, such as school nurses. Elizabeth agrees to take the additional assignment and arranges to receive orientation from the lead nurse. During this briefing, the lead nurse explains the state’s data-privacy laws, the state health department’s infectious disease reporting requirements for pertussis, and the report form that needs to be completed by the healthcare provider or the lab associated with the clinic for each suspect or confirmed case. This is a lot of new information!
ELIZABETH’S NOTEBOOKCOMPETENCY #2 Utilizes Basic Epidemiological (The Incidence, Distribution,  and Control of Disease in a Population) Principles in Public Health Nursing Practice
A. Understandstherelationshipbetweencommunityassessmentandhealthpromotion/diseasepreventionprograms,especiallythepopulationsandprogramswithwhichthePHNworks
B. Understandstherelationshipsbetweenrisk/protectivefactorsandhealthissues
C. Obtainsandinterpretsinformationregardingrisksandbenefitstothecommunity
D. Appliesanepidemiologicalframeworkwhenassessingandinterveningwithcommunities,systems,individuals,andfamilies
Source: Henry Street Consortium, 2017(continues)
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76 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
USEFUL DEFINITIONS
Agent:Theprimarycauseofthehealth-relatedcondition.Agentsaremostoftenclassifiedintosixmaintypes:physicalagents,chemicalagents,nutritiveagents,infectiousagents,geneticagents,andpsychologicalagents(Valanis,1999).[Notethattheterminfectious agenthasbeenreplacedwithcausative factors(Merrill,2017,p.11).]
Communicability:Theabilityofadiseasetobetransmittedfromonepersontothenext;communicabilityisdeterminedbyhowlikelyapathogenoragentistobetransmittedfromadiseasedorinfectedpersonwhoisnotimmuneandissusceptible(Merrill,2017,p.43).
Environment:Reflectstheaggregateofthoseexternalconditionsandinfluencesaffectingthelifeanddevelop-mentofanorganism…physical,chemical,biological,andsocialfactorsthataffectthehealthstatusofpeople(Merrill,2017,p.214);factorsexternaltothehumanoranimalthatcauseorallowtransmission(p.8).
Epidemic:Occurrenceofcasesofanillness,specifichealth-relatedbehavior,orotherhealth-relatedeventsclearlyinexcessofnormalexpectancyinacommunityorregion(Merrill,2017,p.5).
Epidemiological Triangle:Showstheinteractionandinterdependenceoftheagent,host,environment,andtime(Merrill,2017,p.8).
Epidemiology:Thestudyofthedistributionanddeterminantsofhealth-relatedstatesoreventsinhumanpopulationsandtheapplicationofthisstudytothepreventionandcontrolofhealthproblems(Stedman’s Medical Dictionary for the Health Professions and Nursing(5thed.)inMerrill,2017,p.2).
Herd Immunity:Resistanceapopulationhastotheinvasionandspreadofaninfectiousdisease.Herdimmunityisaccomplishedwhenthenumberofsusceptiblepeopleisreducedandthenumberofprotectedornon-susceptiblepeopledominatestheherd(population);providesbarrierstodirecttransmissionofthedisease;occurswhen85%levelofimmunityexists(Merrill,2017,p.53).
Host:Thehumanbeingaffectedbytheparticularconditionunderinvestigation.Factorsthatthehostbringstothetriangleincludeintrinsicfactors(age,gender,race,etc.),physicalandpsychologicalfactors,andthepresenceorabsenceofimmunity(Clark,2008).Hostcanbeahumanoranimalthatissusceptibletodisease(Merrill,2017,p.8).
Immunity:Thestateofnonsusceptibilitytoadiseaseorcondition.Typesinclude(a)active immunity,wherethehostisexposedtotheantigenthroughhavingthediseaseorviaimmunization;and(b)passive immunity,whereantibodiesareprovidedtothehostviaimmuneglobulinormother-to-fetustransferacrosstheplacenta—passiveimmunityisshort-lived(Merrill,2017,p.52).
Incidence:Thenumberofindividualswhodevelopthediseaseoveradefinedperiodoftime(Le,2001)orthenumberofnewcasesofaparticularhealth-relatedstateoreventreportedoveraspecificperiodoftime(Merrill,2017,p.74).
Life Course Epidemiology:Thestudyoflong-termeffectsonlaterhealthortheriskofdiseaseduetophysi-calorsocialexposuresduringgestation,childhood,adolescence,youngadulthood,andlateradultlife(Kuh,Ben-Shlomo,Lynch,Hallqvist,&Power,2003,p.778).
Prevalence:Thepresenceofadiseaseorhealthconditioninagivenpopulationatagivenpointintimedividedbythenumberofpersonsinthatpopulation(Friis,2018,p.64).
Protective Factor:Healthdeterminantsthatprotectonefromillnessorassistinimprovinghealth(seeChapter1).
Risk Factor:Aconditionthatisassociatedwiththeincreasedprobabilityofahealth-relatedstateorevent(Merrill,2017,p.3).Riskfactorsarealsohealthdeterminants(seeChapter1).
Surveillance:Theongoingsystematiccollection,analysis,interpretation,anddisseminationofhealth-relateddatatoimprovethehealthofpopulations(CentersforDiseaseControlandPrevention[CDC],2001).Publichealthsurveillanceisthesystematicongoingcollection,analysis,interpretation,anddisseminationofhealthdata(Merrill,2017,p.112).
ELIZABETH’S NOTEBOOK  (continued)
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77CHAPTER 4  n  Competency #2
n Which interventions can reduce the spread of this occurrence/disease?
n Will I be working at the individual/family, community, or systems level?
n Do I need to consider any ethical issues? n How will I know whether the interventions are effective?n What could have prevented this outcome?
At its core, epidemiology is the study of solving mysteries—of understanding where and to what extent diseases, events, and behaviors are influencing the health of populations. Epidemiology is more than simply under-standing what is going on. It also involves acting on what you learn to prevent or control problems. Similarly, a PHN should be committed not only to understanding what is con-tributing to a problem and the extent of the problem but also to identifying and implementing disease prevention and health promotion strategies. In fact, this use of core epide-miological tools—namely, mathematics and data analysis—contributed to advancing the role and view of nursing in the 19th century (Earl, 2009). See Evidence Example 4.1 to examine how Lillian Wald and Florence Nightingale used data gathering and analysis to understand and address key health problems. By doing so, they advanced the profession of nursing beyond what had, up until that time, been a fairly ill-considered occupation.
Using Data to Solve Health and Disease MysteriesNurses often want to know why something happens or does not happen. This inquisitive nature is useful when nurses are working to prevent something from happening or to intervene before something gets worse. In some situations, if questions are not asked, credible solutions might be over-looked, and health outcomes might not be optimal. In a worst-case scenario, lives might be lost or seriously harmed if the status quo is maintained and curious questions are not asked and acted upon. At the foundation of effective population-based public health nursing is the science of epi-demiology. Epidemiology guides the questions that PHNs ask and the steps that they take to find answers and solu-tions. Following is a list of questions nurses ask or should ask regularly:n When did the problem start (end, worsen, improve)?n What has contributed to the change? Triggered a
response?n Why have x, y, z not improved?n How did this occur?n Who should be involved to contribute to the solution?n Where are available resources to aid in addressing this
situation?
EVIDENCE EXAMPLE 4.1Origins of Epidemiology and Nursing
CatherineEarl(2009)haswrittenafascinatingandthoroughhistorical article that describes the influence of epidemiol-ogyinthedevelopingroleofpublichealthnursing.Beginningintheearly19thcentury,Earlpresentsasummaryofhistorythatremindsthereaderofhowfarnursingandsciencehavecomeinthepast200years.Notthatlongago,diseaseswereaddressedsolelywithintheindividual,withlittleappreciationgiven for trends among the group or population. Advancesinmathematicaltheoriescausedashift,notablywhenPierreCharles Alexandre Louis, a leading 19th-century physician,declaredthatthepracticeofbloodletting(oftenwiththehelpof leeches)wasineffectiveandusedstatisticstosupporthisclaims.Itisintriguingthat,accordingtoEarl,theuseofquan-titativemethodswasnotwellsupportedatthattimeandwaspoorlyunderstood. In the21stcentury,quantitativeanalysesarecoretorandomizedcontrolledtrials(RCTs),whicharecon-sideredthegoldstandardforestablishingevidence. LillianWaldusedthisadvanceinhealthandsciencetosup-port her work with families in New York. She advocated fornursestoliveandworknearandamongthosetheywerealsoserving.Sheusednumberstosupportherneedforresources,includingthenumberofnurses.Hersuccessesaremany,andthey are in part based on her foresight and wisdom in rec-ognizingtheneedfordatatoaccomplishgoalsandmeetthe
health and social needs of society. Earl summarizes well thecontributionPHNs—ledbyLillianWald—madeinaddressingtuberculosis,becausetheycollectedandreportedcriticaldata:“Nurses’involvementinthecareofTB[tuberculosis]patientsin1914wasconsideredamajoradvancementintheuseofsta-tisticalmethods,becausenursesbecameinvolvedinimprov-inghealththroughtheirroleasdatacollectors”(p.262). Florence Nightingale, considered by many to be the firstbiostatisticianandthe firstepidemiologist,alsouseddata tosupporthereffortstoaddresshealthandsanitation.Inherera,itwasnotcommonforwomentobeeducated,yetherfatherencouraged her to learn varied subjects, including mathe-matics.Asaresult,Nightingalehadskillsthatenabledhertoidentifycausesofproblemsandtointervenenotonlytohealorcurebutalsotoprevent.AsEarlstates,“Withanepidemi-ologicalperspectiveandfurtherdiscussionsofmortalityandmorbidityratesandtheimportanceofsanitaryconditionsasdescribed by Florence Nightingale, the first preventorium, aprogram established to save children, was designed for theprevention, not the treatment, of TB” (p. 263). Both LillianWald and Florence Nightingale contributed to a significantshift fromsolelyfocusingontreatmenttoalsoconcentratingonprevention,whichtodayisalsoaprimaryfocusofPHNsallovertheworld.
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78 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
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Although most PHNs are not epidemiologists, many activities that PHNs engage in parallel the work of epide-miologists. Often, epidemiologists work at the systems level of a healthcare facility or state health department and are responsible for the data collection, analysis, and program development related to a particular health/medical issue. Conversely, PHNs are frequently found in the grassroots level of healthcare, working with local vulnerable popula-tions and community partners, interpreting and promot-ing the recommendations, protocols, and policies that have been developed by an authoritative body. See Table 4.1 for a sample list of activities that an epidemiologist often engages in, and note the similarities to many public health nursing activities and interventions.
Elizabeth realizes she needs to have a better understand-ing of terms that she is reading as she investigates state and county reports about infectious disease threats in her community. She is getting confused by the different labels for cases and isn’t exactly clear on the difference between quarantine and isolation. She finds the following defini-tions that provide clarity and adds them to her notebook:
✔ Case:Personorpopulationidentifiedashavingaparticulardisease,disorder,injury,orcondition(Merrill,2017,p.7)
l Primary case:Thefirstdiseasecaseinthepopulation(p.7)
l Index case:Thefirstdiseasecasebroughttotheattentionoftheepidemiologist(p.7)
l Secondary case: Personswhohavebecomeinfectedandillaftercontactwithaprimarycase(p.7)
✔ Incubation period:Timeintervalbetweentheinvasionbyaninfectiousagentandtheappearanceofthefirstsignsorsymptoms(Friis,2018,p.284)
✔ Isolation:Personswhohaveacommunicablediseasearekeptawayfromotherpersonsforaperiodoftimethatcorre-spondsgenerallytotheintervalwhenthediseaseiscommu-nicable(Friis,2018,p.284)
✔ Quarantine: Persons,animals,orobjectsthathavebeenexposedtoacontagiousdiseasearekeptawayfromotherpersonsforaspecifiedperiodoftime(adaptedfromMerrill,2017,p.57)
Historically, nurses participated in epidemiological inves-tigations to determine the cause of a recurring problem, such as cholera outbreaks. As part of that process, nurses realized very early on that numerous risk factors often contributed to the spread of disease. This realization led to creative inter-ventions that had multiple components to aid those already sick or affected and to prevent others from becoming sick. Quarantine (i.e., separation of an exposed individual from the rest of the community) laws are a good example of a spe-cific effort to contain the spread of disease in the absence of other strategies. Interestingly, quarantine strategies are still used today, because some infectious viruses can spread
TABLE 4.1 Alignment of Epidemiologist Activities With PHN Intervention Wheel
Epidemiologist Activities
Public Health Nursing Activities and Interventions
Identifying risk factors for disease, injury, and death
Disease and Health Event Investigation
Describing the natural history of disease
Health Teaching
Identifying individuals and populations at greatest risk for disease
Outreach
Screening
Referral and Follow-Up
Advocacy
Case Management
Identifying where the public health problem is greatest
Surveillance
Disease and Health Event Investigation
Monitoring diseases and other health-related events over time
Surveillance
Evaluating the efficacy and effectiveness of prevention and treatment programs
A key part of the nursing process, but not a specific component of the interven-tion wheel
Providing information useful in health planning and decision-making for estab-lishing health programs with appropriate boundaries
Consultation
Collaboration
Community Organizing
Policy Development and Enforcement
Assisting in carrying out public health programs
Most interventions on the Public Health Intervention Wheel
Serving as a resource Consultation
Communicating health information
Outreach
Health Teaching
Social Marketing
Consultation
Source: Adapted from Merrill, 2017
during an incubation period before symptoms are present. Examples of such illnesses in the 21st century include per-tussis, chicken pox, measles, Ebola, avian influenza, and seasonal flu. When an individual is diagnosed with pertus-sis and other family members have been exposed, the per-tussis case is strongly encouraged to stay isolated from the
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79CHAPTER 4  n  Competency #2
home environment remains unchanged, the child’s recov-ery might not be maintained. In this case, the nurse might link the family to resources such as financial heat assistance, food banks, food stamps, etc. The nurse might begin to cre-ate long-term solutions by helping adult family members to explore financial management strategies as well as possi-bilities for higher-paying employment or more affordable, reliable housing. Finally, the nurse might advocate for leg-islation that prohibits companies or landlords from turning off heat sources during cold winter months. Nurses encoun-ter numerous possible mechanisms for influence when they face a problem that might appear to have a simple solution but often requires complex intervention approaches to keep that problem from recurring.
Understands the Relationship Between Community Assessment and Health Promotion and Disease Prevention Programs, Especially the Populations and Programs With Which the PHN WorksMany public health agencies and community organizations use community assessments to prioritize their resources and subsequent programs and services. Fundamental to the community assessment is the understanding of the inci-dence and distribution of disease in the community. The PHN might begin by reviewing the birth and death (mor-tality) data available through the state department of health. Morbidity (illness/disease/injury not resulting in death) data can also be reviewed to determine trends in reportable diseases (such as tuberculosis or sexually transmitted infec-tions) or conditions such as cancers or motor vehicle fatali-ties. A comprehensive review of data sources generally leads and directs the community assessment process.
A variety of other strategies (e.g., needs assessment via focus groups or key-informant interviews, windshield survey) can be used to expand the community assess-ment. (See Chapter 3 for more information on community assessment.) PHNs work collaboratively in conducting assessments and using the resulting data for informing pri-orities and actions. Although it might be natural to focus on needs because the nurse is trying to address a problem, it is extremely valuable to take an asset-based approach toward the issue (Lind & Smith, 2008). An asset-based approach ensures that the assessment includes documentation of existing or potential strengths. In this way, the possible problem-solving strategies will ideally build on identified strengths and assets. If nurses focus only on problems, they might reach a solution that consists of outside resources rather than builds on what is available. Asset-based per-spectives inherently encourage capacity building as well as self-care among individuals and families, communities, and populations. (See Chapter 8 for discussion of incorporating community assets.)
broader community until five days of antibiotic treatment have been completed. During the Sudden Acute Respira-tory Syndrome (SARS) event in 2002 and 2003, quarantine of exposed individuals was key to containing the epidemic. Individuals placed under quarantine were monitored twice daily by public health workers until the SARS incubation period was completed. Although quarantines are not always enforced as they were years ago and in the SARS event, they can be effective when they are followed and when individu-als and families adhere to the restrictions.
More broadly, Lillian Wald offers a great example of a PHN using a variety of intervention tools to address uncon-trolled disease and unnecessary deaths in New York City tenements, as shown in Figure 4.1. At the individual level, she provided direct care for sick individuals in crowded apartments. At the community level, she organized com-munity care for neighborhood children in need of a place to engage in physical activity. At the systems level, she advo-cated for programs that would meet the needs of many (e.g., welfare, food accessibility, child labor laws).
Today’s PHN needs a repertoire of intervention strat-egies so that when health improves, it can be maintained over time—which is sometimes hard to do, especially in the presence of poor health determinants. For example, if a child recovers from an illness that worsened as a result of malnourishment and lack of warmth, but the family
FIGURE 4.1 How Lillian Wald Practiced the  Individual/Community/System Approach to Healthcare
Individual/FamilyProvided direct carefor sick individuals
CommunityOrganized communitycare for neighborhoodchildren
SystemAdvocated for programs tomeet the needs of many(welfare, food accessibility,child labor laws)
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80 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
’’
‘‘ because of fear, and without a known cause, they had little confidence that the disease could be stopped or prevented. John Snow created a map that began to identify where the deaths from cholera were occurring across London. This now-famous map (see Figure 4.2) yielded some clues for Snow, because he managed to visualize the areas where the deaths were most heavily concentrated. He suspected a water source, so to prohibit people from accessing this source of “risk,” he removed the water pump handle:
1854: Physician John Snow convinces a London local council to remove the handle from a pump in Soho. A deadly cholera epidemic in the neighborhood comes to an end immediately, though perhaps serendipitously. Snow maps the outbreak to prove his point… and launches modern epidemiology (Alfred, 2009, p. 1).
In the 21st century, PHNs continue to solve mysteries in identifying and eliminating health risks, and although con-ditions have improved in many parts of the world, reducing the risks from unsanitary conditions, these improvements are not universal. Consider the following observation:
The 2010 cholera epidemic in Haiti (and the 2017 chol-era outbreak that persists in Yemen) reminds us that cholera remains a deadly disease, not all that differ-ent from the time of John Snow. While Snow debated the appropriateness of the germ theory versus the miasmatic theory for the cause of the disease, cur-rent scientists are focusing on different, but related, hypotheses (University of California, Los Angeles [UCLA], 2010, p. 1).
Elizabeth looks at the faxed pertussis report she has been given on 11-year-old Billy Johnson. Information includes Billy’s birth date, address, phone number, and laboratory results, which are positive for pertussis. Next, Elizabeth looks up Billy in the computerized state immunization registry. She sees that he was vaccinated with five doses of DTaP vaccine, the last of which was administered at 5 years of age. Elizabeth recognizes that the immunity provided by the vaccine has possibly waned.
ActivityReflect on the following questions:
n What has Elizabeth discovered so far? 
n What are her next steps? 
Understands the Relationships Between Risk and Protective Factors, and Health IssuesNo better classic example of understanding the relation-ship between a risk factor and a health issue exists than that of John Snow in mid-1800s London (Alfred, 2009). For unknown reasons, many people in London began to suffer and die as a result of cholera. People were fleeing the city
FIGURE 4.2 A Map Detailing Cholera Deaths in 1800s London; the Beginning of EpidemiologySource: Alfred,2009
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81CHAPTER 4  n  Competency #2
‘‘
Indeed, it is true that more than a century since Snow’s solved mystery, PHNs continue to seek clear answers and solutions regarding the risks and diseases that are present in public health settings across the globe. In the United States, PHNs face complex challenges in meeting the needs of indi-viduals, families, communities, and populations. Nurses need to identify risk and protective factors at multiple influ-encing levels. For example, a nurse might be working with a child recently diagnosed with asthma. The nurse needs to identify risk factors in the family environment that might be triggers for asthma episodes. Similarly, the nurse needs to assess for protective factors in the family, such as parental commitment to preventing episodes, which is an import-ant asset the nurse can support with education and related tools. The nurse might want to go further and explore the neighborhood environment, including collaborating with school personnel, for possible risks or protections influenc-ing the child.
It can take time to carefully and thoroughly assess risk and protective factors using a strengths-based approach. Usually, the time is well spent because the PHN will have a very clear picture of available assets as well as deficits to address when intervening on a particular health issue. Doing this proactively is a critical part of health promotion. Conducting assessments of risk and protective factors after a health issue has become apparent is important to mini-mize the effect of the health problem and to encourage pos-itive intervention results. PHNs continually reassess for risk and protective factors, because these factors can be tempo-ral; one day a risk might exist (e.g., lack of health insurance coverage), but the following week the family might have new health insurance coverage. PHNs commit to efforts that routinely assess, intervene, evaluate, and reassess.
A PHN also stays informed about emerging diseases and pandemic threats. For example, during 2015 pertussis cases decreased by 37% compared with 2014. See Table 4.2 for states that had the highest reported rates of pertussis in 2015. The majority of deaths continue to occur among infants younger than 3 months of age, and the incidence rate of per-tussis among infants exceeds that of all other age groups. The Centers for Disease Control again observed increased
TABLE 4.2 States With Incidence of Pertussis the Same or Higher Than the National Incidence During 2015, Which Is 6.5/100,000 Persons
Nebraska 27.2 Oregon 14.6 Minnesota 10.9
Montana 22.3 Kansas 14.5 California 9.2
Maine 21.1 Alaska 14.2 Arizona 8.5
Washington 19.3 Wisconsin 13.1 Vermont 7.8
Colorado 16.7 Idaho 11.7 Pennsylvania 6.9
Utah 16.6 New Mexico 11.6
Source: 2015 Final Pertussis Surveillance Report, Centers for Disease Control and Prevention [CDC], 2015
rates in adolescents ages 13–15 as well as in 16-year-olds. In the case of pertussis, the PHN would recognize pertus-sis vaccination as a protective factor. Lack of vaccination, waning immunity from vaccination, and posing immune- compromising conditions would be risk factors.
Elizabeth prepares to call Billy’s parents. She places the pro-tocol nearby and has her report form ready. Billy’s mother answers the phone, and Elizabeth introduces herself as a PHN who works with infectious diseases. She explains how she has obtained a pertussis report on Billy and inquires whether his mother has about 15 minutes to speak with her. Billy’s mother states that she operates an in-home daycare, but most of the children have not yet arrived.
Elizabeth mentally notes this information about the daycare and then explains that the purpose of the call is to identify what can be done to prevent the spread of the disease. Elizabeth starts with what she thinks is the most logical question—when did this cough start? Billy’s mother recalls that he started coughing on September 17 and had a paroxysmal cough without a whooping sound. He occa-sionally coughed so hard that he vomited. About 1 week before his cough started, he had a low-grade fever and a runny nose.
Because his cough was not getting any better, his mother brought Billy to the clinic on September 26. Billy did not have pneumonia or any other complications of pertussis. He was given azithromycin antibiotic and is now on his third day of a 5-day course of treatment. Elizabeth jots down a note that states the period of infectivity started about Sep-tember 10, or about a week before the cough started.
Next Elizabeth asks how many other family members are in the home. Billy lives with his parents and has no siblings. Neither parent has been coughing. Elizabeth dis-cusses with his mother the public health recommendation that other household members take a preventive course of antibiotics. She agrees to call the clinic for prescriptions.
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82 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
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a PHN might be interested in exploring trends related to tuberculosis cases in the community over the past 5 years—that is, the nurse is doing surveillance of TB in the juris-diction (see Figure 4.3). The data in a graph form provide a snapshot of how the number of cases is increasing, main-taining, or decreasing. In the tuberculosis example, it is apparent that active TB cases are progressively increasing, whereas latent TB cases can dramatically decrease, increase, and then stabilize. This information might lead the PHN to ask questions about pulmonary versus nonpulmonary TB or population changes in the community and explore spe-cific intervention strategies to reduce the number of active TB cases over the next few years.
healthypeople.gov
Healthy People
  The Healthy People 2020 website offers    opportunities to explore the uses of data in    public health. On the website, click “Data Search.” From here, you can do a data search on a public health topic of interest to you. Select the health topic and then limit your search by a variety of factors, such as sex, age, race/ ethnicity, and geographic location. The results are presented using the Healthy People 2020 indicators (goals/markers) and show trends over the past few years. What do you observe in the data you explore? How might these data be useful to a PHN engaged in health promotion?
Data Trend per 100,000 in a GraphSimilarly, a PHN might examine the trend of chlamydia cases over a period of five years. Rather than looking at the raw number of cases (as in the tuberculosis example), the PHN might prefer to examine the rate of cases, which is always based on a ratio or number of cases per 100,000 persons. The raw case number in the tuberculosis exam-ple does not give a picture of how serious the problem is,
To further assess for close contacts, Elizabeth asks questions about Billy’s school. Billy told his mother “a lot of kids” were coughing in his classroom. Elizabeth states that she will talk to the school nurse about sending a noti-fication letter to the parents of the students in Billy’s class-room; Elizabeth is careful to inform the mother that Billy will not be identified in the letter. Elizabeth explains that she will also be working with the school to identify children who sit adjacent to Billy, as they might also need preventive antibiotics.
Obtains and Interprets Information Regarding Risks and Benefits to the CommunityPHNs need to know how to find and use data. Data drive so much of what PHNs do. In fact, PHNs determine health priorities by using data to identify key problem areas or con-cerns. PHNs also use data to evaluate whether interventions or programs are successful in reducing the risks or health problems in a local community. Unfortunately, data are not always easy to interpret or understand; data are often pre-sented in such formats as tables, figures or graphs, or raw numbers. They might be posed as percentages or risk ratios. Although in-depth knowledge of data, formulas, and calcu-lations is not necessary for entry-level PHNs, some aware-ness of how to read data and data types is useful.
Data Trend in a GraphOften, data are presented over time by using graphs to show what is happening in a community with respect to a par-ticular health problem or population trend. For example,
FIGURE 4.3 Sample Trend of Active and Latent Tuberculosis Cases in a Community
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83CHAPTER 4  n  Competency #2
because the graph does not indicate how many people are in the community. For example, if the community popu-lation count were 100 and there were 50 cases of latent TB, the PHN would be much more concerned than if there were 50 cases in a community population of 100,000. In the chla-mydia example, the rate of cases appears to be increasing, from around 340 per 100,000 in year 1 to nearly 428 per 100,000 in year 5 (see Figure 4.4). This increase is concerning by itself, but the PHN might want to compare the rate in one community with the rate in another community. Compar-ing rates in different communities or populations provides the PHN with perspective about the relative severity of the disease incidence or prevalence and helps determine how to prioritize efforts to prevent the spread of chlamydia.
Evidence Example 4.2 discusses using data regard-ing incidence rates to identify a problem and evaluate the impact of a system-wide intervention—in this case the rate of tuberculosis among correctional system inmates.
Data Comparison Between State  and National SourcesComparing health and disease trends across communities can be challenging and create turmoil if it is not done care-fully. No community wants to appear worse than another when it comes to a health problem or condition. On the other hand, if resources are scarce, a community might want to justify acquiring greater access to available resources. Care-ful comparison of data within and across communities is vital to ensure that public health priorities are appropriate and that the chosen resource allocation is warranted. Com-parison is useful because it can bring understanding of the severity or scope of a problem, especially if policymakers are unaware of the problem or not convinced that it requires attention.
EVIDENCE EXAMPLE 4.2Use of Epidemiological Tuberculosis Data to Inform a New York State Corrections Intervention
Inastudyaddressingtuberculosis,datawereusedtoinformstrategies to prevent increases of tuberculosis amonginmatesintheNewYorkStateCorrectionssystem(Klopf,1998). Data indicated that the incidence of tuberculosishad increasedovera6-yearperiod from43per 100,000to 225 per 100,000, a serious problem that warrantedintervention.Collaboratively,people fromcorrections, thelocaldepartmentofhealth,andtheparoledivisiondevel-opedacomprehensiveTBcontrolprogramthatfocusedonthe prevention and containment of disease. Importantly,theyimplementedanurse-ledcasemanagementprogram,using infection control nurses to carefully monitor andinterveneonactiveandsuspectedTBcases.Theprogramwastrulycomprehensive, includingpolicies,developmentof a TB registry, surveillance, detection, and case man-agement involving preventive and directly observed ther-apy among the inmates. The staff and inmates receivededucation regarding testing, diagnoses, disease process,andtreatment.It isbelievedthatthiscomprehensivepro-gramcontributedtothereducedincidenceofTB.Sixyearslater, the ratedecreased from225per 100,000to61per100,000—a 73% reduction! The data informed the needforaninterventionthatreliedheavilyonnurses.Thedataalsodemonstrated, inpart,the impactofthe interventionprogram,showingasignificantreductioninthenewcasesofTBamongNewYork’sinmates.
FIGURE 4.4 Chlamydia Example of Case Rate per 100,000 Over 5 Years
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84 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
different timeframes, and it’s good to note when discrepan-cies exist. In Figures 4.5 and 4.6, both MDH and CDC data are reported for 2015, which offers a useful comparison. An effective PHN tries to find the most comparable data possi-ble but does point out discrepancies when comparisons are made between incomparable data. Using data that are not a perfect match is not wrong, but these differences must be identified so that people can make informed decisions based on the existing data. It might not be true that people can make data say exactly what they want them to say, but it certainly is possible to inadvertently or purposefully present data in ways that might not be entirely accurate. Therefore, PHNs need to spend time practicing how to present data in meaningful, representative ways, and, equally vital, they need to have the ability to interpret and critique any data that are presented to them.
Data Comparison Between National  and Global SourcesTo understand the context from which a client originates, a PHN may be interested in disease incidence in other parts of the world. The earlier PHN who graphed active TB cases against latent TB cases may have found increasing numbers of families from several parts of the world now living in her community. Reviewing information from the World Health Organization (WHO) will inform her of the distribution of TB elsewhere. This information can then be applied to determine communicable disease risk related to immigra-tion patterns in her community.
Data as Population TrendsEqually valuable are data that demonstrate population trends. These are most commonly presented in the form of a population pyramid, which at a glance provides a picture of population growth (see Figure 4.7). In this figure, the age distribution of people in the U.S. is portrayed. Compared with other years, one can visually see changing trends in population age distribution. This could be valuable to determining priorities for PHN interventions, particularly
A good example of this scenario is Lyme disease, which is contracted through exposure to ticks. Lyme disease cases between 1996 and 2016 have varied from 252 to 1,431 cases in Minnesota and have steadily increased since 2002 (see Figure 4.5). However, without being able to compare these numbers to those of another state, it is difficult to determine whether the problem is serious or relatively consistent with national trends. The PHN investigating this issue might look beyond state-level data to what is occurring nationally. Review of national data provided by the CDC demonstrates that Minnesota has one of the highest density areas of Lyme disease, second only to states along the East Coast (see Figure 4.6). The data in Figure 4.6 are from a Geographic Information System (GIS) wherein a dot is placed within the county of residence for each confirmed case of Lyme disease. GIS is an example of a mapping tool that PHNs may use for surveillance. (See “Innovative Data Collection: Maps and Apps,” for more GIS information.) These data would sup-port efforts by PHNs to bring attention to the problem and to invest in preventive messages for Minnesotans regarding the spread of Lyme disease.
Often data are not easily and perfectly comparable between sources due to different years of reported data or
EVIDENCE EXAMPLE 4.3Comparing Virtual and Outpatient Tuberculosis Clinic Models of Care
Inarecentstudy,theuseofavirtualpublichealthclinicwascomparedwithatraditionaloutpatientclinicformanagingtuberculosisinaCanadianprovince(Long,Heffernan,Gao,Egedahl,&Talbot,2015).TheTBpreventionandcaremodelwasdeliveredthroughonevirtualandtwooutpatientclin-ics,whichweresubsequentlyassessedon28performanceindicators. Overall, one clinic type did not demonstratesuperiority to the other, which is promising for virtual ortele-healthmodelsofhealthcaredeliveryandmanagementforchallengingpublichealthconcernssuchasTB.
Addressing Asthma to Improve Health in Cities
GOAL 11 Nurses are on the front line globally for addressing asthma, which is the most commonchronicconditionamongchildrenthatcanhavelong-termconsequenceswhenleftundiagnosedandundertreated.NursesinIcelandandtheUnitedStatesdevelopedanInternationalSchoolNurseCareCoordination Model that informs strategies addressing asthma at both the student and the schoollevels, includingsymptommanagement,carecoordinationwithinandoutsidetheschoolsetting,andbroadereducationalstrategies(Garwicketal.,2015).CollaborativeeffortssuchasthisofferpromiseofachievingthisSDGbyrecognizingwhereglobalchallengesmightbemetwithsimilarstrategicmodels.
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85CHAPTER 4  n  Competency #2
FIGURE 4.6 Reported Cases of Lyme Disease—United States, 2016 Source: CentersforDiseaseControlandPrevention[CDC],2016
FIGURE 4.5 Reported Cases of Lyme Disease in Minnesota, 1996–2016 (n = 17,744)Source:MinnesotaDepartmentofHealth[MDH],2016
Reported Cases of Lyme Disease in Minnesota by Year, 1996–2016 (n = 17,744)
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86 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
be interested in more in-depth statistical comparisons and analysis, such as chi-square analysis. PHNs might not rou-tinely calculate these numbers, but they often read and ana-lyze research that includes reported rates, risk ratios, odds ratios, chi-squares, and levels of significance (i.e., p < .001 or p < .05). It is beyond the scope of this book to completely explain how to calculate each of these, but it is useful for PHNs to have an awareness of what the numbers mean and how to appropriately interpret them.
Table 4.3 shows an example of data used to calculate odds and an OR. This ratio is useful in identifying the odds of con-tracting the disease, given the presence or absence of a risk factor. The formula for calculating the OR is (a/c) / (b/d) = ad/bc. Specifically, the odds of contracting the disease in the presence of the risk factor is calculated by dividing the num-ber of people with the disease and the risk by the number of people without the disease but with the risk (i.e., 75/25, or 3). Similarly, the odds of contracting the disease but not having the risk factor can be calculated 2/98, or 0.0204. The OR is calculated by dividing the odds with the risk factor by the odds without the risk factor (3/0.0204), or 147. In this exam-ple, someone with the risk factor is 147 times more likely to contract the disease than someone without the risk factor. A PHN with this information needs to make decisions on how to act based on many factors. For example, even though the OR is so high, the disease might not be life threatening, or
when resources are limited. Population data are important because they offer a glimpse into the big picture of how peo-ple are distributed, but the data by themselves might not be sufficient to guide intervention decisions or justify program budget priorities.
Data as Risk Ratios and Odds RatiosAnother very common tool used to examine the data regard-ing risks and health outcomes is a 2×2 table (see Table 4.3). This table aids in understanding how a disease is distributed in a population based on the presence or absence of a risk fac-tor. From this table, a PHN can calculate the rate of disease in each group; the risk ratio (RR: the rate of disease for those with the risk behavior divided by the rate of disease for those without the risk behavior); and the odds ratio (OR), which is regularly used to describe the likelihood of contracting a disease for someone with the risk factor compared to some-one without. In the example shown in Table 4.3, the rate of disease for the “Yes” risk behavior group is 0.75 (75/100), and the rate of disease for the “No” risk behavior group is 0.02 (2/100). Already a relationship between the risk behav-ior and the disease seems obvious given the raw rates (0.75 versus 0.02). Taking this a step further, you can calculate the RR (0.75/0.02 = 37.5). PHNs do not often use the RR by itself, but it is an important calculation for those who might
FIGURE 4.7 Population Pyramid of United States—2016Source: CentralIntelligenceAgency:The World Factbook, 2016
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87CHAPTER 4  n  Competency #2
Innovative Data Collection:  Examples of Maps and AppsData are typically collected through surveillance systems at the local, state, or national levels. Sometimes healthcare professionals provide the data, and other times individuals, families, or communities are surveyed. PHNs need to be aware of the variety of tools used to collect epidemiologi-cal data, because they might participate in data collection, interpretation, or dissemination. A Geographic Informa-tion System (GIS) is an example of a tool growing in pop-ularity in the field of public health. Technological advances make it possible for local PHNs (and the general public) to access GIS data and contribute to mapping efforts readily via smartphones, tablets, and laptops.
GIS tools can yield data useful to a neighborhood, com-munity, state, or country in advancing public health pri-orities. The County Health Rankings & Roadmaps provide an annual check-up of the health of each county in the U.S. (County Health Rankings & Roadmaps, 2012). This publica-tion shows that some places are doing very well, while oth-ers have room for improvement. Figure 4.8 shows maps that provide insights about health outcomes and health factors in Minnesota, with healthier counties depicted in lighter colors. See Figure 4.8, County Health Rankings & Road-maps; and Figure 4.9, a sample interactive GIS map from the California Department of Public Health that addresses nutrition, from www.cnngis.org.
TABLE 4.3 Association Between Risk Factor and Disease
Disease
Risk Factor Yes No Total
Yes a c a + c
No b d b + d
Total a + b c + d a + b + c + d
Disease
Risk Factor Yes No Total
Yes 75 25 100
No 2 98 100
Total 77 123 200
the risk factor might not be common. The risk factor might easily be eliminated with an intervention, or the risk factor might not be easily identified, making it difficult to inter-vene. PHNs need to consider numerous factors when data are interpreted and then acted upon. PHNs have an import-ant role in helping interpret data so that they are not used inappropriately to justify action or inaction.
FIGURE 4.8 County Health Rankings & Roadmaps: Minnesota Source: CountyHealthRankings&Roadmaps,2018
2018 Health Factors: Minnesota2018 Health Outcomes: Minnesota
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88 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
n Federal Emergency Management Agency (FEMA) Geoplatform (at http://fema.maps.arcgis.com/ home/index.html) provides geospatial data and analytics for emergency management (see also www.geoplatform.gov)
n FEMA Geospatial Coordination Mapping and Data (see https://data.femadata.com/ NationalDisasters/HurricaneHarvey/Documents/ Geospatial%20Coordination%20Call%20Notes/ for Hurricane Harvey examples)
n American Red Cross Online Mapping provides infor-mation about open shelters and ongoing storm data (see http://arc-nhq-gis.maps.arcgis.com/home/index.html)
n National Oceanic and Atmospheric Administration NowCOAST provides real-time coastal observations, warnings, and forecasts (see https://nowcoast.noaa.gov/)
n Ushahidi crowdsource mapping was used to aid in response and recovery efforts (see https:// irmamiami.ushahidi.io/views/map) including oil spill tracking after Hurricane Harvey (see https:// skytruth.ushahidi.io/views/map)
GIS data are also being used to carefully examine community-level assets and risks related to public health problems such as obesity prevention. For example, GIS data can aid in understanding how communities compare in terms of access to full-scale grocery stores, corner supermar-kets, gas stations, and liquor stores. Additionally, GIS data can indicate the location of parks and transpose (e.g., over-lay) violent crime data, which might provide insights into why youth in certain neighborhoods are reporting higher levels of physical activity than youth in other neighborhoods.
In emergency situations, GIS programs are playing a cru-cial role. In Haiti in 2010, a GIS program was used within the first few hours after the earthquake to update a base-line map of Haiti. People on the ground used OpenStreet-Map, a GIS crowdsourced mapping program, to modify the existing map in real time, thereby facilitating rescue efforts. The pre-earthquake terrain maps that existed were not very helpful, but the real-time maps provided valuable support to search-and-rescue teams. Since then, the use of GIS to map disaster events and response has dramatically increased. Consider just a few of the following GIS resources that were available and used in 2017 to aid in addressing hurricanes (Harvey, Irma, Matthew, and others):
FIGURE 4.9 Sample GIS Map Viewer: Network for a Healthy California
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89CHAPTER 4  n  Competency #2
Mapping is also being used to monitor and visualize outbreaks across the globe (see http://www.healthmap.org/en/) and can be valuable historically to review an outbreak, such as the 2014 Ebola outbreak (see https://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html). The data behind the mapping are useful not only in the real-time incidents that require response and interven-tion, but also in the future, as scientists use data to develop algorithms that could help to predict future outbreaks. With public health professionals questioning when, not if, the next worldwide outbreak or pandemic threat might occur, the ability to see and process a large amount of real-time data, and historic data, is very important.
Consider learning about the Global Health Security Agenda (see https://www.ghsagenda.org/) to “advance a world safe and secure from infectious disease threats, to bring together nations from all over the world to make new, concrete commitments, and to elevate global health security as a national leaders-level priority” (Global Health Secu-rity Agenda [GHSA], 2017, para. 1). This initiative is exten-sive, promoting efforts that engage global partners, local government, universities, those already in the workforce, and those who are about to graduate and enter the public health workforce as public health nurses, veterinarians, and environmental health professionals. Examples of these ini-tiatives are found online: One Health Workforce at https:// medium.com/one-health-workforce and PREDICT at http:// www.vetmed.ucdavis.edu/ohi/predict/.
In addition to broad use of mapping data in public health, there are real-time data collection strategies being used to more quickly and more thoroughly understand public health problems and to more efficiently deliver public health interventions. Consider the extensive and overwhelming availability of smartphone apps designed to help individu-als manage their health, quit an unhealthy behavior, begin a
healthy one, and track every step along the way. Visit an app store and do a search for a common public health challenge you might address as a PHN working with individuals or families. You will find dozens, if not hundreds, of possible tools. Of value are articles that summarize the benefits and challenges of these apps, as well as websites that offer rank-ings and scores to help potential users consider the right app for them. An example is provided for mental health apps at https://adaa.org/finding-help/mobile-apps. Not every sit-uation warrants use of an app (or a map), and it is really important for PHNs to understand this. Just because a tech-nological tool exists does not inherently mean it should be used. PHNs need to consider the challenge being addressed, the stakeholders, the benefits or challenges associated with the technological solution, and then make an informed decision about using it.
Applies an Epidemiological Framework When Assessing and Intervening With Communities, Systems, Individuals, and FamiliesHow a PHN comes to understand a problem and its possible causes and solutions is somewhat dependent on the frame-work that the PHN uses. The epidemiological triangle has traditionally been used to understand disease transmission. This triangle consists of identifying a host system affected by the condition, an agent that causes the condition, and the
EVIDENCE EXAMPLE 4.4Using Big Data to Inform PHN  Home Visiting Interventions
Thereissomuchdatageneratedineveryhomevisit,andovertimeandacrossvisits,thedatarepositorygrowsandbecomes a valuable source of broad information. PHNshave traditionally provided the data, offering rich chart-ing and thorough details for each home visit, but nowPHNs are using these data to understand patterns andinform interventions to a much greater extent. Monsenet al. (2017) analyzed data from 4,263 women who hadreceived home visits, examining social and behavioraldeterminantsofhealthaswellasoutcomes following thehomevisits.Analysesdemonstratedthatminoritywomenshowedgreater improvementsfollowingthe interventionsandrevealedthevalueofusingbigdatatobegintounravelinterventionelementsandinterventionoutcomes.
EVIDENCE EXAMPLE 4.5Screening for Neurodevelopmental Delays in  Four Communities in Mexico and Cuba 
Cuban and Mexican PHNs used a newly developed com-puterized evaluation instrument to assess and comparethe prevalence of neurodevelopmental problems in threeareas: language/communication, psychomotor, and hear-ing/vision (Guadarrama-Celaya et al., 2012). Four hun-dred children ages 1 to 5 years were screened using theNeuropediatric Development (NPED) screening tool inurban and suburban cities in Cuba and Mexico. Resultsdemonstratedfailuresinallcommunities(e.g.,2.3%vision,16.5% language) and differences by country (e.g., higherfailures rate for hearing in Cuban communities). Resultsalso demonstrated successful use of this computerizedSpanish-language tool for broad community assessmentof key neurodevelopmental problems among children atimportant stages of development. This tool can facilitateearlier identification and intervention so that long-termneurodevelopmentalproblemscanbeavoidedaschildrendevelop.
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90 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
the web design to identify all the factors influencing the cen-ter of the web (i.e., the disease, such as cardiovascular disease or asthma, or the social health problem, such as teen preg-nancy). After you have drawn the web, you are faced with a dilemma—specifically, which related thread to address first. How do you decide whether to prioritize a biological-related factor or a social-based factor? The web might help identify numerous potential causes, contributors, and influences, yet the model by itself does not yield readily apparent strat-egies or solutions. More than 10 years ago, Nancy Krieger (1997) identified these criticisms of the web framework and proposed an ecosocial framework for developing epidemio-logical theories about public health problems and possible solutions. The central question answered using an ecosocial framework is, “Who and what is responsible for population patterns of health, disease, and well-being, as manifested in present, past, and changing social inequalities in health?” (Krieger, 2001a, p. 694).
A shift in thinking about traditional epidemiology mod-els has occurred, with growing recognition of the impor-tance of social epidemiology, the field that acknowledges and seeks to address the complex combination of biological and social factors influencing health and well-being. Social epidemiology was initially defined in the 1950s but has in more recent decades grown in popularity and use among public health professionals (Krieger, 2001b, 2012). PHNs need to be aware of the trends in public health as well as the theories that guide understanding of the “risk-asset- problem-intervention” relationships in public health.
environment that contributes to the condition. Host consid-erations include genetics; inherent characteristics, such as age and gender; acquired characteristics, such as immune status; and lifestyle factors. Agents are typically categorized as infectious, chemical, or physical agents. Environmental factors might include a variety of physical, social, and eco-nomic factors. Interactions between these three elements of the triangle are examined to determine how diseases are transmitted and how intervention strategies can be targeted to stop or prevent transmission of the health conditions. Using influenza as an example of the three triangle compo-nents, the host would be the individual susceptible to the flu, the agent is the influenza virus, and the environment might be the physical apartment that is overcrowded and under-heated (Clark, 2008).
This model has been adapted to consider more complex scenarios that might be contributing to disease or illness (see Figure 4.10). It is an important adaptation, because for most health problems that PHNs address, the contributing factors are complex and multifaceted. Illnesses result not merely from a simple transmission in the right time and place but also because of factors not easily controlled or resolved (e.g., poverty, inadequate housing, food shortages).
For many in public health, complex contributing factors to poor health or well-being have been informed by such models as the web of causation. The name itself implies greater complexity than the epidemiological triangle, yet this model is also not perfect. For example, imagine a spider web (where the name is drawn from) and how you might use
FIGURE 4.10 Epidemiological Triangle in the 21st CenturySource: Merrill,2017,p.11
EnvironmentBehavior and culture,physiological factors,
ecological factors
Causative FactorsBiological (infectious agents),chemical (drugs, acids, alkali,heavy metals, poisons, some
enzymes), physical (excessiveheat, cold, noise, radiation,
collisions, injuries, etc.)
Group or PopulationAge, gender, ethnicity, religion, customs,
occupation, heredity, marital status,family background, previous diseases
Time
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91CHAPTER 4  n  Competency #2
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Permanente (see https://www.cdc.gov/violenceprevention/acestudy/index.html) have been done, showing the strong—and in some cases, predictive—relationship between expo-sure to these risks in childhood and poor outcomes in young adulthood and adulthood (Holman et al., 2016; Wolff, Baglivio, & Piquero, 2015).
The life course perspective views health not in stages separate from each other (infancy, early childhood, adoles-cence, adulthood) but as a continuum. As Krieger (2001a, p.  695) describes, “Life course perspective refers to how health status at any given age, for a given birth cohort, reflects not only contemporary conditions but embod-iment of prior living circumstances.” A classic life course study was the research on the effects of the 1944–1945 Dutch famine that linked malnutrition with subsequent effects on human development and mental performance (Stein, Susser, Saenger, & Marolla, 1975). Throughout the life course con-tinuum, biological, behavioral, environmental, psycholog-ical, and social factors dynamically interact, contributing to one’s health. As Matthias Richter (2010, p. 458) summa-rizes, “This perspective was truly helpful to contribute to a better understanding of biological, behavioural and social influences—from gestation to death—for health as well as health inequalities.”
The next area for Elizabeth to assess for close contacts is the in-home daycare. Billy’s mother states that they have a split-entry home and that the lower level is for the licensed daycare. On a normal day, she has five children who stay until 5:30 p.m. In addition, a set of 1-year-old twin girls stay until approximately 11:00 p.m. Billy’s mother indicates that since Billy has been ill, he has stayed only on the upper level, away from most of the lower-level childcare children. However, the situation with the twins is different: Billy eats supper with them and plays with them until bedtime. The twins have been exposed to pertussis and, according to the definition in the protocol, are considered face-to-face contacts.
Elizabeth asks whether the twins’ parents have been told about Billy’s pertussis. The mother states that she has not told them because she is concerned about losing her clients and income. Elizabeth explains that the public health rec-ommendation is that the twins receive preventive antibiot-ics because of their close contact with Billy. Billy’s mother agrees to notify the twins’ parents by passing out to all par-ents a standardized notification letter from the PHN.
Public health nursing is grounded in the science of epidemiology. On numerous levels, epidemiological data help describe the scope of a problem, prioritize interven-tion strategies, and evaluate outcomes or trends over time. Data are presented and collected using many different for-mats; nurses need the skills to interpret and critique these data, regardless of how they are presented. PHNs also use
Nursing practice should always be informed by theory. It is relatively easy in nursing practice to get caught up in the tasks one has to do and to forget, at times, to take a step back, reflect, and consider why something is being done a certain way or why certain events are occurring. Theories are always advancing, and an effective PHN strives not only to use theory but also to keep up with theoretical ideas that guide and inform practice and the care of individuals, fam-ilies, communities, and populations. Epidemiology is an ideal example of the value and importance of theory as a guide for understanding and intervening in extremely com-plex societal health problems and conditions.
Another important theoretical framework in public health that PHNs should be aware of is referred to as life course epidemiology. Historically, as the focus of epidemiol-ogy shifted from infectious disease to chronic illness in the mid–20th century, new and expanded paradigms emerged to better recognize and understand the antecedents and causes of chronic diseases. Consider adverse childhood experiences (ACEs); these are now commonly understood as important life events that can have physical and men-tal health effects that persist into adulthood (Felitti et al., 1998). ACEs include a range of experiences, but most com-mon are those that children experience directly (e.g., sex-ual abuse, emotional abuse, physical abuse), and through exposure in the home (e.g., parental substance use or incar-ceration, parental mental health problems, parental abuse, parental divorce or separation). Numerous studies since the original ACEs Study conducted by the CDC and Kaiser
THEORY APPLICATIONEcosocial Theory
Krieger’secosocial theoryoffersan integratedframeworkthat considers pathways of public health problems in thecontextoflifecourse(e.g.,frominfancytoolderadulthood),and ecological layers (e.g., individual, family, community,system,etc.).Criticaltothetheoryistheexplanatoryman-nerinwhichcomplex, intersectionalrisksandprotectionscanbeconsideredwhenexaminingapublichealthorsocialproblem(seeKrieger,2012,p.938, foramodelingof theframeworkappliedtoracism,forexample).Kriegerstatesthattheecosocialtheoryisatoolthat:
fostersanalysisofcurrentandchangingpopulationpatterns of health, disease, and well-being in rela-tiontoeachlevelofbiological,ecologicalandsocialorganization (e.g., cell, organ, organism/individual,family, community, population, society, ecosystem)asmanifestedateachandeveryscale,whetherrel-ativelysmallandfast(e.g.,enzymecatalysis)orrel-atively large and slow (e.g., infection and renewalof the pool of susceptible for a specified infectiousdisease)(Krieger,2001b,p.671).
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92 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
epidemiological theories to inform actions and priorities for addressing public health problems. PHNs need to use and contribute to the development of theories that recognize the social complexities influencing public health problems in the 21st century.
Ethical ConsiderationsAs seen in the narrative woven throughout this chapter, the daycare provider was concerned about a loss of income and her reputation as a provider. Many times, PHNs confront challenging situations in their practice. For example, report-ing a nuisance house situation to the city building inspector might prompt the eviction of a renter or harassment from a landlord. Although they are trying to protect children living in less than desirable circumstances, PHNs’ actions
TABLE 4.4 Ethical Action in Using Epidemiological Principles in Public Health Nursing
Ethical Perspective Application
Rule Ethics (principles) n PHNs should use epidemiology to assess and develop interventions that promote beneficence.n PHNs can support the autonomy of those they are working with, even when uncomfortable
changes are needed to minimize the spread of disease.
Virtue Ethics (character) n PHNs need to demonstrate respect for individuals, families, and communities when suggesting promotion or prevention strategies; this can be challenging but necessary, especially when some might refuse to adhere to the actions being recommended.
n PHNs should be persistent in understanding the complexity of factors contributing to a problem so that potential solutions are comprehensive and yield lasting changes.
Feminist Ethics (reducing oppression)
n PHNs can advocate for system-level changes that promote the well-being of those who often feel they have no voice (e.g., tenants who are unable to ask a landlord to maintain heat levels during the winter).
n PHNs should explore societal changes that can improve the underlying environment for people, such as increasing the minimum-wage law so that families have additional resources to sustain and promote health.
might have unintended consequences for entire families. Similarly, interventions focused on reducing the expo-
sure to lead paint in older homes might be embarrassing or financially difficult. Although the health department might offer a free home/environmental inspection for the detection of lead paint, this activity might force families to temporarily leave their homes, which some may per-ceive as an invasion of privacy. Moving in with relatives for a day might be embarrassing for some; for others, staying in a hotel might be beyond the family budget. Some health departments offer a free service to abate lead in a home if the family has not done so. Although this solution is helpful in covering up a lead source, the repainting services are often spotty and unsightly in appearance. The benefits of reduc-ing lead exposure to children must be weighed against the other consequences for the family. See Table 4.4 for ethical perspectives and applications relevant to epidemiological principles in public health nursing.
n Epidemiological data, including prevalence and inci-dence data, help set national and local public health priorities.
n PHNs can and should use epidemiological data to advocate for health promotion priorities in their areas of influence.
KEY POINTS
n Epidemiology is an important foundation to the work of PHNs.
n There is a growing shift from traditional epidemiologi-cal models toward more complex models that consider social influences on health, such as a social epidemio-logical model.
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93CHAPTER 4  n  Competency #2
Clark, M. (2008). Community health nursing: Advocacy for popula-tion health (5th ed.). Upper Saddle River, NJ: Pearson Education.
County Health Rankings & Roadmaps. (2012). Minnesota. Univer-sity of Wisconsin Population Health Institute. Retrieved from http://www.countyhealthrankings.org/app/minnesota/2018/overview
Earl, C. (2009). Medical history and epidemiology: Their contri-bution to the development of public health nursing. Nursing Outlook, 57(5), 257–265.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Koss, M. P. (1998). Relationship of child-hood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258.
Friis, R. H. (2018). Epidemiology 101 (2nd ed.). Burlington, MA: Jones & Bartlett
ReferencesAlfred, R. (2009). Sept. 8, 1854: Pump shutdown stops London
cholera outbreak. Retrieved from http://www.wired.com/thisdayintech/2009/09/0908london-cholera-pump/
Centers for Disease Control and Prevention. (2001). Updated guidelines for evaluating public health surveillance systems: Recommendations from the Guidelines Working Group. MMWR, 50(RR13), 1–35. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm
Centers for Disease Control and Prevention. (2015). 2015 Final Pertussis Surveillance Report. Retrieved from https://www. cdc.gov/pertussis/downloads/pertuss-surv-report-2015.pdf
Centers for Disease Control and Prevention. (2016). Lyme dis-ease maps. Reported cases of Lyme disease by state or locality, 2005–2015. Retrieved from https://www.cdc.gov/lyme/stats/maps.html
Central Intelligence Agency: The world factbook. (2016). North America: United States. Retrieved from https://www.cia.gov/library/publications/resources/the-world-factbook/geos/us.html
REFLECTIVE PRACTICE
Investigating outbreak possibilities can be challenging, but it can also present opportunities to practice great commu-nication skills. Elizabeth handled a situation that could have been extremely difficult in a professional, thoughtful man-ner. She asked the right questions and managed to express concern rather than judgment. By building a good relation-ship right away, Elizabeth received honest responses from the childcare provider, and together they determined who had been exposed and an appropriate course of action.
 1.  What do you imagine will be some follow-up steps that Elizabeth will take in this situation?
 2.  How can Elizabeth be a resource for the childcare pro-vider if her clients grow angry when they are informed about the possible exposure?
 3.  Who might be additional partners to Elizabeth within the health department as she follows this case until it is resolved?
 4.  How might Elizabeth address an ethical issue, such as whether some of the exposed refuse preventive treatment?
 5.  How will Elizabeth know whether this case investiga-tion has been successful? What will be important for Elizabeth to document?
 6.  How will the numbers that Elizabeth has collected as part of this investigation be useful to others at her local health department? At the state level? At the national level?
 7.  How might Elizabeth use each of the Cornerstones of Public Health Nursing (see Chapter 1) in this case investigation?
APPLICATION OF EVIDENCE
 1.  What are some ways you can use the ecosocial theory to examine contributing and influencing factors on complex public health problems in the United States in the 21st century, such as obesity or the opioid epidemic?
 2.  Examine the different types of data presented in this chapter (e.g., rates, maps) and identify when you might use one type of data more than another type.
 3.  As a PHN working in a community, identify three to five sources of state- or federal-level data you would want to use in demonstrating how your community issues compare to others.
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94 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
Lind, C., & Smith, D. (2008). Analyzing the state of community health nursing: Advancing from deficit to strengths-based practice using appreciative inquiry. Advances in Nursing Science, 31(1), 28–41.
Long, R., Heffernan, C., Gao, Z., Egedahl, M. L., & Talbot, J. (2015). Do “virtual” and “outpatient” public health tuberculosis clinics perform equally well? A program-wide evaluation in Alberta, Canada. PLoS ONE, 10(12), e0144784. doi:10.1371/journal. pone.0144784
Merrill, R. M. (2017). Introduction to epidemiology (7th ed.). Sudbury, MA: Jones and Bartlett.
Minnesota Department of Health. (2016). Reported cases of Lyme disease in Minnesota by year, 1996–2015. Retrieved from http://www.health.state.mn.us/divs/idepc/diseases/lyme/casesyear.pdf
Monsen, K. A., Brandt, J. K., Brueshoff, B. L., Chi, C., Mathiason, M. A., Swenson, S. M., & Thorson, D. R. (2017). Social determi-nants and health disparities associated with outcomes of women of childbearing age who receive public health nurse home visiting services. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 46, 292–303.
Richter, M. (2010). It does take two to tango! On the need for theory in research on the social determinants of health. International Journal of Public Health, 55, 457–458.
Stein, Z., Susser, M., Saenger, G., & Marolla, F. (1975). Famine and human development: The Dutch hunger winter of 1944–45. New York, NY: Oxford University Press.
University of California, Los Angeles. (2010). John Snow. Retrieved from http://www.ph.ucla.edu/epi/snow.html
Valanis, B. (1999). Epidemiology in health care (3rd ed.). Stamford, CT: Appleton and Lange.
Wolff, K., Baglivio, M., & Piquero, A. (2015). The relationship between adverse childhood experiences and recidivism in a sample of juvenile offenders in community-based treatment. International Journal of Offender Therapy and Comparative Criminology, 61(11), 1210–1242.
Garwick, A. W., Svavarsdóttir, E. K., Seppelt, A. M., Looman, W. S., Anderson, L. S., & Örlygsdóttir, B. (2015). Development of an International School Nurse Asthma Care Coordination Model. Journal of Advanced Nursing, 71(3), 535–546.
Global Health Security Agenda. (2017). About. Retrieved from https://www.ghsagenda.org/about
Guadarrama-Celaya, F., Otero-Ojeda, G. A., Pliego-Rivero, F. B., Porcayo-Mercado, M., Ricardo-Garcell, J., & Perez-Abalo, M. C. (2012). Screening of neurodevelopmental delays in four commu-nities of Mexico and Cuba. Public Health Nursing, 29(2), 105–115.
Henry Street Consortium. (2017). Entry-level population-based public health nursing competencies. St. Paul, MN: Author. Retrieved from http://www.henrystreetconsortium.org
Holman, D., Ports, K., Buchanan, N., Hawkins, N., Merrick, M., Metzler, M., & Trivers, K. (2016). The association between adverse childhood experiences and risk of cancer in adulthood: A systematic review of the literature. Pediatrics, 138(Suppl. 1), S81–S91.
Klopf, L. (1998). Tuberculosis control in the New York State Department of Correctional Services: A case management approach. American Journal of Infection Control, 26(5), 534–538.
Krieger, N. (1997). Epidemiology and the web of causation: Has anyone seen the spider? Social Science and Medicine, 39(7), 887–903.
Krieger, N. (2001a). A glossary for social epidemiology. Journal of Epidemiology and Community Health, 55(10), 693–700.
Krieger, N. (2001b). Theories for social epidemiology in the 21st century: An ecosocial perspective. International Journal of Epidemiology, 30(4), 668–677.
Krieger, N. (2012). Methods for the scientific study of discrimina-tion and health: An ecosocial approach. American Journal of Public Health, 102(5), 936–945.
Kuh, D., Ben-Shlomo, Y., Lynch, J., Hallqvist, J., & Power, C. (2003). Life course epidemiology. Journal of Epidemiology and Community Health, 57(10), 778–783.
Le, C. T. (2001). Health and numbers: A problem-based introduction to biostatistics (2nd ed.). New York, NY: Wiley-Liss.
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95
CHAPTER
5COMPETENCY #3Utilizes the Principles and Science of Environmental Health to Promote Safe and Sustainable Environments for Individuals/Families, Systems, and Communities
n  Patricia M. Schoon with Noreen Kleinfehn-Wald, Carolyn M. Porta, and Stacie O’Leary
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Jeff, Gena, Max, and Dana are working with Candace, the school nurse, at an environmental mag-net elementary school. Candace tells them that she has documented an increase in asthma attacks and asthma-related absences since the beginning of the flu season a month ago. She asks the students to do an assessment, kind of like a modified community assessment, to identify the potential causes of the increased incidence. The students are having a meeting to discuss how to organize their assessment.
Jeff states, “I think we need to research all of the causes of asthma and asthma attacks and what might place these students at risk for increased attacks.”
Gena responds, “This is going to be complicated. My niece has asthma and my sister is always looking for asthma triggers. My sister also recently met with the school nurse to develop an asthma action plan to use at school. There are so many risk factors.”
Dana comments, “I don’t know much about environmental health. I think I want to do some reading about what it is and what environmental health has to do with nursing.”
Max responds, “I agree with Dana. When I think of environmental health and nursing I think of how we dispose of hazardous waste materials in the hospital. There is also the climate change issue, but I don’t know what this has to do with nursing. I need to figure out where asthma triggers fit in all of this.”
Gena reflects, “Besides this community assessment, we are all making home visits with a public health nurse [PHN]. Maybe some of what we learn will help us with our assessment of the families we are visiting and with the interventions we do with our PHN preceptors.”
The students review the environmental health PHN competencies they will be developing as they com-plete this project. Jeff starts a to-do list and writes a list of definitions the group will need as they research their topic from an environmental perspective.
JEFF’S NOTEBOOKCOMPETENCY #3 Utilizes the Principles and Science of Environmental Health to Promote Safe  and Sustainable Environments for Individuals/Families, Systems, and Communities
A. Promotesenvironmentsthatfacilitateholisticwell-beingandhealth,healing,andhealthylifestylesforindividuals/families,systems,andcommunities
1) Assessesenvironmentalriskfactorsandprotectivefactorsforindividuals/families,systems,andcommunities
2) Engagesinactionstoreduceenvironmentalriskfactorsandstrengthenprotectivefactorsforindividuals/families,systems,andcommunities
3) Takesactionstoreduceandmanageharmfulwasteproductsfromindividuals/families,systems,andcommunities
4) Evaluatestheoutcomesofactionstopromotehealthyenvironments(continues)
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96 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
B. Seekstoprotectindividuals/families,systems,andcommunitiesfromenvironmentalhazards
1) Educatesindividuals,families,systems,andcommunitiesaboutenvironmentalhazardsandharmfullifestylefactors
2) Recommendsmodificationsinhome,neighborhood,workplace,andcommunityenvironmentstoincreasesafetyforindividualsandfamiliesacrossthelifespan
3) Supportsright-to-knowlegislationandregulationsthatprotectandinformthepublicabouthazardousproducts
C. Considersthediversevalues,beliefs,cultures,andcircumstancesofindividuals/familiesandpopulationswhenrecommendingandimplementinghealthyenvironmentalinterventions
1) Isattentivetodiverselifestylefactorsandassessespotentialhealthandsafetyrisksrelatedtothem
2) Acceptsandsupportsdiversityinenvironmentallifestylefactors
3) Makesreferralswhenappropriatetogovernmentalagencieswhenharmfulenvironmentallifestylefactorsplacechildrenandvulnerableadultsatrisk
D. Promotesstewardshipoftheenvironmentatlocal,national,andinternationallevels
1) Advocatesforsustainablenaturalandbuiltenvironments
2) Advocatesforenvironmentaljusticeforvulnerableandunder-representedpopulations
3) Supportspoliciesthatpromotesafeandsustainablenaturalandbuiltenvironmentsandwaterandfoodsystems
Source: Henry Street Consortium, 2017
USEFUL DEFINITIONS
Built Environment:Includesproducts,structures,buildings,ortransportationcreatedormodifiedbyhumanbeings.
Environment:“Reflectstheaggregateofthoseexternalconditionsandinfluencesaffectingthelifeanddevelop-mentofanorganism…physical,chemical,biological,andsocialfactorsthataffectthehealthstatusofpeople”(Merrill,2017,p.214);“factorsexternaltothehumanoranimalthatcauseorallowtransmission”(p.8).
Environmental Health:“Environmentalhealthcomprisesthoseaspectsofhumanhealth,includingqualityoflife,thataredeterminedbyphysical,chemical,biological,social,andpsychosocialfactorsintheenvironment.Italsoreferstothetheoryandpracticeofassessing,correcting,controlling,andpreventingthosefactorsintheenvironmentthatcanpotentiallyaffectadverselythehealthofpresentandfuturegenerations.”—draftdefini-tiondevelopedataWHOconsultationinSofia,Bulgaria,1993(U.S.DepartmentofHealthandHumanServices[U.S.DHHS]EnvironmentalHealthPolicyCommittee,RiskCommunicationandEducationSubcommittee,1998).
Environmental Stewardship:Theresponsibilityforenvironmentalqualitysharedbyallthosewhoseactionsaffecttheenvironment(EnvironmentalProtectionAgencyEnvironmentalActionCouncil,2005).
Exposure:Athree-phaseprocess:“1)contactisbetweenatargetandoneormoreagentsinthesameenvironment;2)agentaccessestargetbyoneormoreroutesofentry;and3)theagententersthetargetbycrossingabarrierorboundary”(Thompson&SchwartzBarcott,2017,p.1315).
Hazard:Abilityofanenvironmentalagenttodoharm.
Natural Environment:Includesthephysicalenvironment(e.g.,air,water,land,soil,plants,weather,climate)andbiologicalandchemicalentitiesthatexistintheenvironment.
Planetary Health:Theachievementofthehighestattainablestandardofhealth,well-being,andequityworld-widethroughjudiciousattentiontothehumansystems—political,economic,andsocial—thatshapethefutureofhumanity,andtheEarth’snaturalsystemsthatdefinethesafeenvironmentallimitswithinwhichhumanitycanflourish.Planetaryhealthisthehealthofhumancivilizationandthestateofthenaturalsystemsonwhichitdepends(LancetCommission,2015;Whitmeeetal.,2015).
JEFF’S NOTEBOOKCOMPETENCY #3 (continued)
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97CHAPTER 5  n  Competency #3
and morbidity is referred to as the global disease burden, as illustrated in the following quotation:
Twenty-three percent of global deaths and 22% of global disability adjusted life years were attributable to environmental risks in 2012… The global disease burden attributable to the environment is now domi-nated by noncommunicable diseases. Susceptible ages are children under five and adults between 50 and 75 years (Prüss-Ustün et al., 2017).
Responses to environmental health challenges involve efforts to eliminate or weaken the hazard, reduce the poten-tial for exposure to the hazard, and mitigate the effects of the exposure.
History of U.S. Environmental Health MovementThe contemporary environmental health movement in the United States began with the 1962 publication of the book Silent Spring, written by Rachel Carson, a marine biologist. She published her research on chemical pesticides, which resulted in the government banning the agricultural pesti-cide DDT, a synthetic aromatic hydrocarbon (U.S. Fish and Wildlife Service, 2012).
From 1942 to 1953, a chemical company dumped chem-ical hazardous waste into Love Canal, an aborted Niagara River canal project that ran through a 15-acre working-class neighborhood (Kleiman, 2017). In the 1970s, investigative reporters revealed a cluster of illnesses including epilepsy, asthma, migraines, and nephrosis, as well as abnormally high rates of birth defects and miscarriages occurring in families that lived near Love Canal. Contaminated water was found in the basements and yards of residents as well as in the school playground built over the canal. Activist women, mostly mothers in the Love Canal neighborhood, tried to get the New York State government to take action, but it did not. Between 1978 and 1981, 939 families were relocated by the federal government. This tragedy mobi-lized concerned citizens nationwide to lobby Congress to act to make businesses responsible for cleanup of toxic
What Is Environmental Health?When you think of the environment, what comes to your mind? The first things that probably come to mind are the physical locations in which you spend your daily life, such as your home, neighborhood, parks, and open green spaces. When you consider the health of the environment, you must pay attention to both the seen (e.g., air, water, land) and the unseen (e.g., microscopic pollutants) as well as the social factors, including individual and societal behaviors, that shape the world. A holistic definition of environmental health would include physical, chemical, biological, social, and behavioral factors that influence the environment. A thorough understanding of environmental health requires looking beyond the factors that compose “environment” and determining whether it is healthy or unhealthy. You need to also carefully consider the interactive effects, and you need to further analyze the role of human behavior and response to the environment that is consequently shaping the world and impacting health.
Challenges of Environmental HealthIn this chapter, you will read about both the immediate and the long-term challenges of environmental health, ranging from the hazards and exposures that you encounter on a daily basis to the broader encompassing global challenges of climate change. Public health nurses (PHNs) give atten-tion to the immediate environmental risks faced by individ-uals, families, and communities, such as the availability of clean water, healthy food, and safe home and community environments. In many parts of the world there are threats to health related to the presence and disposal of biological and chemical hazards. These environmental challenges to health are substantial and necessitate action to mitigate them and promote health and well-being. Exposure to envi-ronmental hazards poses significant threats to health that include acute illness, infectious and chronic diseases, and premature deaths (i.e., those occurring before expected life span). The impact of environmental hazards on mortality
Precautionary Principle:Whenanactivityraisesthreatsofharmtohumanhealthortheenvironment,precau-tionarymeasuresshouldbetakenevenifsomecauseandeffectrelationshipsarenotfullyestablishedscien-tifically.Inthiscontext,theproponentofanactivity,ratherthanthepublic,shouldbeartheburdenofproof(Chaudry,2008).
Risk:Thelikelihoodofharmoccurringonceanindividualisexposedtoahazard(UnitedNations[UN],2015).
Social Environment:Socialinteractions,behaviors,norms,institutions,andaccesstohealthcare.
Sustainable Community:Asustainablecommunityisonethatiseconomically,environmentally,andsociallyhealthyandresilient.Itmeetschallengesthroughintegratedsolutions,ratherthanthroughfrag-mentedapproachesthatmeetoneofthosegoalsattheexpenseoftheothers(InstituteforSustainableCommunities,n.d.).
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98 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
environmental health as a core function of nursing practice in all clinical practice areas and not just the province of nurses who specialize in environmental health (IOM, 1995). The IOM also identified the importance of using the pop-ulation-based public health nursing approach for environ-mental health issues and the need to prepare more nurses at the baccalaureate level so that the nursing profession would have greater capacity to address the environmental health concerns of populations as well as individuals. In 2007, the American Nurses Association (ANA), recognizing the importance of environmental health as a core component of the scope of practice of professional nursing, published the ANA’s Principles of Environmental Health for Nursing Prac-tice with Implementation Strategies (see Table 5.1).
A coalition of U.S.-based nurses created the Alliance of Nurses for Healthy Environments (ANHE) in 2008 (ANHE, 2017). This alliance has published standards for environ-mental health nursing, developed an online free eBook, Environmental Health in Nursing (2016), maintains a listing of environmental hazards (see https://envirn.org/) and has
waste dumps that they created. In 1980, Congress passed The Superfund Bill (i.e., Comprehensive Environmental Response, Compensation, and Liability Act). These citizen actions were the beginning of a grassroots environmental movement that continues to the present day.
Environmental Health— At the Core of Nursing PracticePHNs are concerned about how the environment affects individuals, families, and the community/society at large. They consider the ongoing interactions between their clients and the environment and the cumulative effects of envi-ronmental hazards on health status. PHNs assess both the protective and the risk factors of the natural and the built physical environment and take actions to reduce environ-mental risk factors to improve the health status of individu-als, families, and communities.
Since the time of Florence Nightingale, nurses have iden-tified the relationship between the environment and health outcomes. In Notes on Nursing, Nightingale lists five things that must be present to have a healthy home; although gen-erated in the 19th century, they remain relevant to the 21st century: pure air, pure water, efficient drainage, cleanliness, and light (Nightingale, 1860). Nightingale was responsi-ble for applying principles of cleanliness in the care of the injured during war, which likely resulted in numerous saved lives.
Clara Barton, trained as a teacher and not a nurse, pro-vided nursing care to Union soldiers during the Civil War and was officially named head nurse for one of General Ben-jamin Butler’s units in 1864. Her experience in the Civil War began her long history of helping those in need in times of conflict and disaster. Barton was instrumental in starting the American Red Cross in 1881 and was president of the Red Cross until 1904. She then started National First Aid Association of America; the organization’s priority was emergency preparedness (Michaels, 2015).
Years later, Lillian Wald, recognized as the first public health nurse in the U.S., worked to improve horrifically overcrowded and infested housing conditions in New York City. She believed that the crowded and dismal living con-ditions of immigrants and children on the Lower East Side of New York resulted in poor health outcomes and began providing nursing services in peoples’ homes. She used her societal position to lobby for safe spaces for children to play in New York City, and helped to establish the first parks and playgrounds for children in the 20th century (Filiaci, n.d.). Wald founded the Henry Street Settlement in 1893 and led that organization until 1933, providing health and social services to people who suffered health consequences for the environmental health condition of their place of residence (Henry Street Settlement, 2017).
The Institute of Medicine’s (IOM) 1995 landmark pub-lication, Nursing, Health, and the Environment, addressed
TABLE 5.1 ANA’s Principles of Environmental Health for Nursing Practice
1. Knowledge of environmental health concepts is essential to nursing practice.
2. The Precautionary Principle guides nurses in their practice to use products and practices that do not harm human health or the environment and to take preventive action in the face of uncertainty.
3. Nurses have a right to work in an environment that is safe and healthy.
4. Healthy environments are sustained through multi-disciplinary collaboration.
5. Choices of materials, products, technology, and practices in the environment that impact nursing practice are based on the best evidence available.
6. Approaches to promoting a healthy environment respect the diverse values, beliefs, cultures, and circumstances of patients and their families.
7. Nurses participate in assessing the quality of the environ-ment in which they practice and live.
8. Nurses, other health care workers, patients, and commu-nities have the right to know relevant and timely informa-tion about the potentially harmful products, chemicals, pollutants, and hazards to which they are exposed.
9. Nurses participate in research of best practices that promote a safe and healthy environment.
10. Nurses must be supported in advocating for and imple-menting environmental health principles in nursing practice.
Source: ANA, 2007, p. 16
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99CHAPTER 5  n  Competency #3
decisions about actions you should take. For example, long before the causal relationship between the ultraviolet rays of the sun and skin cancer was known, people took precautions about time spent in the sun to avoid sunburn. The acronym ACT serves as a critical-thinking approach to known and potential environmental hazards, including those that pose both immediate and long-term actual and potential risks:
A. Assessment: Assess environmental hazards and health risks.
C. Critical thinking: Reflect on the consequences of these risks and how best to mitigate or eliminate them in the short and long term. Consider the sus-tainability of interventions and the evidence base for their likely success.
T. Take Actions: Know best practices to reduce envi-ronmental hazards and risks, and apply them. Consider PHN interventions at the individual/family, community, and systems levels of PHN practice.
Environmental Health— The Role of the PHNThe role of the PHN in environmental health is dependent in part on the employment location of the PHN, the structure of the public health agency, and existing laws and regula-tions. Some agencies include an environment health section, and some employ a single environmental health special-ist or a sanitarian. Agencies provide services for building code compliance, solid waste disposal, and hazardous waste removal. If there is a sanitarian on staff, the PHN may serve as a consultant to the sanitarian or work with those cases that need long-term follow-up due to a medical or health impact. In agencies where there is not a sanitarian, PHNs may do the environmental risk assessment themselves.
PHNs often collaborate with human service providers working in child protection or with vulnerable adults. The PHN might accompany a social worker to a home to assess safety conditions or might request a social worker to inter-vene after doing an initial home visit. Family lifestyle pat-terns are diverse, so it is important to consider whether the differences in conditions are benign or harmful to family members. The PHN might need to make a determination as to whether the conditions are significant enough to warrant removal or temporary relocation of an individual. The PHN may also be involved in a plan to improve the livability of a dwelling. Some environmental situations, such as hoard-ing, can be very complex and could involve social workers, mental health professionals, law enforcement, and others to address the situation.
Existing laws and ordinances greatly shape the role of the PHN in addressing environmental hazards or risks. For example, a state law or local ordinance may designate a pub-lic health inspection. If such is the case, then there is usu-ally a process to give legal orders to abate a situation, and a
workgroups for education, research, practice, and policy/advocacy. ANHE has identified ten reasons why it is import-ant and appropriate for nurses to be involved in environ-mental health (see Table 5.2).
The Precautionary PrinciplePHNs take actions to prevent harm to their clients. How-ever, the cause-effect relationship between some environ-mental hazards or potential hazards is not always clear. PHNs use the Precautionary Principle to guide their actions in protecting themselves and their families, clients, and community. The following definition provides guidelines for applying the Precautionary Principle to nursing actions.
When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect rela-tionships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof. The pro-cess of applying the Precautionary Principle must be open, informed, and democratic and must include potentially affected parties. It must also involve an examination of the full range of alternatives, includ-ing no action (Science and Environmental Health Network, 1998).
Using the Precautionary Principle makes good sense. Start by considering what you can do in your home, neigh-borhood, and workplace to reduce exposure to hazards. You can also look at correlation and make common sense
TABLE 5.2 Top Ten Reasons That Nurses and Environmental Health Go Together
n Nurses provide healing and safe environments for people.n Nurses are trusted sources of information.n Nurses are the largest healthcare occupation.n Nurses work with persons from a variety of cultures.n Nurses effect decisions in their own homes, work settings,
and communities.n Nurses are good sources of information for policymakers.n Nurses translate scientific health literature to make it
understandable.n Nurses with advanced degrees are engaged in research
about the environment and health.n Health organizations recognize nurses’ roles in
environmental health.n Nursing education and standards of nursing practice
require that nurses know how to reduce exposures to environmental health hazards.
Source: ANHE, 2016, p. 2
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100 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies
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Online Activity    Help Max and Jeff research environmental asthma triggers. Here are a few online resources for you to use. Refer to the information on the following websites and make a list of environmental asthma triggers. 
n Environmental Health in Nursing, an open-source text-book, written by members of the Alliance of Nurses for Healthy Environments at https://envirn.org/wp-content/uploads/2017/03/Environmental-Health-in-Nursing.pdf 
n Environmental Triggers of Asthma at https:// www.atsdr.cdc.gov/csem/csem.asp?csem=32&po=6
n Asthma and Allergies and Their Environmental Triggers  at https://kids.niehs.nih.gov/topics/pollution/ asthma-and-allergies/index.htm
n Childhood Asthma at http://asthmaandallergies.org/asthma-allergies/childhood-asthma/
Individual/Family Level of PracticeThis section focuses on identifying key environmental haz-ards that have a direct effect on individuals and families and strategies for how to prevent or mitigate the exposures and their effects. A few hazards often encountered by PHNs in their personal lives and daily work are discussed. Five com-mon types of environmental hazards are found in the home, in the workplace, and in schools: n Chemical: Medications; illegal drugs; pesticides; form-
aldehyde (found in almost all new products containing glue); volatile organic compounds (VOCs) found in household products such as paints, varnishes, wax, mothballs, many cleaning and disinfecting products, personal hygiene products, and cosmetics; and indus-trial chemicals used in cars and in the workplace
n Physical: Radon, radiation, weather, sound, vibration, impact
n Mechanical: Pressure, ergonomics, confined space, repetitive motion
n Biological: Bacteria, viruses, parasites, mold, allergens, pet dander
n Sociocultural: Violence and war, interpersonal abuse, institutionalized racism
The impact of the exposure to human beings and ani-mals is often multifaceted and might have immediate, short-term, or long-term influence. The three-phase process of exposure includes: 1) exposure of the target host with one or more environmental agents; 2) ability of the agent to access one or more routes of entry in the target host; and, 3) entry of the agent into the target host by crossing a barrier or boundary (Thompson & Schwartz Barcott, 2017, p. 1315).
process to follow in the event the property owner does not comply. The PHN may be involved in tracking the progress made or consulting with the local court system if there is noncompliance. Some states legally designate local public health to be the final authority on cleanup of methamphet-amine houses (homes that have been contaminated because of the presence of a meth lab). Often public health nurses need to be fluent on issues related to lease agreements, tenant rights, and accessing low-cost legal assistance as they provide counsel to vulnerable clients.
Nurses also need to advocate with medical providers and insurance companies to provide equipment that reduces the risks of those with chronic disease who are exposed to envi-ronmental hazards in the home. For example, home care nurses who have clients with respiratory conditions may need to advocate for air purifiers to improve the quality of indoor air. PHNs may also be the advocate for those living in sub-standard housing or in areas where there are sig-nificant outdoor environmental hazards. There is a known disparity in the availability of healthy homes and healthy living environments, which has a disparate impact on the poor and minorities (U.S. DHHS, 2009). PHNs may need to advocate with policymakers to improve the opportuni-ties for disadvantaged populations to have access to healthy homes and neighborhoods.
Jeff and Max have been thinking about the role of the nurse in environmental health. They feel overwhelmed. They talk with Gena and Dana, who have just made their first home visit with a public health nurse. Dana made a home visit to a young woman who is pregnant and was worried about environmental exposures she might have had that could harm her baby. During a visit to a young family with a child with asthma, Gena found out that the family has bedbugs.
Dana reflects, “What we are learning in our home vis-iting experiences about environmental health can help us determine what environmental factors we need to consider when looking for the causes of increased asthma attacks. I think we need to look at the physical environment both at home and at school to see what the risks are. Let’s focus on the students’ homes and their families. We need to look for the asthma triggers.”
Gena reminds them, “We also need to think about the school environment—both the physical and the social aspects. We need to find out what the school staff know about asthma triggers and what they are doing that pro-tects the children with asthma.”
Max states, “I am going to research environmental asthma triggers.”
Jeff responds, “We need to find more resources.”
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