Exam 1: Community Health 440

Global Health Concerns: Climate Change

- A major concern affecting the entire planet is global warming. - Nurses, especially public health nurses, should be keenly aware of the impact of the environment on health. - Extreme weather and temperatures create significant health risks to all by exacerbating heart and respiratory conditions, increasing the mosquito population, and placing the homeless and those living in poverty at risk for exposure. - Droughts and floods affect access to clean water and the production of foods essential for good health. - Climate change also causes significant displacement and expense. Extreme heat affects labor patterns and mental health and often promotes aggression and violence. - While nurses cannot change the climate, they can advocate for climate-friendly policies and behaviors and carry out their duties in ecologically minded ways. - In 2008, a group of nurses came together to form the Alliance of Nurses for Healthy Environments (ANHE). This organization is involved in research, education, and advocacy and includes members in the U.S. and abroad.

Foundations of Public Policy:

- ANA reported in 2020 that nursing has been recognized as one of the most trusted health care professions. The nursing profession is required by standards to be well-educated, follow the code of ethics, adhere to standards of care, and follow policies from nursing organizations and state legislation. Community and public health nurses can be active in social policy and public arenas. Through their daily practice in community and public health roles, they have a strong influence over health care policies. Nurses are strong advocates for community and public policy development.

Trends in Community Health Nursing:

- According to the National Academies of Science, the next decade will demand a "stronger, more diversified nursing workforce" to address the challenges ahead. - Future trends likely to contribute to these challenges include the increasing use of technologies like telehealth and telemedicine, the realities of an aging population, workforce shortages, and a change in the skill sets needed to provide population-focused health care.

Global Health Concerns: Food Security

- According to the United Nations Report on sustainable goals mentioned earlier in this lesson, more than 2 billion people in the world do not have enough to eat on a regular basis. - The global pandemic has undoubtedly increased this number because of supply-chain issues, lack of production, and lockdowns. - Also mentioned in this report is the impact of poor nutrition on people of childbearing age, with an estimated one-third of them experiencing anemia. - Nurses working with pregnant patients stress the importance of good nutrition for them and their families. Food insecurity is a problem for many Americans, especially BIPOC, who are twice as likely to live in cities with limited access to food that is of high quality and affordable. - Food insecurity has been linked to long-term health problems, increased emergency room visits, and more hospital days. The number of food deserts is declining but still represents a significant health concern. - Working with a population focus requires nurses to recognize that while working with client's one-on-one is important, they must expand their scope of concern to include the extent to which healthy food is available in the community. - Berkowitz et al. found that most people in food-insecure families tended to be poor, non-Caucasian, and young. It is estimated that in 2019, more than 1 in 7 U.S. children were in food-insecure families.

Beneficence:

- Actively promote all good benefits, protecting one from harm by taking positive action helping others.​​​​​​​ - Nurses act in the best interest of the clients that are more important than their own. - A nurse is caring for an end stage congestive heart failure client and the client has requested to have a Do Not Resuscitate (DNR) order, but the nurse offers oxygen to keep them comfortable. They are accepting the client's decision and also providing comfort.

(WHO) World Health Organization Goals:

- Address global emergencies. - Improve Health care inequities. - Promote Health worldwide.

Lesson 4: Social Influences + Learning Outcomes

- Analyze the trends that influence access to quality health care for diverse communities. - Explore benefits of community access to quality education for diverse communities. - Analyze the effects of economic stability on community and population health. - Evaluate how social and community support impact the health of the community. - Examine the evidence on the importance of neighborhoods and environments on the health of the community.

Antibiotics:

- Antibiotics have also saved lives that would have been needlessly lost to the many bacterial infections of the time. Penicillin was discovered by Dr. Alexander Fleming in 1928, and this discovery, along with that of sulfonamides a few years earlier, changed the way medicine was practiced forever. - Physicians now had the means to treat the source of morbidity and mortality, rather than merely treating symptoms and hoping for the best. - Although Fleming is credited with discovering penicillin, it took a team of researchers to get it into a usable form, and in 1945, Fleming, Howard Florey, and Ernst Chain were awarded the Nobel Prize for this accomplishment.

Sanitation:

- Around the world, cities in the late 1700s and early 1800s were overcrowded and lacked proper housing, clean water, adequate sewage, and waste removal. - People were dying from cholera, typhus, tuberculosis, and dysentery. - In 1838, Edwin Chadwick commissioned a report about the living conditions of the working class in England. Influenced by Chadwick's findings, Lemuel Shattuck conducted a similar study in the U.S. in Massachusetts. - His report concluded that the diseases occurring in the U.S. were related to a lack of sanitation. - This report and its recommendations provided the framework for many public health initiatives and are credited with advancing life expectancy. - Another important milestone related to the use of sanitary measures was the work of Dr. John Snow. - Dr. Snow was an obstetrician in London but was also interested in the spread of disease. - He believed that cholera was spread by water but had no evidence to support it. In 1854, there was an outbreak of cholera in a suburb near where he lived. - He decided to interview the people who lived in the area. Through his data collection and mapping activities, he discovered that the epidemic in the area was the result of contaminated water in a particular pump located near the then-polluted Thames River. - These early efforts in contact tracing led to the development of epidemiology as a discipline. - Dr. Snow became known as the father of epidemiology.

ANA Key Competencies:

- Assessment of communication skills. - Demonstration of cultural empathy when communicating to others. - Effective communication with interprofessional teams and others. - Assesses communication skills, health literacy, resources, and preferences of health care clients to inform the members of the multidisciplinary team. - Demonstration of continuous improvement of effective communication skills. - Demonstration of various communication styles and methods that demonstrate caring, respect, deep listening, authenticity, and trust.

Autonomy:

- Autonomy is the ability to explain one's actions and make informed decisions independently. - Nurses must respect clients and their decisions and actions. - Allowing a client to choose when they would like a bath or the type of bath they want is applying the ethical standard of autonomy.

Global Health Concerns: Racism

- Both racism and violence have been called public health crises, and it has been suggested that the increase in violence is a result of a long history of systemic racism that has deprived BIPOC, as well as individuals from certain countries of origin, ethnicities, and religions, of the resources needed to build strong neighborhoods with schools, recreation, and access to quality foods and health care. - This systemic racism has created pockets of poverty, despair, and substance abuse. - The U.S. has traditionally relied on the criminal justice system to address acts of violence, but the Black Lives Matter movement, which grew from a social hashtag into an influential movement after the acquittal of George Zimmerman in the shooting death of Trayvon Martin back in 2012, has led to a re-evaluation of strategies to both address and prevent violence in our communities.

(CMS) Centers for Medicare and Medicaid Services:

- CMS is the agency that oversees Medicare and Medicaid. - Medicare is for people 65 years or older, younger people with disabilities, and those with end-stage renal disease. - It is managed by the federal government, and therefore, the benefits and eligibility are the same across the U.S. - Initially, Medicare had only two parts: Part A, which covers hospitalization, and Part B, which covers doctors' visits and some durable medical equipment. - It has undergone several changes since its inception in 1965, including the expansion of benefits for people with end-stage renal disease and other disabilities, and the addition of other benefits like prescription drug coverage (Part D). - Medicare is not free. - Medicaid is a state-managed insurance program for people younger than 65 and pregnant individuals who meet specific poverty levels. - Eligibility and benefits vary from state to state. - It was originally designed to help low-income individuals receive government assistance. - It has expanded to cover pregnant people, people with disabilities, and those who need long-term care. - In 1997, the federal government provided funding for states to expand health coverage to children whose families did not qualify for Medicaid but were too poor to afford health care for their children. - Some states chose to provide this coverage by expanding Medicaid. - Others set up special plans outside of Medicaid referred to as SCHIP. - Standalone plans are overseen by state agencies and not CMS. - Both Medicare and Medicaid programs have improved public health by making it possible for low-income people and families to afford basic health care.

Nine provisions of the code of ethics include:

- Compassion - Commitment - Advocacy - Responsibility - Self-regard - Safety - health care advancement - Human rights - Social justice

Global Health Concerns: Domestic Violence

- Domestic violence (DV) is a global public health issue. - It involves violence against children, older adults, and intimate partners (IPV) of all genders. - It is a significant problem in the U.S. with more than 60% of adults reporting at least one adverse childhood event (ACE) and 1 in 4 women and 1 in 10 men reporting physical trauma as a result of IPV. - IPV includes rape, physical abuse, and stalking and is reported by nearly 38 million men and 43 million women annually. - Women are more likely to experience DV, which has been reported as the leading cause of death among women younger than 45. - Also, domestic violence is generally underreported. - Public health nurses who make home visits are in a position to observe relationships and provide information and support. - If confronted with DV, the nurse should consider their personal safety and attempt to deescalate rather than intervene and exit as quickly as possible. - Using a population perspective, nurses would identify populations, especially at risk—for example, those without financial resources and support systems—and connect them with those resources.

Frameworks for Community Health Nursing:

- Ecological Model - Health Belief Model - Stages of Change Model (Transtheoretical) - Social Cognitive Theory - Upstream/Downstream Thinking Model - Pender's Health Promotion Model

(WHO) World Health Organization Sustainable Goals:

- End poverty and hunger - Ensure good health and well-being - Achieve gender equality - Ensure clean water and sanitation - Ensure affordable and clean energy - Promote decent work and economic growth - Build industry innovation and infrastructure - Reduce inequalities - Make cities and communities sustainable - Ensure sustainable consumption and production - Take action on climate change - Preserve oceans - Protect ecosystems - Promote peaceful societies - Strengthen global partnerships

Health Trends: Aging:

- Every year, the proportion of the U.S. population older than 65 years increases. - This population generally has more chronic conditions than their younger counterparts. - According to the CMS, health care spending for individuals older than 65 is three to five times that of the general population, accounting for almost one-third of health care expenditures. - There is growing concern that there will not be sufficient providers to meet the care needs of this group. - This change in population makeup also creates a shift in focus away from morbidity and mortality to issues of life quality, disability, and frailty. - Increasingly, people want to age in place rather than in institutional settings, increasing the need for home care, community-based services, and providers, as well as accessible transportation. - While the expansion of communities that serve those 55 years and older will continue, many senior citizens do not have the financial resources to take advantage of these living spaces. - A study by Ahn et al. found that older adults who need or prefer to stay in their homes could do so, in many cases, with affordable personal care and minor home repairs or structural modifications, such as ramps and safety bars in bathrooms. - There are agencies and programs that support older Americans, but most are designed for the poor or disabled. - Most older Americans do not qualify for these programs. - Community and public health nurses can advocate for policies to assist this population and connect older Americans to the resources that are available.

Health Trends: Technology

- Health information technology (HIT) has transformed the way providers communicate as well as document care and access records and large data sets aggregated by government, health care, and private organizations. - The field of public health informatics (PHI) is relatively new and, unlike clinical informatics, deals with primary and secondary prevention measures. - For population health to move forward, PHI will need to be integrated so that providers can have access to health, social, and environmental data in a consolidated manner. - For these data sets to yield useful information, there must be interoperability, analytic software, and providers able to perform and understand the analytics produced. - PHI also needs to establish best practices so workforce development plans can be created. - One of the competence areas for Quality and Safety Education for Nurses (QSEN) is informatics, defined as the ability to use information and technology to communicate, manage knowledge, mitigate error, and support decision making. - Examples include navigating electronic health records and using data to improve outcomes.

Nurses often need guidance on how to get involved with policy development. Some suggestions on how to get engaged are:

- Identify and communicate with stakeholders and policymakers. - Determine the likely impact on health care or public health and how it could be achieved. - Identify where policy development happens, such as nursing organizations, local, state, or federal public health arenas. - Advocate for specific approaches or policies that the nurse has identified

Global Health Concerns: Gun Violence

- In 2020, there were 611 mass shootings. - The number of homicides and violent crimes was also on the rise, with homicides increasing by 30% in 2020. Also of concern are the number of suicides, most of which are committed with guns. - Taking a population-focused approach helps us realize that we need to address the roots of the problem, rather than focusing on treating individuals affected by it. - We need to work with schools, families, and individuals to address DV, adverse childhood experiences, mental health disorders, gun violence, and bullying. - These situations lead to stress responses, which may exacerbate violence. - The American Academy of Nursing, recognizing that 34% of those convicted of mass shootings had been banned from owning a gun, recommends policy changes that support funding for anti-violence education programs and research to explore the causes of gun violence.

Regulations of Standards:

- Nursing care for community and public health nurses includes following regulations and standards of practice that guide them in delivering appropriate, safe, and ethical care to promote, protect, and preserve the health of the community. Regulations and standards for nursing care are provided and recommended from organizations like the ANA, as well as from state and federal regulators. - The primary purpose of the ANA is to provide high standards of nursing practice and promote the education and welfare of all nursing roles by defining nursing practice, lobbying for the profession, and promoting legislation that affects nurse's welfare and practice. The ANA describes the scope of nursing practice, asking the key questions of "who," "what," "where," "when," "why," and "how" of the practice. The "who" refers to licensed practical nurses (LPNs), registered nurses (RNs), and advanced practice registered nurses (APRNs). The "what" is the care and commitment to protect and promote the health and well-being of clients. Nursing care is provided wherever it is needed, which answers the "where" question. The "when" refers to the appropriate time to provide nursing care. The "why" informs the reason nurses want to provide quality care and have positive client outcomes. The "how" is how nurses provide care following the scope of practice guidelines and utilizing the tools provided to them.

ANA Code of Ethics:

- The ANA Code of Ethics for nursing practice includes nine provisions. The provisions help guide nurses to provide the best evidence-based quality care with compassion, respect, and accountability. The development of the code of ethics was meant to shape, guide, and inform new and current nurses. The provisions focus on the moral values and actions by nurses to clients, community, and the health care profession. The basic description of the nine provisions are compassion, commitment, advocacy, responsibility, self-regard, safety, health care advancement, human rights, and social justice. Review the details of the nine provisions in the table for the description and examples from the ANA Code of Ethics for Nursing.

Health Trends: Decreasing Workforce/Shortage

- Nursing has experienced many shortages over the years, and with baby boomer nurses reaching retirement age, the workforce is projected to decrease by one-third by 2030. - To address this shortfall, a major shift in how nurses are deployed and compensated will be required to meet the demands of a population-based care system. - There will need to be changes in care provision strategies and rewards, including pay, for nurses engaged in care coordination as opposed to care provided in acute care settings, where salaries are usually higher. - That will create a substantial paradigm shift within regulatory bodies and boards of nursing that determine what the focus of nursing education ought to be and what skills are needed. - Also, delivery systems will need to provide incentives for nurses to seek opportunities outside of hospitals. - QSEN competencies that need to be covered with more depth and with opportunities for application include collaborative care management as opposed to care delivery, analysis of data sets versus client records, planning and financing quality improvement initiatives, and working with interdisciplinary teams versus hospital-based teams.

(OSHA) Occupational Safety and Health Administration:

- OSHA was established in 1970 to address the high numbers of workplace injuries and deaths and is charged with maintaining safe workplaces. - It has decreased worker fatalities from an average of 38 per day in 1970 to about 15 per day in 2019. - It is housed within the Department of Labor but still addresses public health concerns. - Workplace exposures to contaminants, dangerous equipment, adverse weather, and unfair labor practices are factors known to contribute negatively to overall health and well-being. - OSHA was one of the first agencies to address the need for Personal Protective Equipment (PPE) for industrial and construction workers, which then expanded to those working with hazardous materials in labs and hospitals, the importance of which has been underscored by the COVID-19 pandemic. - OSHA also protects whistleblowers and aids community-based agencies involved in disaster response and recovery.

Social Justice:

- Provision 9 of the ANA Code of Ethics for Nurses addresses the need for nurses to be engaged with issues of social justice as part of their professional nursing role. - Social justice is related to respect, equity, and inclusion. The ANA defines social justice as equal rights, equal treatment, and equitable opportunities. The ANA further states that nurses need to have a commitment to social justice and health through their role as advocates and identifying the SDOH to promote healthy outcomes in all areas of care. Social justice in health care means that everyone deserves the right to appropriate health care and is given the same opportunities and resources regardless of race, age, gender, or socioeconomic status. Unfortunately, inequities still exist, which is why an assessment of social determinants of health (SDOH) is important to do before providing care. - The ANA Public Health Nursing Scope and Standards of Practice calls for community and public health nurses to uphold social justice to advocate, protect, and promote human rights and social justice concerns. The nursing profession strives for social justice activism. Nursing organizations like the ANA guide the nursing profession in ethical situations and how nurses should act when social injustice occurs in health care to clients. Nurses can impact change and advocate for health equity and social justice.

Global Health Concerns: Racism needing to be addressed by public and community health

- Public and community health nurses have long addressed the health consequences of disparity and inequity in health care. - Using the social determinants of health as a framework, nurses need to consider how race intersects with each of these determinants. - For example, poverty has an impact on health, but when poverty and race intersect, the disadvantage of poverty is compounded. - In other words, individuals who are white and poor have advantages that BIPOC people who are poor do not share. - Failure to recognize or accept that disparity is a form of racial bias. Public and community health nurses need to be aware of the effects of intersectionality and practice cultural humility. Yearby identified four criteria for evaluating community efforts at addressing racism: - Plans must be actionable, budgeted with an equity lens, focused on structural determinants of health, and developed with the participation of the community. - Nurses are well-positioned to be the bridge between clients and policymakers. - However, they must have a deeper understanding of racial inequities, too. - For the first time, the American Nurses Association in the 4th edition of the Scope and Standards of Practice for nurses addressed the need for nurses to be culturally prepared and address social injustice. - Equipped with these competencies, firsthand knowledge, and scientific evidence, nurses can be valuable members of advisory boards at local, state, and federal levels.

Health Trends: Telehealth and Telemedicine

- Telehealth, in general, is the use of technology in care delivery, health information, and remote health education. - Telehealth generally involves encounters on the internet, such as streaming and video conferences and visits; however, the use of telephones, faxes, and email are not included as telehealth modalities. - The internet has also made it possible for providers to see clients and provide care remotely, which is generally referred to as telemedicine. - The COVID-19 pandemic has demonstrated that assessments and even procedures can be followed or guided virtually, often without in-office visits. - Both technologies have the potential to address inequity across populations, particularly around access, and decrease costs. - Of course, those living in impoverished areas may lack either the computer hardware or connectivity required, creating a disparity in access. - However, a 2018 study of cell phone usage in the U.S. reported that more than 90% of Americans have cell phones and that the majority of those are smartphones with internet capability. - Telehealth is increasingly used in every aspect of nursing practice, from medical records to patient visits, and this trend is likely to continue. - As nurses continue to use digitized means of accessing data and working with clients, we must be mindful of our ethical obligations to put the needs of the client first, protect client privacy, and maintain confidentiality, which may be difficult with electronic media. - There has also been some concern about the erosion of the relationship between clients and providers. - To that end, nurses should be skilled in telehealth etiquette, making sure that they are being responsive to clients' verbal and nonverbal messages just as they would if they were seeing them face-to-face. - The American Health Information M

Six Client Rights: 6. Redress

- The right to dispute and oppose. - The right to compensation.

Six Client Rights: 5. Information

- The right to information about one's health. - The right to information about health care providers. - The right to information about rights and entitlements

Six Client Rights: 2. Confidentiality

- The right to information privacy. - The right to access one's own medical record.

ANA's Public Health Nursing: Scope and Standards of Practice:

- The ANA was established in 1896 and represents all nurses in the United States. Its main goal is to improve health care for all. ANA states that they play a role in fostering high standards for nursing practice, advocate for the health and wellness of nurses by promoting a safe and ethical working environment, and stand up for health care issues that affect the public and nurses. ANA empowers nurses by standing by them when fighting or lobbying for issues that affect the nursing profession. - A newly revised scope and standards of practice for nursing was released by ANA in May 2021. The 4th edition replaces the previous 2015 edition. These scopes and standards are for all professional nurses. The publication of the Public Health Nursing Scope and Standards of Practice from the ANA establishes the legal standards of practice for public health nursing with several characteristics.

Introduction of Policy:

- The ANA's Scope and Standards of Practice suggests that nurses be engaged in the development, communication, and implementation of public policy as part of their advocacy role. As community and public health nurses serve as advocates for clients, families, communities, the nursing profession, and health care organizations, they can also influence health care policy. - Community and public health nurses' education and experience allow them to have more influence over public health policy. To help shape policy development, nurses should know how policy is made, and know who makes policies in both the workplace and community. It also helps to seek out policies that one might have a personal interest in. The development of policy can be explained through the policy lifecycle, which includes four phases: Agenda setting, policy development, policy implementation, and policy evaluation. These phases are linked and represent the process of policy development.

Effective Communication Skills:

- The ANA's standard 11 of the standards of professional performance in the Public Health Nursing Scope and Standards of Practice is communication. The standard states "The PHN communicates effectively in a variety of formats in all areas of practice". The ANA's 4th edition of the Scope and Standards of Practice lists communication as the 10th standard of practice. Both standards state that the nurse will communicate effectively in all areas of nursing practice.

Legislative and Political Advocacy:

- The American Organization for Nursing Leadership (AONL) is a professional association that assists and encourages nurses in their role as legislative advocates to promote the value of the nursing profession. AONL makes it easier for nurses to advocate for change in their profession because they are able to identify what is needed and can understand the needs of the facilities in which they work. The association's goal is to align with nurses to improve care and ensure safety to clients, families, the community, and public health. - Nurses are strong advocates already in their nursing care to clients, but they can also be strong advocates for the health care needs of the general public. Because nurses have a greater understanding of the challenges of working in a busy or complicated work environment, they are well-suited to be advocates in the legislative and political arena. The ANA Public Health Nursing Scope and Standards of Practice notes the importance of public health nurses being involved in legislative action.

(CDC) Center for Disease Control:

- The CDC is the country's foremost "science-based, data-driven, service organization" that is charged with protecting the public's health. - The CDC receives a lot of attention whenever there is an outbreak of foodborne illnesses or infectious diseases, such as Zika, Ebola, and COVID-19. - However, the CDC is a large agency with responsibilities that extend beyond those mentioned. The CDC strategic plan (2021) lists the following priorities: - Securing global health and America's preparedness - Eliminating disease - Ending epidemics - These are enormous undertakings and require many institutes, centers, and offices to accomplish them. - The major divisions are the National Institute for Occupational Safety and Health (NIOSH) and the divisions of Public Health Service and Implementation Science, Public Health Science and Surveillance, Noninfectious diseases, and Infectious Diseases. - Each division has several centers and offices that report to the deputy director of that division.

Global Health Concerns: Global Pandemics

- The COVID-19 pandemic has created challenges for nurses in public health and exposed and intensified the long-standing challenges of inequity and chronic illness. - While obtaining actionable data is a common problem, it has been especially difficult during the COVID-19 pandemic. - Collecting usable data involves getting data that is accurate and comprehensive and examines differences within groups and across groups, as well as ferreting out misinformation. - Improving structures and systems to support informatics, which was discussed earlier in this lesson, also requires changes in policies. - Large-scale efforts to manage misinformation will also require an investment of time and money at state and national levels. - Nurses, as trusted members of the profession, need to correct inaccuracies whenever encountered. Nurses can also offer to provide accurate information at local organizations, such as schools and churches. - As a result of the pandemic, public health nurses are likely to see an increase in poverty resulting in homelessness and food insecurity, leading to stress and despair, which further leads to exacerbations of chronic illness and substance abuse. - Faced with dwindling resources, public health nurses need to work with similarly aligned community organizations and coalitions to address these issues in a way that is sustainable. - The COVID-19 pandemic has shown us that population-focused, evidence-based solutions can only be achieved with community acceptance and support.

Global Health Concerns: Food Security (SNAP) and (WIC)

- The U.S. Department of Agriculture supports several programs aimed at improving nutrition across the life span, including Supplemental Nutrition Assistance Program - (SNAP), which provides food for low-income families; and Women, Infants, Children - (WIC), which provides food, education, and referrals for pregnant clients and clients who recently gave birth, nursing clients and children up to 5 years old, and the school lunch program, which provides free or reduced-price school lunches to children from low-income families. - Schools in very low-income neighborhoods can also apply for the school breakfast program. - The USDA supports farmers' markets and day care centers, too. - Nurses can assist by accessing community-based programs, ensuring adequate, affordable food supplies, and helping families access the resources available to them.

Six Client Rights: 1. Self-Determination

- The right to informed consent. - The right to take part in clinical decisions and treatment alternatives.

(WHO) World Health Organization:

- The WHO was established by the United Nations on April 7, 1948. - This day is now celebrated as World Health Day. - The WHO is composed of 194 member states around the world and employs more than 8,000 health experts to address global emergencies, resolve health care inequities, and promote health worldwide. - Similar to the Healthy People initiative in the U.S., the WHO also sets 10-year goals. - The 2030 goals address global issues and sustainability. - One very important contribution from the WHO is the expanded definition of health found in their 1948 constitution, which states, "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".

Health Trends Focus on Populations:

- The aging of the population and the use of advanced technologies have resulted in increasing the cost of health care across the developed world. - The U.S. spent approximately $4 trillion on health care in 2019, accounting for almost 18% of the gross domestic product (GDP), more than all other developed countries. - This number is expected to reach $6.2 trillion by 2028. However, compared to peer countries, the U.S. continues to rank the lowest in health care outcomes. - Clearly, money and technology have failed to achieve the goal of improving cost, quality, and access sometimes referred to as the triple aim. - As a result, the U.S., along with several other countries, is turning to population health strategies to address this issue. - In 2015, the CMS initiated the Accountable Health Communities project to improve efforts aimed at social determinants of health. - While this project has had some success in improving health outcomes, it has not made a significant impact on cost. - The U.S. is not alone in turning to population health strategies to improve outcomes and contain costs. - Van Vooren et al., in researching the phenomenon in the Netherlands, suggested that success depends largely on collaboration across disciplines as well as across public and private sectors.

Core Public Health Function and Essential Public Health Services:

- The core functions of public health were formulated by the National Academy of Sciences (formally known as the Institute of Medicine) in 1988 to define their roles on governmental levels. They are assessment, policy development, and assurance. The core functions can be defined as: - Assessment: Gathering and analyzing data about a defined area and making that data available for the public to access. This can include epidemiological statistics and community health issues. - Policy development: Collaborating with leaders and lawmakers to develop public health policies, based on sound research and reliable data, that are fair and equitable for the whole population. - Assurance: Ensuring that all the services that were agreed upon by the population are accessible and available to all by motivating collaborative entities in the community, through direct services or regulations of services in the defined community.

Historical Influences - 1900s:

- The importance of public health nurses came to light during and after the dramatic world events of the 1900s. D'Antonio maintains that it was nursing care, not medical care, that made the difference in whether people lived or died during the flu epidemic of 1918. While medical care was important, D'Antonio states that the skilled care of the nurses in helping families manage fever and dehydration was life-sustaining. - The 1940s and '50s saw an increased focus on nursing education and federal funding to support it. The Nurse Training Act of 1943 established the Nurse Cadet Corps and prohibited discrimination. This opened the door for Black nurses who, prior to this time, were not allowed to join the Red Cross, the military, or the major professional nursing organizations. This legislation did not represent a change in social consciousness as much as a need for more nurses. - In the 1960s and '70s, nurses began to specialize and take on duties that were generally assigned to physicians, which led to the advanced practice roles that nurses enjoy today. In the late 1980s and '90s, the focus turned to research and global health. The National Center for Nursing Research (now called the National Institute of Nursing Research) was established in 1986 and continues to receive government funding.

Health Trends: Medicalization

- The past several decades have seen an expansion in the production and use of pharmaceuticals to treat illnesses and conditions that have been considered lifestyle issues and are amenable to changes in lifestyle behaviors. - It has been suggested that as much as 50% of chronic disease risk can be successfully managed by improving socioeconomic circumstances, particularly for individuals at risk for obesity and type 2 diabetes. - Medicalization and investments in pharmaceuticals have shifted national attention and, therefore, resources away from public health programs to address hypertension, obesity, and factors that lead to cardiac disease like elevated cholesterol. - This shift has disadvantaged many Americans, especially Black, indigenous, and people of color (BIPOC) who cannot afford these medications and do not have insurance to pay for them, and now no longer have public programs that provide non-medical pathways to health improvement. - Also, there has been a widening of protocols. For example, the point at which hypertension needs to be treated has changed over the years. - Widening protocols means adding more people to "medication vs. lifestyle change," adding more cost burden to the individuals and the system. - Nurses can influence individual behaviors like diet and exercise through educational programs in schools and clinics. - However, there is a need for nurses to be involved in local, state, and federal health-related planning boards and commissions to influence how resources are allocated. - There is a need to address the systemic sources that contribute to the creation and management of conditions that could be prevented through public health strategies.

Nonmaleficence:

- The practice of "do no harm" by balancing the risks and benefits of care. - Nurses actively seek to do no harm to clients and promote good actions on behalf of their clients. - When a nurse immediately stops a medication when a client is experiencing harmful side effects is a demonstration of practicing nonmaleficence.

Justice:

- The principle of fairness, commitment to provide fair treatment on the basis of equality and equity. - Nurses ensure that all care and resources are provided fairly throughout the population. - When a nurse needs to triage clients in a busy emergency room and the nurse must decide which clients requires immediate attention. The nurse looks at what may depend on where the nurse can do the most good, or where the need is greatest while trying to be fair to all that are in need.

Six Clients Rights: 3. Access to Health Care

- The right to benefit from medical treatment. - The right to obtain timely, safe, and high quality of care.

Six Client Rights: 4. Choice

- The right to choose a health care provider. - The right to a second opinion.

Legal Guidelines/Standards:

- The standards of care are legal guidelines to provide save and adequate care to clients. Along with the professional standards of practice and professional performance provided by ANA, nurses are expected to follow the legal guidelines and regulations set by the Nurse Practice Act (NPA) that are enforced by the state the nurse is licensed in by the Board of Nursing. Nurses are expected to always practice nursing care according to the standards of practice and their state's NPA, which includes demonstrating clinical decision-making and understanding the legal boundaries in their practice. The NPA regulates the scope and standards of nursing practice for the state, and it protects public health, safety, and welfare of individuals and the community. - Reports or complaints that are made to the state's board of nursing about nursing practice or conduct that are considered violations of the NPA can be made anonymously, and the board begins an investigation. Examples of unprofessional conduct are the following: - Criminal behavior Stealing from a client, which may include medications. - Being under the influence of drugs or alcohol. - Providing care out of scope of practice. - False documentation - Abusing a client physically or sexually. - Not following standards of practice

Global Health Concerns: Human Trafficking

- The statistics related to human trafficking are difficult to obtain because of the secrecy surrounding it and rely heavily on tip lines and help centers. - It is estimated that 40 million people are trafficked worldwide. - A form of slavery, trafficking is a violation of human rights, which has long-lasting consequences not only for those trafficked but for families and communities as well. - Victims of trafficking suffer from physical and emotional stress related to violence, sexual abuse, and deprivation. - As a result of these injuries, victims are often seen in emergency departments but are misidentified as sex workers or victims of domestic violence. - According to Raker, failure to identify victims and intervene in a meaningful way allows trafficking to flourish. - Therefore, there is a need for schools of nursing to include content related to human trafficking in their curricula. - Unfortunately, human trafficking is underreported and there is little research available to establish best practices. - Rothman et al. have identified several research priorities, including determining prevalence, identifying risk factors, and evaluating screening and response strategies.

(UNICEF) United Nations Children's Fund:

- UNICEF was established in 1946. Its goals are similar to the sustainable goals of the U.N., but its focus is on children. - Its founding mission was to help at-risk children after World War II regardless of what role their country had played in the war. - UNICEF continues to work in more than 190 countries protecting the rights of children. - The organization provides emergency relief and works to provide clean water, sanitation, nutrition, education, and gender equality for children around the world and claims to provide more vaccinations worldwide than any other agency.

Vaccines:

- Vaccines are consistently recognized as major public health achievements by the CDC. - Vaccines are credited with saving millions of lives, perhaps second only to the number of lives saved by providing clean water. - The use of vaccines began with the work of Dr. Edward Jenner, who is credited with developing the vaccine for smallpox. - In the 1700s, smallpox was a global disease that killed about 30% of those who contracted it. - In the late 1700s, Dr. Jenner noticed that milkmaids who had contracted a less serious disease called cowpox seemed to be immune to smallpox. He then developed a vaccine based on those findings. The success of the smallpox vaccine paved the way for the development of vaccines against other diseases, contributing to significant advancements in public health. - Vaccines were first mandated for schoolchildren in Massachusetts in 1855. - Today, all 50 U.S. states and the District of Columbia (DC) have immunization requirements to enter school. - While the CDC establishes the recommendations, each state determines what immunizations are required and what exemptions are allowed. - Vaccines have continued to play a significant role in protecting the public, up to the present-day development of vaccines to protect against COVID-19. - Major accomplishments in vaccine development and school mandates are listed in the table below.

Global Health Concerns: Violence:

- Violence is a serious problem for all ages in communities across the U.S. Community and public health nurses are in a position to promote and participate in violence prevention strategies. The CDC lists four steps for a population-based model of violence prevention, as shown in the table below. - Community and public health nurses must also be aware of how to work safely in the communities they serve. These nurses need to be aware of the character of the neighborhoods they serve. When making home visits, they need to make sure someone knows where they are, be aware of their surroundings, park on the street for easy access, and keep their keys available.

Global Health Concerns: Racism Continued

- Yearby and Mohapatra identify three levels of racism: institutional, interpersonal, and structural. At any level, racism results in advantages for the white population while placing individuals of racial, ethnic, religious, and other backgrounds that do not identify as part of the majority at a disadvantage. - According to Yearby, decades of systemic racial bias have resulted in unequal treatment. - Yearby also asserts that research shows a positive link between the stresses of this systemic bias and the likelihood of needing health care due to cardiovascular disease and hypertension.

Sources from ANA that Guide the Critical Thinking and Decision-Making of Nursing Practice for Community and Public Health Nursing:

1. ANA Nursing: Scope and Standards of Practice 4th Edition. 2. ANA Public Health Nursing: Scope and Standards of Practice 2nd Edition. 3. ANA Code of Ethics for Nurses with Interpretive Statements. Who: licensed practical nurses (LPNs), registered nurses (RNs) and advanced practice registered nurses (APRNs) What: The care and commitment to protect and promote the health and well-being of your clients. Where: Nursing care is provided wherever it is needed. When: Whenever there is a need to provide nursing care. Why: Basically, because nurses want to provide quality care and have positive client outcomes. How: How nurses provide care following the scope of practice guidelines utilizing the tools provided to them.

ANA 6 Standards of Practice:

1. Assessment: Relevant data and information is collected. 2. Analysis/Diagnosis: The data is analyzed, and actual or potential diagnoses are formed. 3. Outcomes Identification: Expected outcomes/goals are determined. 4. Planning: The plan of care is developed. 5. Implementation: Interventions are implemented. 6. Evaluation: The progress of care is evaluated, goals and outcomes met or not. The rest of the standards of practice for nursing professional performance are: - Ethics - Advocacy - Respectful and equitable practice - Communication - Collaboration - Leadership - Education - Scholarly inquiry - Quality of practice - Professional practice evaluation - Resource stewardship - Environmental health

Healthy People 2030: Broad National Goals for Public Health:

1. Influence Public Health Policy: - Example: Healthy People 2030 aims to influence public health policy by setting specific objectives. For instance, one goal is to reduce tobacco use. These influences policies related to tobacco regulation, public awareness campaigns, and support for smoking cessation programs. 2. Re-evaluated Every Ten Years: - Example: The ten-year cycle allows for continuous improvement and adaptation to emerging health challenges. In the previous iteration (Healthy People 2020), the focus included objectives like increasing vaccination rates, which saw ongoing evaluation and adjustment based on changing health landscapes.

Specific Goals within Healthy People 2023:

1. Reducing Chronic Diseases: - Example: Healthy People 2030 includes goals to reduce the prevalence of chronic diseases such as diabetes and heart disease. This involves implementing strategies like promoting healthy lifestyles, early detection, and improving access to preventive healthcare. 2. Advancing Health Equity: - Example: To address health disparities, Healthy People 2030 emphasizes achieving health equity for all populations, regardless of socio-economic or demographic factors. Initiatives may include targeted interventions to improve healthcare access in underserved communities. 3. Promoting Mental Health: Example: - Healthy People 2030 focuses on mental health by setting goals to reduce the stigma surrounding mental illnesses and improving access to mental health services. This includes community-based programs and policies that support mental well-being. 4. Enhancing Environmental Health: - Example: Goals related to environmental health in Healthy People 2030 involve improving air and water quality, promoting sustainable practices, and addressing environmental justice issues. This influences policies on pollution control and urban planning. 5. Preventing Infectious Diseases: - Example: With a global perspective, Healthy People 2030 includes goals to prevent infectious diseases. Strategies involve vaccination campaigns, international collaboration on disease surveillance, and response planning for emerging infectious threats. In summary, Healthy People 2030 serves as a comprehensive framework, influencing public health policies and guiding efforts to improve health outcomes across diverse populations by addressing a wide range of health-related goals.

Nursing advocacy is a fundamental aspect of patient care, ensuring that individuals have the autonomy to make their own healthcare decisions. Here's a closer look at various aspects of nursing advocacy:

1. Supporting a Cause, Idea, or Policy for Someone Else: - Example: A nurse advocating for improved healthcare policies to enhance patient outcomes, ensuring that the broader healthcare system aligns with the best interests of the individuals they serve. 2. Self-Determination (Informed Consent, Decision-Making): - Example: Empowering patients to make decisions about their own care by providing comprehensive information for informed consent. This involves explaining treatment options, potential risks, and benefits, allowing patients to make choices based on their preferences and values. 3. Providing Education so Clients Can Make Informed Decisions: - Example: Offering educational resources to patients about their medical conditions, treatment options, and lifestyle choices. This empowers individuals to actively participate in their care and make decisions that align with their health goals. 4. Speaking for Clients When They Are Unable to Do So: - Example: Advocating for patients who may be unable to communicate their needs or preferences due to medical conditions or emergencies. Nurses act as a voice for the patient, ensuring their wishes are considered and respected. 5. Providing Community Resources to Clients: - Example: Connecting patients with community resources such as support groups, counseling services, or financial assistance programs. This ensures that patients receive holistic care beyond the clinical setting. 6. Requesting Appropriate PPE in the Workplace: - Example: Advocating for proper personal protective equipment (PPE) in healthcare settings to ensure the safety of both healthcare professionals and patients, especially during public health emergencies like infectious disease outbreaks.

Definition of Community Health:

A field of study on improving the health of a group (health promotion), usually within a specific geographic area, like a neighborhood. Community health looks at a community of people all living in a defined area such as a nursing home or congregants of a place of worship. Interventions are preventative.

Definition of Public Health:

A field of study that focuses on improving and protecting the health of a population through health promotion and disease prevention. Public health tends to have a much wider scope that can span from a town of people to a whole nation. Focusing on faulty Healthcare Trends.

Definition of Population Health:

A field of study that focuses on the health needs of a specific group of people. Population tends to have a narrow focus on a specific subset in any given population, such as those with diabetes or children with sickle cell anemia. They can be defined by a particular characteristic (e.g., age, chronic disease).

Importance of Nursing Advocacy:

An advocate is a person who acts as an advocate for someone or something. Nurses work closely with clients on a daily basis, and part of their role is to be a client's advocate. Nursing advocacy ensures the clients have the right to make their own decisions about their health. The American Nurses Association's (ANA) Code of Ethics provisions address nurses' ethical obligation to advocate for their clients and will be further discussed later in this lesson. ANA: "Advocacy in the care of individuals, families, communities, and populations"

Social Determinants of Health:

External factors, such as their environment and society play a part as well. These are referred to as the social determinants of health (SDOH). According to the CDC, social determinants of health include environmental conditions where people are born and live. These socioeconomic and environmental factors, such as racism, employment, education, housing, access to health care, and economic resources affect health, functioning, and quality-of-life outcomes. The 5 Categories of SDOH: - Economic stability - Access to and quality of education - Access to and quality of health care - Neighborhood/built environment - Social and community context

Tertiary Level of Prevention:

At this level, the target audience consists of those in the population who have the condition and now need help to manage it. The goal is to minimize complications and maximize good health. Activities might include health education on how to manage the condition, rehabilitation services, and long-term social support. The overall objective for the different levels is to prevent poor health. The level of prevention implemented is determined based on the target audience and not necessarily by the activities implemented. For example, education regarding foot care is considered primary prevention if the diabetic client has no wounds. If the client has wounds, the same education on foot care becomes a tertiary prevention activity. These three levels of prevention can be used across any of these settings and by nurses in any of the roles discussed in this lesson. - Targets individuals with health conditions - Goal: Minimize complications and maximize health Examples: - Education on disease management - Rehabilitation - Long-term social support - Home health services - Mental Illness

The Community:

Collective group in same geographical location. May share culture, religion, ethnicity, health issues, or socioeconomic circumstances. Communities can occur in many settings such as schools, towns, or neighborhoods. Client is the community or population, not the individual. Care is delivered based on the needs of the entire community, not just one person.

Community Health Nursing Goals, Addresses, and Practice Settings:

Community health nursing strives to decrease health inequities by focusing on the social determinants of health, such as quality of housing, employment, education opportunities, access to transportation, healthy food, and quality health care, as well as the health conditions that result from inequities in these social determinants. Goal: Decrease Health Inequities Addressing: Social Determinants of Health. The outcomes are measured more broadly than in population health and often focus on the community as a whole instead of individuals. Community health interventions most often focus on prevention strategies at the primary, secondary, and tertiary levels. Interventions are preventative. Overall, the community health nurse promotes healthy living and prevents disease and injury through trusted relationships with the community and its members. The goals can be achieved through various settings in the community. Practice Settings: - Schools - Workplaces - Churches - Correctional Facilities - Home Health/Hospice - Clinics - Case Management Remember, to truly practice any aspect of community health, the client is the community or population as a whole. This means that care is delivered based on the collective needs of all who are defined in that group, not just the individual.

Lesson 1: Introduction to Community, Population, Public, and Global Health + Learning Outcomes:

Define major concepts that guide the practice of community and public health nursing. Compare and contrast the different frameworks (theories/models) used in community health nursing and ethical principles that guide holistic health care to clients, families, and communities. Use the nursing process in the care of populations to meet the needs of aggregates across community health settings. Identify the levels of prevention and major factors influencing holistic health care for clients, families, and communities.

Lesson 2: Historical Influences on Community and Public Health Nursing + Learning Outcomes:

Describe the historical development of community and public health and their influence on the health care system. Identify the functions, roles, and responsibilities of major health organizations (WHO, OSHA, CDC) in community and public health settings. Describe community and public health nursing trends (major drivers of health care change) and the influence on delivery of care for individuals, families, communities, and populations. Explain what is meant by population-focused nursing care and the challenges facing community and public health nurses.

Access to and Quality of Education:

Education helps shape the types of employment individuals can obtain to sustain themselves. It must be of high quality (i.e., high-performing, meets/exceeds career standards, has current books and tools for learning) such that it meets the needs of the various employers who demand certain skill sets for their places of employment. Education must also be available and accessible to the public. There must be schools present in the local area or by virtual platform so that people can attend classes. Education must also be affordable in order for the population to access the institutions of learning. This can be problematic in low socioeconomic areas or rural areas. These areas may have limited government or private funding for local schools and/or limited internet access. Communities with well-funded schools, quality teachers, and access to higher education opportunities tend to have residents with better health outcomes. Education equips individuals with knowledge to make healthier choices and pursue fulfilling careers.

Ecological Model:

Factors that influence health behaviors in society. Also referred to as the social-ecological model, the ecological model of community health nursing shows how various internal and external factors affect healthy behavior on multiple levels of society. These factors are: internal (beliefs); interpersonal (interactions with others); institutional (rules and regulations of an organization); community-related (social norms); and public policy (laws and policies by the government on any level). Ecological models have roots in psychology and human development. Their focus is on the interplay between human behavior and the environment. The ecological model is helpful in looking at specific behaviors and understanding how these determinants have a positive or negative effect on health behaviors when developing health programs. Nurses working with communities may use the ecological model to design a program to promote heart health or decrease teen pregnancy.

Communication Skills:

Effective nursing communication that is direct, compassionate, and informative can decrease errors and improve patient outcomes. This can be achieved through both verbal and nonverbal communication. Some key competencies recommended by the ANA are listed below. - Effective communication is critical for keeping clients informed, educating, and supporting clients. Interpersonal skills allow nurses to perceive a client's verbal and nonverbal communications accurately. Effective communication skills are needed to communicate patient problems and needs clearly to the rest of the health care team. Effective communication is essential to the nurse-client relationship. Ineffective communication makes it difficult for nurses to advocate for their clients. Without effective communication, the nurse may find it difficult to provide comfort and emotional support and establish a trusting relationship with the client. - Effective communication is essential in public health nursing and is one of key elements of public health nursing's core competencies. The element of communication is mentioned throughout the Scope and Standards of Practice for Public Health Nursing. Communication in public health can mean prevention and well-being education in local communities. It's also essential during a health crisis in providing information on infection outbreaks, chemical hazards, and pandemics. Effective communication between health care providers and public officials helps prevent the spread of illnesses and diseases and minimize the damage to the health of the communities. Quality communication is essential to being able to meet the needs of the clients, families, and communities.

Upstream/Downstream Thinking Model:

Example: A person who has been continuously rescuing people from the river as they float downstream only to find the pace and the sheer number of people needing rescuing too overwhelming to handle. The objective for the reader is to ponder what is happening upstream for this issue downstream to occur. This mindset is used to describe the approach to issues in public health. Downstream thinking tends to focus on the individual's current problems without necessarily looking at the larger systemic and social issues (no access to health care, low income, limited public transportation) that may have contributed to it. Upstream thinking focuses on those larger systemic and social issues and seeks to address them. Solutions from that mindset might look like national social policies on the expansion of government-funded health insurance. An upstream thinking approach in public health is encouraged and seeks to implement wide-reaching changes. Addressing issues this way increases the population's chance of better health through interventions such as affordable housing and increased green spaces to prevent problems downstream. Examples of Upstream Thinking: - Government funded health insurance. - Affordable housing.

Lesson 3: Principles in Community Health and Public Health Nursing + Learning Outcomes

Explain the importance and application of nursing advocacy in the provision of care for clients, families, groups, and populations. Discuss regulations and standards for nursing in community and public health settings. Apply the use of ethical principles to the care of clients in community and public health settings. Use effective communication skills in client interactions and interprofessional collaboration. Discuss the foundations of public policy and its effect on health care delivery.

Historical Influencers of the 1800s - Florence Nightingale and Lillian Wald:

Florence Nightingale, born in 1820: - Considered the founder of modern nursing is probably best known for her work to improve care on the battlefield and in the hospital. - She was committed to improving the health of the public, and it has been suggested that her focus on environmental influences on health anchored nursing as a profession focused on the public good. The first public health nurse was Lillian Wald (1867-1940): - Considered the founder of public health nursing. - She attended nursing school in New York City, which had experienced an explosion in immigrant populations resulting in overcrowded, substandard living conditions, especially among the poor. - Troubled by the plight of these individuals, in 1893, she created the Henry Street Settlement in the lower east side of Manhattan, where she cared for the sick and provided classes on health, hygiene, and childcare. The Henry Street Settlement later expanded to include a gymnasium and a park where children could play. It is still in operation today. - Wald, along with help from Mary Brewster, established the Henry Street Settlement House in 1893, and later the Visiting Nurse Service of New York City. - Metropolitan Life Insurance - She was among the first to care for people in their homes and started the first training program for school nurses. - Lillian Wald established the formal roles of school nursing and occupational health nursing, as well as the informal roles of public health educator and advocate for improved social conditions and human rights.

Utilization of the nursing process assists the nurse in advocating for clients and providing client-centered care. There are four stages of the advocacy process. The first stage is to evaluate the client's needs. In the second stage, the nurse identifies the client's goals. The third stage of the advocacy process is when the plan is developed and includes goals and objectives. The fourth stage is to evaluate all the steps taken and the outcomes:

Four Stages of the Advocacy Process: 1. Evaluate the client's needs: A thorough assessment of what the client needs by assessing interest and values and their full understanding of their rights. 2. Identify the client's goals, working with the client to create goals: Include the client in their plan of care and development of goals and what they want to achieve. 3. Develop a plan to meet the goals: The implementation of the plan involves facilitating communication with the client and the health care team. 4. Evaluate the results of the advocacy steps: Evaluate if the needs of the client, family, caregivers, and the health care team have been met.

Client education and health literacy, a mode of advocacy, are essential aspects of nursing care. Nurses educate clients and assist them to understand their disease process and related medical procedures, allowing them to make informed health care decisions. Empowerment begins with education. The education the nurse provides for the client helps empower them to understand and make informed choices.

Health Literacy: The degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. Nurses can advocate for clients by being their voice and speaking up for them in situations where they may not understand what is going on and help them ask questions to get clarification from providers. Nurses also help translate medical terminology into basic terms that clients can understand. Nurses help clients with resources within and outside of the hospital in the community in which they live. Client advocacy is also a team effort with other providers, such as case managers and social workers, to ensure the client is safe in the hospital and in community settings such as the home.

It is helpful when identifying and addressing societal factors (e.g., finance, environment, and social support) that may:

Hinder or enhance their access to healthcare.

Healthy People Initiative (Healthy People 2030):

In 1980, the Office of Disease Prevention and Health Promotion (ODPHP) launched the Healthy People initiatives that serve to set measurable goals to move the nation's people to a healthier state of being. With a mission and vision focused on achieving optimal health and well-being of the country's population, the overarching goals are: 1. Attain healthy, thriving lives and well-being free of preventable disease, disability, injury, and premature death. 2. Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. 3. Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all. 4. Promote healthy development, healthy behaviors, and well-being across all life stages. 5. Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all. Healthy People addresses a wide range of health issues, such as environmental health and disease prevention. According to the ODPHP, the third goal aims at addressing the challenges of social determinants of health in some areas of the country. There are founding principles that guide how these objectives are formulated and an action plan for how they are executed. These initiatives not only drive the nation's public health agendas but also influence public health activities at multiple levels of society. In a 40-year time span, change is inevitable, so every 10 years, committees of experts from various professions evaluate the objectives for progress and relevance and make revisions. They use the data gathered over the current decade to decide what to change for the coming decade and build upon this cumulative work.

Social and Community Context:

Individuals and families need a social support system for mental and social well-being. The support system can include anyone from members of extended family, friends, and neighbors to community organizations (e.g., religious organizations, civic clubs). The support can be in the form of a listening ear in times of stress, transportation to the doctor's office, or long-term care in the home. When people have a strong support system, they tend to have access to more resources when problems arise (e.g., group problem-solving, materials resources, moral support). When those with weak support systems, especially those who are isolated and disenfranchised, are met with adversity (e.g., financial crisis, family death, teenage pregnancy), they often lack support people they can reach out to for help, increasing their stress and negatively affecting their mental health.

Pender's Health Promotion Model:

Internal motivation factors to adopt healthy lifestyle. Pender's health promotion model is used to help nurses understand factors that affect an individual's health and use those factors to guide them toward healthier behaviors. Rooted in social cognitive theory and expectancy value theory (which states that people work toward actions that are of value to them and are achievable), Pender's model describes how certain factors affect an individual's motivation to adopt a healthy lifestyle. Some of them are prior experiences; perceived benefits, barriers, and capability to do the desired behavior; current life situation; and the presence of social support. Main Takeaway: According to Pender, people are more likely to engage in healthier behaviors when they perceive fewer barriers, see greater benefits, believe in their own abilities for success, and have a supportive social system that engages in the activity with them.

Health Belief Model:

Internal motivation for improving health. The health belief model looks at the internal factors that motivate people to practice health-related behaviors, specifically their perceptions of their own health and any possible threats to it. Important factors, which focus on the individual, in this model are the likelihood of developing an illness, how severely it will manifest if the illness is not treated, benefits and barriers to adopting a lifestyle that will prevent the illness, and the presence of motivation to implement a plan of action and the likelihood of success. This model is useful when creating a step-by-step blueprint on how to present the need to engage in healthy behaviors in health programs. It can also guide the creation of interventions to execute in the present and in the long term. As an example, nurses can utilize principles of the health belief model to help teenagers who are overweight move toward a healthy weight. The nurse can help the teens identify internal and external contributors to their unhealthy weight. The nurse can assist the teen to identify points of control and barriers related to food and activity choices. The nurse can provide external support until the teens are ready to utilize internal motivators that support healthy weight and activity levels. While the health belief model is often applied to individuals, it can also be used with families, groups, and communities. Communities often have beliefs or biases about limitations regarding the ability to improve their health. The nurse can help these groups and communities address systematic barriers by assessing the health beliefs and then working with the members to design interventions to improve overall health.

Historical Influencers of the 1800s: - Jessie Sleet Scales and Mary Breckinridge

Jesse Sleet Scales, the first Black public health nurse in the U.S. (1865 - 1956): - Initially worked in New York, with Black families suffering from tuberculosis. She was very successful, and her caseload grew. She reported making almost 160 home visits in a two -month period. - She earned the respect of her peers and colleagues, who reported her efforts in one of the earliest editions of the American Journal of Nursing. - Scales went on to work with two other Black nurses, Elizabeth Tyler and Edith Carter, to establish the Stillman House, a branch of the Henry Street Settlement in an area of New York City known as San Juan Hill. - The house provided care to Black families similar to the Henry Street Settlement and offered a variety of services, including a bank, classes, and a civic club. Mary Breckinridge, a nurse and midwife, is credited with creating the Frontier Nursing Service (FNS) (1881 - 1956): - Breckinridge started her career as a public health nurse in Washington, D.C., caring for victims of the 1918 influenza pandemic. - Afterward, she traveled to Europe, where she studied midwifery, and in 1925, she came back to the U.S. where she found a woeful lack of prenatal care and high infant and maternal mortality rates. - She started the FNS, a home care visiting program, along with other nurses who, because of a lack of roads in rural Kentucky, visited their clients on horseback. - Realizing that the local midwives she encountered were uneducated, she helped establish the Frontier Graduate School of Midwifery in 1939.

Nurses advocate for clients by ensuring their safety in all settings, and that they are safely discharged home or to another facility. The safety of all clients is the basis for providing nursing care in all health care settings, including inpatient, outpatient, communities, schools, occupational centers, and clinics. Clinical errors, adverse events, and risks associated with health care continue to be a major patient safety challenge worldwide. In 2019, the 72nd World Health Assembly addressed key issues for patient safety and mandated the development of a Global Action Plan for Patient Safety.

Nurses ensure identification and management of clinical risks, such as medication errors, health care-associated infections (HAI), diagnostic errors, sepsis, and harm to the client's safety in mental health settings. Many opportunities for a nurse to advocate for safety in a home care setting would occur when caring for an older adult client. It is the responsibility of a community nurse providing home care services to ensure the security, safety, and access to community services for the older adult client. Along with the client's family and friends of this client, the community nurse advocates to provide services to ensure the client has adequate nutrition, access to medical care, transportation services, medical supervision, and access to community resources.

Ethical Decision Making:

Nurses must understand their own ethics and values in their practice. Ethical dilemmas frequently come up while caring for clients and the community. Nurses must be able to recognize when ethical dilemmas occur and apply professional ethics and core values in their judgment and decision making. There are four principles of nursing ethics to assist with the ethical analysis in making decisions. - Autonomy - Beneficence - Nonmaleficence - Justice

What is Nursing in The Community:

Nursing in the community involves healthcare professionals providing nursing care outside of traditional healthcare settings, often within communities, homes, or public health contexts. Community nurses focus on preventive care, health promotion, and supporting individuals and families to achieve and maintain optimal health. This can include activities such as health education, immunizations, disease prevention, and addressing the specific needs of diverse populations within a community. Community nursing aims to enhance overall community well-being and reduce health disparities.

Neighborhood and Built Environment:

Places where people live and work can play a significant role in their health. For optimal health, housing and neighborhoods must be safe for people to live and move around in. This means that the housing must adhere to local, state, or federal codes. It also means that people must feel safe when engaging in everyday activities. There must also be a low criminal element in the local areas so that individuals feel safe to enjoy the outdoors. There needs to be safe, potable water, clean air, and functioning waste treatment systems. Another needed resource is quality, reasonably priced food. Racial and ethnic minorities and people of low socioeconomic status are more likely to live in communities where these resources do not exist or are in short supply. Work sites need to be safe to help decrease the incidence of injuries. Green spaces, such as parks, should be available to promote healthy, active lifestyles. In low-income communities, there may not be financial resources available to repair or rebuild damaged buildings or create safe outdoor spaces such as parks and walking trails. In high-crime areas, it may be so unsafe that individuals in that community can only spend a limited amount of time outside. Regardless of the cause, contaminated water sources, limited ability to enjoy more active lifestyles (e.g., walking, jogging, playing in the park), unsafe housing (substandard construction, asbestos, or lead pipes and lead-based paint), and systemic racism issues can negatively affect the individual's health.

As health care and the nursing profession have evolved, different specialties of nursing practice in the community evolved with them. Today _______, ________, _______ are recognized as distinct field of community health practice:

Public Health Community Health Population Health

Core Functions of Public Health Nursing + Examples:

Public health works toward protecting the health of the public at all levels of society (local to global) Assessment (collect and analyze data within the public and what resources are available) - Gathering/analyzing health data - Examples—epidemiological statistics: on the incidence and prevalence of diseases, tracking trends to inform public health strategies. Definition: Systematic collection and analysis of data to understand health needs, risks, and resources in a population. Policy Development (working with legislators to put things into place) - Collaboration with lawmakers: to create legislation promoting healthy behaviors, such as tobacco control policies or regulations on food safety. - Development of public health policies Definition: Developing and implementing evidence-based policies and interventions to address public health issues. Assurance - Improve accessibility and delivery of services: such as vaccination programs, maternal health services, and emergency preparedness initiatives. - Quality Assurance: making it sure it's doing the action it needs to do without harming the patient. Definition: Ensuring the availability and accessibility of essential health services and maintaining a competent public health workforce. These core functions and pillars collectively form the foundation of public health practice, emphasizing the importance of assessment, policy development, and assurance in promoting and protecting the health of communities.

Stages of Change Model (Transtheoretical Model):

Readiness to adopt healthy behaviors. The readiness for a person to adopt a healthy behavior happens in stages. During the maintenance stage, the individual may go back to the old behavior when under stress or in conflict. Identifying triggers to engage in unhealthy behavior and avoiding them should be included in the individual's plan. Identifying a support system and encouraging the individual to use it can truly help their plan to be more successful. This model is helpful when customizing individual plans in a health program like tobacco cessation or weight management for the client. The transtheoretical model can be also applied to communities. The model can be used when designing programs to deal with tobacco cessation and weight management for a group. Think about another application of the transtheoretical model in the community where there is a high higher than the average number of children with cognitive impairment in the school district. Are the community members even aware of the problem (precontemplation stage)? The school nurse can work with the school district personnel, city leaders, and public health officials to identify potential environmental causes (lead pipes or paint in older homes) thus raising awareness (contemplative stage). The Stages of Change: Pre- contemplative (not seeing a need to change) Contemplative (seeing the need for change but blocked by barriers to adopt change) Preparation (creating a plan to change) Action (implementing the plan to change) Maintenance (implementing and maintaining the plan for change) Termination (the healthy behavior is ingrained without thoughts of reverting to previous behavior)

Access to and Quality of Health Care:

Regular wellness check-ups, reliable health education, and availability of health care providers, services, and facilities are needed to monitor one's health and detect any illnesses early enough for treatment and better outcomes. Individuals and families may have comprehensive insurance coverage to be able to pay for those commodities. Finding affordable comprehensive health insurance coverage has become more challenging over the last decade. Insurers report the rate of increase is affected by the overall increase in health care costs. The cost of coverage can be difficult for everyone but is more challenging for those with low socioeconomic backgrounds. These individuals are often made to choose between using their finances for essential goods (e.g., utilities, food, housing) or buying health insurance. When the former is chosen, they could be forced to use the emergency department or urgent care center as a primary care provider. Individuals who are working may also choose a low premium, high deductible plan to afford the premiums. These choices may contribute to limited care options or waiting until a condition worsens, sometimes beyond cure, before seeking care. Finding affordable, quality health care is not only a problem for the poor. Having limited resources in a given area also decreases the options available for health care services. In rural and inner-city areas, coverage may not necessarily be the most important issue. Often, there is a shortage of providers and facilities in the local community, compelling them to travel long distances to access health care services or leading to delayed care. Distance to the provider and reliable, available transportation can have a significant impact on access to quality health care services.

A nurse advocate supports and informs the client of their rights including:

Self Determination Confidentiality Access to Healthcare Choice Information Redress

Population Health Nursing:

Targets those at risk for specific health conditions. Assist clients in managing health conditions in community. - Example: A population health nurse may work closely with individuals diagnosed with diabetes in the community. This could involve conducting regular health check-ups, providing education on dietary management, and offering support in navigating the healthcare system for necessary treatments. Connect clients to community resources. - Example: A population health nurse might identify an elderly individual struggling with social isolation. The nurse could then connect this person to local senior centers, recreational programs, or transportation services to improve their social engagement and mental well-being. Coordinate care across health care spectrum. - Example: In a community, the population health nurse could collaborate with primary care physicians, mental health professionals, and social workers to ensure a coordinated approach for individuals with complex health needs, such as those with both physical and mental health conditions. Create health initiatives that target specific population. - Example: Recognizing a high prevalence of smoking among teenagers in a particular area, a population health nurse might initiate a school-based anti-smoking campaign. This could involve educational workshops, peer-led activities, and collaborating with local schools to create a smoke-free environment. Goal: Overall improvement in quality of life - Example: A population health nurse may implement a community-wide initiative focused on healthy aging. This could include exercise classes for seniors, workshops on nutrition, and improvements in the accessibility of public spaces for the elderly, ultimately enhancing their overall quality of life.

Historical influences - 1800s

The 1800s saw the establishment of health departments, hospitals, and schools of nursing. However, hospitals of the time were places where many people died because of infection and poor sanitation. - High mortality in hospitals from infection.

Before nursing expanded into acute care settings, most of nursing was practiced in:

The Community

Economic Stability:

The economic stability of an individual or community is affected by various factors. The level of education and skill set determine what kind of employment may be obtained. However, the availability of jobs in any given area of the world, particularly those that match the abilities of the individual, will also determine economic stability. Some areas, especially rural areas, may be limited in what they can offer families so that they will be able to meet their financial needs. In these areas, there may be lots of employment available, but the jobs pay minimum wage. This may leave families and individuals pursuing multiple jobs to make ends meet, which can also put stress on their psychosocial well-being. The more jobs with livable wages that can cover the cost of living in an area, the more stable the local economy can be.

Secondary Level of Prevention:

The target audience for this level are those within the population who are possibly "at risk" for having a condition that the community health team was trying to prevent on the primary level. Here, the activities done at this level are screening or assessing for the condition and early treatment. Examples of screenings might be blood pressure screenings or testing for disease (e.g., TB skin test). If the screening or assessment is positive for the condition, early treatment is implemented. Early treatment might be a referral to health services, medication, quarantine, or mandatory reporting. If the results are negative, then primary levels of intervention should be employed at this time. - Targets those "at risk" for illness - Goal: Early detection/Early treatment Examples: - BP screening - STD testing - MRI/Scans - Blood work

Primary Level of Prevention:

The target audience for this level of prevention is the well population. This group of people do not have a condition yet (e.g., communicable or chronic disease, injury, social condition). The goal for this population is to implement interventions that will prevent conditions of poor health. Types of activities that would be done at this level are education on healthy living, ways to prevent spread of disease (e.g., hand hygiene), and immunizations. - Targets healthy individuals/communities - Goal: Prevention of illness Examples: - Hand hygiene - Education - Immunizations - Tobacco and substance abuse prevention - Birth control and condoms

Social Cognitive Theory Model:

This theory focuses on an individual's personal beliefs about self and their interactions with their interpersonal relationships and environment. Opportunities for social support are provided as expectations are instilled. Reinforcements, like observational learning or coaching, are used to achieve behavior change. Self-efficacy is a critical component of success. This theory can be used in guiding behavior change once a plan for change has been implemented. Social cognitive theory can be used with groups. Alcoholics Anonymous and weight loss programs include social support from others who are or have been in similar situations. Meetings and sponsors can provide reinforcement and coaching.

Levels of Prevention:

When delivering any kind of care to the public, nurses focus on preventive interventions to improve outcomes. Public health literature divides these interventions into three levels across the health spectrum. The categories are as follows: