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Community Final
Community Health Nursing (NR-442)
Chamberlain University
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Final Exam Study Guide SPRING 2018
Public Health and Nursing Practice
What is public health? What is PH Nursing?
● Public health is what society does collectively to assure conditions in which people can be healthy. ● PHN is the practice of promoting & protecting the health of populations using knowledge from nursing social and public health sciences. ○ Community-oriented ○ Population-based
What are the cornerstones of PHN? Make sure to see handouts posted in eCourseware for class one Cornerstones of PH Nursing and Eight principles of public health nursing.
● Cornerstone of PHN: ○ Focuses on the health of the entire populations ○ Reflects community priorities and needs ○ Establishes caring relationships with communities, systems, individuals and families ○ Grounded in social justice, compassion, sensitivity to diversity, and respect for the worth of all people, especially the vulnerable ○ Encompasses mental, physical, emotional, social, spiritual, and environmental aspects of health. ○ Promotes health through strategies driven by epidemiological evidence ○ Collaborates with community resources to achieve those strategies, but can and will work alone if necessary ○ Derives its authority for independent action from the Nurse Practice Act
● Core functions of PH: ○ Assessment: Systematic data collection about a population (—Includes monitoring the population’s health status and providing/ disseminating information about the health of the community) ○ Policy Development: Developing policies that support the health of the population through leadership and research ○ Assurance: Making sure that essential community-oriented health services are available (—Includes providing essential personal health services for individuals as well as a competent PH workforce) ● Eight principles of public health nursing. ○ The client or “unit of care” is the population. ( Responsibility of population as a whole.) ○ The primary obligation is to achieve the greatest good for the greatest # of people or the population as a whole. ( Rather than advocating for individual rights, the PHN is to uphold the needs of the whole, which may
supersede the needs of the individual. Ex, in cases of disaster or resource shortage.) ○ The processes used by public health nurses include working with the client(s) as an equal partner. (True partnership requires the advanced practice public health nurse (APPHN) to engage the population; to include their “perspectives, priorities and values” (ANA, 2007) at every step, from assessment, to potential policy changes. Other specialties may provide care that is known to be effective, without direct input from the client.) ○ Primary prevention is the priority in selecting appropriate activities. ( Health programs are created to emphasize strategies that prevent disease and disability resulting in optimal health outcomes.) ○ The focus is on selecting strategies that create healthy environmental, social and economic conditions in which populations may thrive. ( The goal for the APPHN is to utilize evidence from the ecological model to design strategies and programs that address the determinants of health for a population, thereby preventing disease. Many nursing specialties address the current disease processes and symptomatology that cause clients to seek care.) ○ There is an obligation to actively identify and reach out to all who might benefit from a specific activity or service. (The APPHN acknowledges that those at most risk are often those least likely to be able to seek care. Emphasis is on locating and engaging these populations, in contrast to treating only those who seek health-care services.) ○ Optimal use of available resources to assure the best overall improvement in the health of the population is a key element of the practice. (The APPHN designs programs of care, based on evidence, most likely to positively influence long-term health of a population while judiciously using limited resources.) ○ Collaboration with a variety of other professions, populations, organizations and other stakeholder groups is the most effective way to promote and protect the health of the people. (While all advanced practice specialties work collaboratively with other professions, PHN, with its emphasis on the ecological model, engages experts in a variety of disciplines to join in creating solutions that address the multiple determinants of health. Communities are engaged in improving their health, and legislative efforts create policies that support long-term outcomes.)
● Healthy people provides science-based 10 year national objectives for improving the health of all americans ● For 3 decades, Healthy People has established benchmarks and monitored progress over time in order to: ○ Encourage collaborations across sectors ○ Guide individuals toward making informed health decisions ○ Measure the impact of preventive activities ● Vision - a society in which all people live long, healthy lives. ● Mission - Healthy People 2020 strives to: ○ Identify nationwide health improvement priorities ○ Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress ○ Provide measurable objectives and goals that are applicable at the national, state, and local levels. ○ Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge. ○ Identify critical research, evaluation, and data collection needs ● Overarching Goals ○ Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death ○ Achieve health equity, eliminate disparities, and improve the health of all groups ○ Create social and physical environments that promote good health for all. ○ Promote quality of life, healthy development and healthy behaviors across all life stages.
Levels of Prevention ● Primary Prevention- measures that actively promote health, prevent illness, and provide protection. ○ Implemented before a problem develops and targets essentially well populations. ○ Ex. Billboard ads ● Secondary Prevention- Early diagnosis and prompt interventions to limit disabilities. ○ Identifies risks or hazards and modifies, removes, or treats them before a problem becomes serious ○ Targets populations that have risk factors in common ○ Screening & testing
○ Ex. going into a neighborhood that has lead pipes and screening kids under 5 ○ Unethical to conduct screening if resources are not available for posible treatments and for referral diagnostic evaluations ● Tertiary Prevention- reduces impairments and disabilities, minimize suffering, promote adjustment to immediate condition, and rehab ○ Prevents complications/ existing problems from getting worse ○ Seeks to restore person to optimal level of functioning ○ Target prevention after a disease or injury has occurred ○ Ex. Substance abuse programs
Population Health
What is population health? What populations are, examples, what a population focus is in PH nursing, Population health versus public health Why does the nurse in the hospital or community based setting need to know about populations?
Population health= the health outcomes of a group of individuals, including the distribution of such outcomes within the group
Populations are a large group of people whose members may or may not interact with one another but who share at least one characteristic such as age, gender, or shared health issue. o Examples COPD population 65+ population University of Memphis students
Population health in PH nursing focuses on outcomes of the ENTIRE population, not on the individual. Population health vs public health o Public Health focuses on health departments to ensure that people are healthy (what we do as a society) o Population health is the outcomes of a group of individuals, including the distribution of such outcomes within the group The nurse needs to know about all populations to help promote, protect, and improve the health of ALL people History of Public Health Nursing -Lillian Wald, Mary Breckinridge, Elizabethan Poor Law
● Florence Nightingale
Community oriented versus community based nursing,
● Community-oriented focuses on the community as a whole ○ Health care: surveys and evaluates the community’s health collectively ● Community-based focuses on the health of individuals, families, and groups within a community ○ Illness care: provision of direct primary care where individuals and families live, work, and attend
The Intervention Wheel--Know levels of practice, assumptions of the Wheel, how it is used, review what the interventions are.
● The intervention wheel is a conceptual framework/model that guides practice of public health nurses. ● LEVELS: ○ Individual/Families ■ You want to change behaviors, knowledge, attitudes, practices, and beliefs
○ Community ■ You want to change community norms, attitudes, awareness, practices and behaviors ○ Systems ■ You want to change organizations, laws, policies, and power structures ● Assumptions of the Wheel? ○ 10 assumptions
■ Defining PHN practice ● Promoting and protecting the health of populations through health and disease prevention ■ PHN practice focuses on populations ● Populations as opposed to individuals ■ PHN practice considers the determinants of health ● Health inequities (race, gender, age) ■ Priorities are identified through community assessment ● Ongoing collection and analysis to create a list of community issues and identify gaps between needs and services ■ Emphasis on prevention ● Primary, secondary, tertiary ● Primary when possible ■ PHN intervene at all levels ● Work at community, systems, and individual levels ■ PHN practice uses the nursing process at all levels of practice ● Assess, diagnose, plan, implement, evaluate ■ PHN practice uses a common set of interventions regardless of practice setting ● Intervention wheel ■ PHN contributes to achievement of the 10 Essential Services ● WHAT the PHN does to protect and promote health ■ PHN practice is grounded in a set of values and beliefs ● Cornerstones of public health (inspire, guide, direct, and challenge PHN practice); synthesizing values and beliefs from both public health and nursing ● Answers WHY? ● How it is used? review what the interventions are. ○ Red, green, and blue are interventions for individuals, families, classes and groups ○ Orange and yellow are interventions systems and communities
Health Education- Know the Domains of learning, educational theories, steps in planning a health program, know health literacy and how it affects patients
● Domains of learning: ○ Cognitive (thinking) ■ Memory, recognition, understanding, reasoning, and problem solving ○ Affective (feeling) ■ Influencing what individuals, families, communities, and populations think, feel, and value ○ Psychomotor (acting)
○ Nursing focus is on the collective or common good of the population instead of on individual health, highlights the complexity of the change process ○ Comprehensive assessment, population-focused assessment, establishing setting-specific assessments, problem or health issue based assessment, health impact assessments, and rapid needs assessment. ■ Comprehensive Assessment: Collection of data about populations living in a community ■ Population- Focused Assessment: Larger group or aggregate; members may or may not interact with one another ■ Setting-Specific Assessments: Must have clear understanding of purpose; identify indicators specific to setting; treats the setting as the community ■ Problem- or Health- Issue Assessments: Focus on specific problem or health issue; Analysis of data determines who is at risk ■ Health Impact Assessments: Provide advice to the community on optimizing its health by identifying the potential effects on the health of a population and the distribution of those effects within the population. ■ Rapid Needs Assessment: measure and present a potential public health impact of an emergency ○ Data sources ■ Health status indicators – key health outcomes such as health access, health behaviors, and more. ■ Primary sources of data – participant observation, key informants, focus group, photovoice (giving camera to homeless), spatial data (geographic information systems (GIS)), using primary data ■ Secondary sources of data – website, printed material ○ Models: Community Health Assessment and Group Evaluation (CHANGE) model (to start with the end in mind – evaluation is at the beginning of the model. ■ Helps communities build action plans based on assets and areas of improvement ■ Provides program evaluation in communities: diagnosis and action plan ● What are the steps in doing an assessment?
○ Identify what the patient wants to know. ○ Collect data systematically to obtain information about learning needs, readiness to learn, and barriers to learning. ○ Analyze assessment data that have been collected and identify cognitive, affective, and psychomotor learning needs. ○ Think about what will increase the patient’s ability and motivation to learn.
○ Assist the patient to prioritize learning needs. ○ Consider learner’s knowledge, skill, motivation, and available resources. ○ Consider barriers to learning. ● Know about diagnosis and then interventions, ways of collecting data, ○ Diagnosis: ■ Community diagnoses clarify who receives the care, provide a statement identifying problems faced by who is receiving the care, and identify the factors contributing to the identified problem. ● Risk of ● Among ● Related to ● Interventions: ○ Identify intervention activities---The means by which the m i objectives are met ■ Use EBP ● Literature review ● Population-based approaches ● Evaluation, if they were successful ● Ways to collect Data: ○ Primary sources of data: ■ Participant observation ■ Key informants ■ Focus group ■ Photovoice ■ Spatial data- Geographic information systems (GIS) ○ Secondary sources of data: ■ Websites, printed materials, published data about the community ●. What is EBP ○ A population based approach to evaluate the effectiveness of actions and interventions taken ● What resources do you use for EBP interventions? ○ Health People 2020- Interventions tab ○ County Health Rankings- What works for Health ● What are steps you take to implement EBP? ○ Five stages: ■ Community acceptance of the program ■ Specifying tasks and estimating needed resources ■ Developing specific plans for program activity ■ Establishing a mechanism for program management ■ Putting the plan into action ● What are the different program planning models and how can they be used?
■ Provisions to expand insurance coverage - Individual mandate, Medicaid expansions, state insurance exchanges, support for community health centers ■ Provisions aimed at improving the quality of care offered - National Strategy for Quality Improvement, CMS Center for Medicare and Medicaid Innovation, Patient-Centered Outcomes Research Institute ■ Provisions which seek to enhance prevention and health promotion measures within the healthcare delivery system ● Accountable Care Organizations (ACO’s ) to incentivize providers to take responsibility for population health outcomes, requirements that private health plans, Medicare, and Medicaid provide specific preventive services (USPSTF rec’s) without cost sharing, expansion of preventive services ■ Provisions aimed at promoting community and population-based activities ● National Prevention Health promotion and Public Health Council, which produced National Prevention Strategy, funding for Community ● Transformation Grants, incentives for workplace wellness programs in the form of small grants for use in developing comprehensive workplace wellness programs ● Components of it.. Care. Patient Centered Medical Home ○ The patient is the focus ○ Patients are partners in their care ○ Core values of primary care: ■ Equity ■ Solidarity ■ Active participation of people seeking care ○ PCMH ■ Personal physicians ■ Whole-person orientation ■ Coordinated/integrated care ■ Safe, high quality care through EBP ■ Expanded access to care ■ Payment that recognizes added value from additional components of patient centered care ● What’s the role of prevention in acute care? ○ Primarily tertiary prevention level ■ Prevention of further morbidity and reduce disability ■ Focus is provision of clinical care during the acute phase of the illness
● How do you prevent/reduce transmission of hospital acquired infections ○ Hand washing ○ Universal precautions
PHN’s at Local, State, and Federal Levels
What do PHNS do? Roles of nurses, levels of prevention! What is each level of health department do? What are they responsible for?
● What do PHNS do? ○ Work together to identify, develop, and implement interventions that will improve and maintain the nations health ● Roles of nurses, levels of prevention! ○ Advocate ○ Case managers ○ Counselors ○ Role model ○ Assessment of literacy ○ Educator ○ Direct primary caregivers ○ Ensuring direct care services are available for at-risk populations ○ Disaster management ○ Communicable disease control ■ Incident commander ○ Levels of prevention
● What is each level of health department do? ○ Federal : develop regulations that implement policies formulated by Congress and provide a significant amount of funding to state and territorial health agencies. ○ State: responsible for monitoring health status and enforcing laws and regulations that protect and improve the public’s health ○ Local: responsibilities vary depending on the locality and are responsible for implementing and enforcing local, state, and federal public health codes and ordinances and providing essential public health programs to a community ● What are they responsible for? ○ Federal : ■ Provide public health services
these people with a new (first) diagnosis of MDD. What is the incidence rate of first MDD? ■ There are 50 new cases per year, 50 cases per 10,000 people, So, the Incidence rate is 0 per year, (or 5 per 1,000 per year) ● Incidence proportion : indicates the proportion of the population at risk who experience the event over SOME PERIOD of time (over time). ○ Ex. neonatal mortality is the number of deaths divided by the number of births over the first 30 days after birth. ● Prevalence Proportion : a measure of existing disease in a population at a particular time (i., the number of existing cases divided by the current population). ○ Ex. 8000 women screened for breast cancer, 35 women screened previously diagnosed, 20 women diagnosed through screening ○ Prevalence proportion of current and past breast cancer events in the 8000 women screened: ■ 55/8000 = 0 or 687 per 100, ● Prevalence Rate: existing cases ; all the people with a health condition in a given population at a point in time. ○ Ex school nurse discovers 20 cases of measles in the middle school. There are already 10 children out with the measles. ● The prevalence rate today is the 10 plus the 20 cases = existing cases divided by the total number of students in the school (250) = 0 or 12% ■ Incidence Prevalence and proportion are used interchangeably ● Attack Rate : defined as the proportion of persons who are exposed to an agent and develop the disease; is often specific to an exposure. ○ Ex. 70 people ate potato salad. 63 of those 70 developed symptoms of food poisoning. What would the attack rate be? 63/ ● Disease Spectrum : Spreads from prevention to treatment. ○ Persons with infectious diseases may exhibit a broad spectrum of disease that ranges from subclinical infection to severe and fatal disease. ○ At the community level, the disease may occur in endemic, pandemic, or epidemic proportions. ■ Endemic: refers to the constant presence of a disease within a geographic area or a population ● Ex: malaria (constant worry in Africa) ■ Epidemic: refers to the occurrence of disease in a community or region in excess of normal expectancy. ● Ex: Flu (outbreak in memphis), adult obesity in the United States ■ Pandemic: refers to an epidemic occurring worldwide and affecting large populations ● How disease is spread, Surveillance ○ Vertical transmission is the passing of the infection from parent to offspring via sperm, placenta, milk, or contact in the vaginal canal at birth. Mother to child (transplacental, perinatal, postpartum)
○ Horizontal transmission is the person-to-person spread of infection through one or more of the following four routes: direct/indirect contact, common vehicle, airborne, or vector borne. ■ Direct Contact - Skin, sexual, person to person ■ Indirect Contact - Fomites (objects), waterborne, airborne, aerosol, transfusions/injections ■ Common vehicle/indirect refers to transportation of the infectious agent from an infected host to a susceptible host via food, water, milk, blood, serum, saliva or plasma. ■ Vectors are arthropods, such as ticks and mosquitoes, or other invertebrates, such as snails, fleas, that transmit the infectious agent by biting or depositing the infective material near the host. ● Know the steps of an investigation/surveillance process, when are outbreak investigations used? Types of surveillance ○ Types of Surveillance ■ Passive system ● Diseases are reported by healthcare providers ● Simple and inexpensive ● Limited by incompleteness by reporting and variability of quality ● Most routine notifiable disease surveillance relies on passive reporting ● The physician, lab, or other healthcare provider takes initiative in submitting the report by following the list of reportable diseases in that state ● Health department waits for reports to be submitted by others. ● Most common type of surveillance ● Case reports are summarized and forwarded to state health department, national government, or organizations responsible for monitoring the problem. ■ Active System ● Health agencies contact health providers seeking reports ○ Local health providers ○ Health care agencies ● Ensures more complete reporting of conditions ● Used in conjunction with specific epidemiologic investigation ● Involve regular outreach to potential reporters to stimulate the reporting of specific diseases or injuries
● Ex. a sharp increase of sales in antidiarrheal meds in a community can indicate an outbreak of gastroenteritis. ● When to investigate: ○ When a population experiences an unusual increase in a specific disease ○ Detecting predictable patterns ■ Naturally occurring diseases fairly predictable ■ Outbreaks due to bioterrorism may not be predictable ● STEPS IN AN INVESTIGATION ○ Confirm the existence of an outbreak ○ Verify the diagnosis/define a case ○ Estimate the number of cases ○ Orient data collected to person, place, and time ○ Develop and evaluate hypothesis ○ Institute control measures and share findings.
Environmental Health
Routes of exposure, steps in environmental assessment, exposure history, environmental protection, risk reduction, MSDS, IPREPARE, home safety
● Exposure Types: ○ Chemical ■ Carbon monoxide, metals, pesticides ○ Biological agents ■ Bacteria, viruses, rickettsia, molds, plant and animal contact, fungi, allergens (dust mites/roaches) ○ Physical agents ■ Injurious exchange of energy: heat, cold, radiation, noise, vibration, falls, vehicle crashes, crush injuries, violence ○ Psychosocial factors ■ Real or perceived threats: living in fear, stress, panic, anxiety ● Steps in Environmental Safety ○ Four phases ■ Hazard identification, the first step of an exposure risk assessment, seeks details to input from government information portals about the exposure. This is determining whether a chemical is known to be associated with negative health effects (in animals or humans) ■ A dose-response assessment, the second step, is based on experiments and looks for the correlation between an increase in harmful effects and the increase in the quantity of a substance. ■ An exposure assessment, the third step, is the consideration of the level, timing, and extent of the exposure.--Estimating how much and by which route of entry the chemical might enter the human body
■ A risk characterization, the last step, pulls together the information gathered in the previous steps to determine the health risk of those affected. ● Individual Environmental Exposure History: I PREPARE ○ I → Investigate Potential Exposures ■ Have you ever felt sick after coming in contact with a chemical, such as a pesticide or other substances? Do you have any symptoms that improve when you are away from your home or work? ○ P → Present Work ■ Are you exposed to solvents, dusts, fumes, radiation, loud noise, pesticides, other chemicals? Do you know where to find material safety data sheets for chemicals with which you work? Do you wear PPE? Are work clothes worn home? Do coworkers have similar health problems? ○ R → Residence ■ When was your residence built? What type of heating do you have? Have you recently remodeled your home? What chemicals are stored on your property? Where is the source of your drinking water? ○ E→ Environmental Concerns ■ Are there environmental concerns in your neighborhood (e., air, water, soil)? What types of industries or farms are near your home? Do you live near a hazardous waste site or landfill? ○ P → Past Work ■ What are your past work experiences? What job did you have for the longest period of time? Have you ever been in the military, worked on a farm, or done volunteer or seasonal work? ○ A → Activities ■ What activities and hobbies do you and your family pursue? Do you burn, solder, or melt any products? Do you garden, fish, or hunt? Do you eat what you catch or grow? Do you use pesticides? Do you engage in any alternative healing or cultural practices? ○ R—Referrals and Resources ■ Environmental Protection Agency (epa), National Library of Medicine—Toxnet Programs (nlm.nih) ○ E—Educate (a checklist) ■ Are materials available to educate the client? Are alternatives available to minimize the risk of exposure? Have prevention strategies been discussed? What is the plan for follow-up? ● Environmental Protection: ○ Federal agencies for environmental health regulation ○ Environmental protection agency (EPA), Food and drug administration (FDA), Department of agriculture ○ United states department of health and human services
Community Final
Course: Community Health Nursing (NR-442)
University: Chamberlain University
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