Community Health Nursing A Canadian Perspective, 5th editionLynnette Leeseberg Stamler Solution Manu

INSTRUCTOR’S MANUAL Aliyah Dosani Mount Royal University

Community Health Nursing: A Canadian Perspective Fifth Edition Lynnette Lesseberg Stamler University of Nebraska Medical Center

Lucia Yiu University of Windsor

Aliyah Dosani Mount Royal University

Josephine Etowa University of Ottawa

Cheryl van Daalen-Smith York University

Contents Chapter 1:

The History of Community Health Nursing in Canada

1

Chapter 2:

Policy, Politics, and Power in Health Care

8

Chapter 3:

Nursing Roles, Functions, and Practice Settings

19

Chapter 4:

Public Health Nursing

27

Chapter 5:

Home Health Nursing in Canada

32

Chapter 6:

Advocacy, Ethical, and Legal Considerations

38

Chapter 7:

Theoretical Foundations of Community Health Nursing

44

Chapter 8:

Health Promotion

49

Chapter 9:

Race, Culture, and Health

62

Chapter 10:

Evidence-Informed Decision Making in Community Health Nursing

69

Chapter 11:

Epidemiology

75

Chapter 12:

Communicable Diseases

88

Chapter 13:

Community Nursing Process

98

Chapter 14:

Community Health Planning, Monitoring, and Evaluation

106

Chapter 15:

Digital Health

112

Chapter 16:

Maternal, Newborn, and Child Health

121

Chapter 17:

School Health

128

Chapter 18:

Family Nursing

143

Chapter 19:

Gender and Community Health

155

Chapter 20:

Lesbian, Gay, Bisexual, Transgender, Queer, and Two Spirit Clients 163

Chapter 21:

Older Adult Health

170

Chapter 22:

Indigenous Health

175

Chapter 23:

Community Mental Health

182

Chapter 24:

Rural and Remote Health

193 . ii

Chapter 25:

Chronic Care, Long-Term Care, and Palliative Care

203

Chapter 26:

Correctional Health

209

Chapter 27:

Ecological Determinants of Health and Environmental Health Inequities

218

Chapter 28:

Violence in Societies

223

Chapter 29:

Poverty, Homelessness, and Food Insecurity

230

Chapter 30:

Substance Use

235

Chapter 31:

Sexually Transmitted and Blood-Borne Infections

242

Chapter 32:

Emergency Preparedness and Disaster Nursing

253

Chapter 33:

Global Health

260

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Chapter 1 The History of Community Health Nursing in Canada

Chapter 1: The History of Community Health Nursing in Canada Suggestions for Guest Speakers 1. Ask a representative from the Canadian Association for the History of Nursing to visit, Skype, or phone conference with the students.

2. Ask a retired Community Health Nurse who worked during an earlier generation to come and speak about what his/her work looked like in the past.

3. Ask women from two generations (e.g., a mother and a grandmother) to visit the class and describe their experience with childbirth, immunization, etc. and ask the students to compare the two experiences.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students to watch the silent film called Public Health Nursing in Manitoba (http://www.youtube.com/watch?v=oIj9CFGETcw). Ask the students to summarize the many roles that they observe the nurse carrying out in the video. What did the video say about knowledge “today” and its impact on tomorrow?

Description: A film produced by Pathescope of Canada, Ltd. that demonstrates the many roles served by nurses of the Provincial Board of Health in Manitoba. It depicts a public health nurse visiting the Charleswood Municipal Office, lecturing students in a schoolhouse on proper hygiene and administering checkups to the students, visiting a mother and demonstrating proper childcare techniques with her baby, meeting with the Women's Institute, participating in a Child Health Conference at the summer fair, demonstrating childcare techniques to girls as part of the Little Mothers League, conducting a nutrition class, and visiting a rural home in conjunction with the Manitoba Red Cross Society.

2. Go together to visit a historical nursing display near you or ask the students to take an online tour of the Canadian Nursing History Museum http://www.civilization.ca/cmc/exhibitions/tresors/nursing/nchis01e.shtml. Have a discussion about the types of nursing practices observed in the displays and the similarities and differences of community health nursing practices of today.

3. Ask the students to look at Figures 1.1 and 1.2 for three minutes. Provide index cards and ask the students to write out the event that they feel was most important in the evolution of Community Health Nursing in Canada. Ask the students to come forward and tape the card to the board as they explain why they chose that event. Line the cards up chronologically across the board. Summarize at the end.

.

1

Chapter 1 The History of Community Health Nursing in Canada Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

2. Ask a representative from the Canadian Association for the History of Nursing to have an on-line chat, Skype, or phone conference with the students.

Practice Application 1. Ask the students to watch the silent film called Public Health Nursing in Manitoba (http://www.youtube.com/watch?v=oIj9CFGETcw). Ask the students to summarize the many roles that they observe the nurse carrying out in the video. What roles that the nurses were demonstrating for public health nurses in 1921 still are a part of PHN today?

From the readings, what do we know about PHNs from 1921 (that they were civil servants, paid, elite, required post-certificate training, etc.)?

Description: A film produced by Pathescope of Canada, Ltd. that demonstrates the many roles served by nurses of the Provincial Board of Health in Manitoba. It depicts a public health nurse visiting the Charleswood Municipal Office, lecturing students in a schoolhouse on proper hygiene and administering checkups to the students, visiting a mother and demonstrating proper childcare techniques with her baby, meeting with the Women's Institute, participating in a Child Health Conference at the summer fair, demonstrating childcare techniques to girls as part of the Little Mothers League, conducting a nutrition class, and visiting a rural home in conjunction with the Manitoba Red Cross Society.

2. Ask the students to visit a historical nursing display near them or take an on-line tour of the Canadian Nursing History Museum http://www.civilization.ca/cmc/exhibitions/tresors/nursing/nchis01e.shtml. Have a discussion about the types of nursing practices observed in the displays and the similarities and differences of community health nursing practices of today.

3. Ask the students to consider how their current practice/learning experience would differ if they were in a rural rather than urban environment. What resources would/would not be available if the students were in the opposite environment? Ask urban students to create a “mind map” of the resources available in rural areas that are not available to their current practice (tight-knit community, close relationship to churches, farm-fresh food, etc.). Ask rural students to create a “mind map” of the resources available in urban areas that are not available to their current practice (resources for disability or disease-specific needs, etc.).

Seminar Discussion Questions 1. Ask the students to consider their community placement and the population that they are working with. Did this community placement exist in Canada before WWII? If so, how might it have changed? What would life have been like for older adults, Indigenous people, people with different abilities, new mothers, or people experiencing poverty) .

2

Chapter 1 The History of Community Health Nursing in Canada before socialized universal healthcare? Have the issues that your community placement is focusing on increased or decreased in severity since WWII? What might be factors influencing the increase/decrease of social issues since that time?

2. What is the proportion of male, female, transgender, and nurses who identify as gender variant working at your community placement? Do you think that there are past or current issues that influence the areas of nursing that male, female, transgender, and nurses who identify as gender variant choose to go into?

Case Study 1. What are some lessons from past leaders in nursing that can influence your advocacy work to respond to the early childhood development in your district?

•

Past leaders in community health nursing learned about the impact of social determinants on the health of their clients. They also learned that Mothers need support and assistance to ensure the health of their children.

2. What current considerations does the PHN need to take into account when establishing priorities to respond to the inequities witnessed?

•

PHNs need to take into account the identified needs of their clients when establishing priorities to respond to the inequities witnessed. The first step in assessing needs is to ask the client themselves and involve them in any planned actions.

3. What are some opportunities the PHN can pursue to strive for health equity for the children in the community?

•

Opportunities the PHN can pursue to strive for health equity for the children in the community are to do a community assessment to determine what the health equity issues are, then establish priority programs designed to assist those most vulnerable such as food banks, housing assistance and shelters.

Canadian Research 1.1 1. What are key factors influencing the development and implementation of the social determinants of health work in community health nursing?

•

.

Students would have to prepare for this discussion by either reading about or actively gathering information about specific public health nursing programs in rural and remote locations. They could examine issues of how nurses respond to the Social Determinants of Health and provide examples of nursing initiatives that are implemented and what some of the facilitators and barriers are in incorporating the Social Determinants of Health in the programs.

3

Chapter 1 The History of Community Health Nursing in Canada 2. What are some of the tensions in enabling nurses to address the social determinants of health?

•

•

A starting point for considering this question is to reflect on historical achievements of women’s groups and CHNs in advocating for essential services for poor, immigrant and underserved communities. Students can reflect on the lives and contributions of nurses such as Eunice Dyke who had a clear vision for CHNs roles’ in addressing poverty and other social determinants of health. Ask the students to consider current local examples of individual nurses or the nursing profession as a whole taking a stand and advocating for professional practice in the interests of populations and communities.

This discussion may also extend to barriers to nurses advocating for social determinants of health within their current positions. Reading the work of FalkRafael and Betker on health equity and the theory of critical caring may help students address issues related to nursing’s power in voice and advocacy.

Advocacy for reform of current community-based healthcare programs can also be achieved through voluntary work. Community health nurses can, in their personal lives, serve on the boards of voluntary agencies that provide health and social services to the community. Their knowledge and experience can be used to shape the policies of these agencies, and to transform the agency’s interaction with its clients and with other voluntary and publicly funded agencies.

3. What are some strategies CHNs can implement in practice for health equity?

•

There are numerous examples of how nurses provided leadership for health equity in the development of essential services throughout history. Students can reflect on specific examples referred to in this chapter and encouraged to pursue further readings on historical figures or groups such as the Victorian Order of Nurses with specific emphasis on how nurses worked to provide the leadership. Examples include how they worked with women’s groups, political advocacy and courage as well as a practical vision for what was needed based on the nature of their relationships with individuals, families and communities. At this point in history characterized by social change and emerging health needs, nurses must provide leadership for the establishment of health services that do not yet exist, for example – in home care, seniors’ care, and public health, to name a few.

Individual Critical Thinking Exercises The sources listed at the end of each question are cited in full in either the References or the Additional Resources section of this chapter. Each source will provide additional insights into the controversies and debates surrounding the history of public health and visiting nursing.

1. Community health nursing has frequently been described as more autonomous than nursing practice in institutional settings. However, Eunice Dyke, Toronto’s first supervisor of public health nursing, once stated that “...public health nursing has in the .

4

Chapter 1 The History of Community Health Nursing in Canada medical profession its greatest friend and not infrequently its greatest stumbling block.”

How autonomous was the practice of early community health nurses? (Sources: Comacchio, 1993, Chapter 7; Stuart, 1992) •

This question encourages students to think about the evolution of autonomy in professional nursing practice. Both Comacchio (1993) and Stuart (1992) discuss the impact that physicians had on the role of community health nurses. Much of the historic evidence points to the fact that, although some male physicians were supportive of community-based nurses, many were not. Their reasons for taking this position were varied, including their belief that women were not capable of autonomous decision making, their concerns that nurses might infringe upon and even compete with their medical practices, and their belief that, ultimately, decision-making was the prerogative of the male. Eunice Dyke, for example, was hired as the first public health nursing supervisor in Toronto’s public health department and enjoyed considerable autonomy in her supervisory role, but she was ultimately fired for her refusal to accept a decision made by a medical officer of health. Stuart (1992) also points out that the opinions of the local community and its leadership also shaped the practices of community-based nurses and constrained their autonomy.

2. What role did middle-class ideas about class, ethnicity, and gender play in the development of public health programs to protect the health of infants and children?

(Sources: Gleason, 2002; Comacchio, 1993, Chapter 3) •

In the past many public health programs adopted beliefs and values based on those of the middle class. These were accepted as the normative standard against which others were evaluated. This question encourages students to critically examine the idea of ‘normal’ and to evaluate the potential impact of its use as a standard to evaluate the health practices of individuals, families, and communities.

3. Reflecting on community health nursing education in your nursing program, what issues do you see that are continuous with the past as described in this chapter?

•

This question prompts students to reflect on their education and how it corresponds to what students were learning when public health nursing education was first initiated. It also encourages them to think about changes in practice and educational needs over time.

Group Critical Thinking Exercises 1. Social historians such as Alan Hunt (1999) argue that charity, philanthropy, and welfare programs are essentially efforts by the elite and middle classes to impose their behaviour, values, and culture upon others. Hunt describes these programs of moral or social regulation as being inspired by “...the passionate conviction that there is something inherently wrong or immoral about the conduct of others” (p. ix). Locate an issue of an .

5

Chapter 1 The History of Community Health Nursing in Canada early public health or nursing journal such as The Public Health Journal (now the Canadian Journal of Public Health) or The Canadian Nurse (particularly the section on public health). Conduct a brief content analysis of the issue, paying close attention to how the recipients of public health interventions are described. What conclusions can be drawn about the attitudes of healthcare professionals? What anxieties seem to underlie the interventions they describe and recommend to other healthcare practitioners?

•

It is often easier to identify prejudice, notions of superiority, and judgmental attitudes in the writings of practitioners who worked in earlier times than it is to see these patterns in contemporary publications. Early issues of professional journals are useful tools to examine not only the health and social needs evident at the time, but also to examine the attitudes, beliefs, and values of the writers. In assisting the students to uncover and examine attitudes, beliefs, and values of early community health practitioners, the instructor may also be providing a foundation that will enable students to critically examine contemporary literature specific to these themes.

2. Nurses were the intermediaries between the clients they served and the social and political elite who employed them to work in the community. However, their perspective on the objectives and effectiveness of community health programs is often absent from published histories of public health. To fill this gap in the historical record, do one of the following: (1) locate a biographical account written by an early visiting or public health nurse, (2) locate an oral history of an early visiting or public health nurse in an archive, or (3) interview a retired visiting or public health nurse. How does their account resemble and differ from the history of community health nursing presented in this chapter? How would you account for any differences you identify?

•

This exercise is similar to the one above. Some of the written accounts, oral histories, or interviews with early community health practitioners would offer an uncritical view of their roles in the community. Other practitioners would provide thoughtful and profound insights into their successes and failures. Instructors can help the students gather multiple perspectives in order to gain a broader understanding of the impact that community health nurses have on the communities they serve.

3. Based on what you have learned about the history of community health nursing in Canada, what do you believe are the greatest challenges facing nurses in this practice setting today and in the future?

•

.

The instructor can encourage students to discuss a wide range of social, economic, and political factors that will have an impact on community health nursing today and in the future.

6

Chapter 1 The History of Community Health Nursing in Canada Further Resources Buhler-Wilkerson, K. (1989). False dawn: The rise and decline of public health nursing, 1900– 1930. New York: Garland.

Buhler-Wilkerson, K. (2001). No place like home: A history of nursing and home care in the United States. Baltimore, MD: Johns Hopkins University Press.

Comacchio, C. (1993). Nations are built of babies: Saving Ontario’s mothers and children 1900– 1940. Montreal: McGill–Queen’s University Press.

Copp, T. (1981). Public health in Montreal, 1870–1930. In S. E. D. Shortt (Ed.), Medicine in Canadian society: Historical perspectives. Montreal: McGill–Queen’s University Press.

Falk-Rafael, A., & Betker, C. (2012). The primacy of relationships: A study of public health nursing from a critical caring perspective. Advances in Nursing Science, 35(4), 315–332. doi:10.1097/ANS.ObO13e318271d127 Gleason, M. (2002). Race, class and health: School medical inspection and “healthy” children in British Columbia, 1890–1930. Canadian Bulletin of Medical History/Bulletin Canadien d’histoire de la médecine, 19(1), 95–112.

Hunt, A. (1999). Governing morals: A social history of moral regulation. Cambridge, UK: Cambridge University Press.

Stuart, M. (1989). Ideology and experience: Public health nursing and the Ontario Rural Child Welfare Project, 1920–25. Canadian Bulletin of Medical History/Bulletin Canadien d’histoire de la médecine, 6, 111–131.

Stuart, M. (1992). “Half a loaf is better than no bread”: Public health nurses and physicians in Ontario, 1920–1925. Nursing Research, 41(1), 21–27.

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7

Chapter 2 Policy, Politics, and Power in Health Care

Chapter 2: Policy, Politics and Power in Health Care Suggestions for Guest Speakers 1. Ask a nurse leader (representative at the federal, provincial, or local level including nursing and health organizations, foundations and associations) to discuss the role of nurse leadership using various social media platforms.

2. If there has been a major policy change in your area related to community health, ask a nurse who was involved in the change to visit to share their experience. Several new laws, policies, and modifications to existing laws frequently come into effect. Here are a few for consideration: a. b. c. d. e. f. g. h. i. j.

Truth and Reconciliation Commission (TRC) Report Medical Assistance in Dying (MAID) Basic Income (Minimum wage) Changes Income tax cuts for the middle class Federal Government Cannabis legalization Post-traumatic stress disorder recognized as a work-related illness Tougher distracted driving penalties Health care premiums rising in British Columbia Ban flavoured tobacco products Advertising directed to children

3. Ask a nurse who is involved in politics to speak to the class about why they decided to enter this area.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students to consider the pros and cons of both fee-for-service financing for healthcare workers and salaried services. Allow them to think about this for two minutes as they read the following definitions: a. Fee-for-service - healthcare providers receive payment for each act provided to each client. b. Salaried - healthcare providers receive payment and benefits for each day or month that they provide care.

Next, ask them to complete the following table and write down their thoughts.

.

8

Chapter 2 Policy, Politics, and Power in Health Care

Pros

Cons

Fee-For-Service

• Providers are rewarded for higher volume of work •

• Providers do not receive benefits •

Salaried Care

•

•

2. Bring in one or two copies of policies that are related to community nursing care in your area (such as a Public Health Unit’s vaccination policy or a home nursing policy on maintaining personal safety). Ask the students to consider how the policies were formed. Who wrote the policy and what information went into creating it? Does the policy appear to be specific enough? Too specific? Ask the students to create a policy for themselves (perhaps around assignments).

Several examples of policies set out by the Canadian Nurses Association can be found on their website www.cna-aiic.ca Ask the students to think about their personal leadership style. Examples of popular leadership styles include: autocratic, democratic, servant leadership, and transformational leadership.

Divide the class into groups of four. Ask each group to demonstrate through a short skit an example of one of the leadership styles in action. Use an example of a decision that community nurses may need to make. One example might be a group of public health nurses deciding how best to encourage clients and families to stay for 15 minutes following their injection at a flu clinic. Ask the students to choose a “leader” who will demonstrate one of the following four styles: a. Autocratic leadership: Autocratic leadership allows leaders to have complete power over their team. Team members are not afforded the opportunity to suggest changes. Autocratic leadership may result in disgruntled and disloyal staff. b. Democratic leadership or participative leadership: As the name suggests, democratic leaders invite other team members to contribute to the process of decision-making. However, the final decision rests with the leader. By including the opinions of others, the leader can capitalize on the input of their team members. Members feel more invested in the outcome and as a result are motivated to work hard. The process of gathering the opinions of others may be time consuming but often results in a better thought out plan of action. c. Servant leadership: Servant leadership may involve a system where the true leader is not formally recognized with a title or position. By meeting the needs of the .

9

Chapter 2 Policy, Politics, and Power in Health Care team at any level within an organization, they are described as a servant leader.

Servant leadership shares a lot in common with democratic leadership, as the decision-making process involves all team members in both styles. d. Transformational leadership: Figure 2.1 identifies contextual and personal factors that impact a nurse’s approach to transformational leadership. Leaders with this leadership style motivate their teams by developing a shared vision of the future.

Next, ask the students to consider which style fits best with their personal philosophy of community nursing care. Ask them to write a brief paragraph to describe their thoughts. If they can’t choose one, or a hybrid of two, have them consider why it is difficult for them. Provide time for them to discuss their thoughts with a neighbour.

Ideas for Self-Study and Distance Students 1. Clarify any questions about the information from the text.

2. Ask the students to consider the pros and cons of both fee-for-service financing for healthcare workers and salaried services. Allow them to think about this for two minutes as they read the following definitions: a. Fee-for-service - healthcare providers receive payment for each act provided to each client. b. Salaried - healthcare providers receive payment and benefits for each day or month that they provide care.

Next, ask them to complete the following table and write down their thoughts.

Pros

Cons

Fee-For-Service

• Providers are rewarded for higher volume of work •

• Providers do not receive benefits •

Salaried Care

•

•

3. Ask the students to locate 1 or 2 copies of policies that are related to community nursing care in their area (such as a Public Health Unit’s vaccination policy or a home nursing policy on maintaining personal safety). Ask the students to consider how the policies were formed. Who wrote the policy and what information went into creating it? Does the policy appear to be specific enough? Too specific?

.

10

Chapter 2 Policy, Politics, and Power in Health Care Several examples of policies set out by the Canadian Nurses Association can be found on their website www.cna-aiic.ca 4. Ask the students to think about their personal leadership style. Examples of popular leadership styles include: autocratic, democratic, servant leadership, and transformational leadership. Divide the class into groups of four. Ask each group to demonstrate through a short skit an example of one of the leadership styles in action. Use an example of a decision that community nurses may need to make. One example might be a group of public health nurses deciding how best to encourage clients and families to stay for 15 minutes following their injection at a flu clinic. Ask the students to choose a “leader” who will demonstrate one of the following four styles: a. Autocratic leadership: Autocratic leadership allows leaders to have complete power over their team. Team members are not afforded the opportunity to suggest changes. Autocratic leadership may result in disgruntled and disloyal staff. b. Democratic leadership or participative leadership: As the name suggests, democratic leaders invite other team members to contribute to the process of decision-making. However, the final decision rests with the leader. By including the opinions of others, the leader can capitalize on the input of their team members. Members feel more invested in the outcome and as a result are motivated to work hard. The process of gathering the opinions of others may be time consuming but often results in a better thought out plan of action. c. Servant leadership: Servant leadership may involve a system where the true leader is not formally recognized with a title or position. By meeting the needs of the team at any level within an organization, they are described as a servant leader.

Servant leadership shares a lot in common with democratic leadership, as the decision-making process involves all team members in both styles. d. Transformational leadership: Figure 2.1 identifies contextual and personal factors that impact a nurse’s approach to transformational leadership. Leaders with this leadership style motivate their teams by developing a shared vision of the future.

Next, ask the students to consider which style fits best with their personal philosophy of community nursing care. Ask them to write a brief paragraph to describe their thoughts. If they can’t choose one, or a hybrid of two, have them consider why it is difficult for them. Provide time for them to discuss their thoughts with a neighbour.

Seminar Discussion Questions 1. Ask the students to consider their community placement and the population that they are working with. How is the organization funded? Where are the organization’s policies kept? Who creates them? How are they implemented? How do organizational politics impact the day-to-day running of the placement area? Where is the first point of contact for the clients at your placement (physician, nurse, pharmacist, chiropractor, etc.)? How .

11

Chapter 2 Policy, Politics, and Power in Health Care are these healthcare providers compensated? How are nurses involved in the care of people during health challenges?

Case Study 1. How is health inequity implicated in this case?

•

Have students discuss the various social determinants of health in relation to the specific situation of Vodina and his family. For example, how might gender, lack of proper housing, unemployment, and limited education and social support networks create health inequities?

2. What is the role of CHNs in addressing alcohol dependency?

•

Community health nurses need to systemically assess to families such as this for both individual and structural factors may impact on health and their coping mechanisms. Community needs assessment, which is a key role of CHNs should involve principles of community development and must tap into the assets and talents of community members and other stakeholders. What are the local factors contributing to this family’s situation? What are the health and needs of the community (i. this particular Ottawa neighborhood? In addition to working with the individual and family (point-of-care), CHNs also focus advocating for broader structural (system) changes to improve access to health and social services.

3. What combination of policy and public health interventions could be used to reduce alcohol-related harms?

•

•

.

Strengthen community action: i. Identify and educate community partners and the public on evidencebased alcohol approaches, intervention and policies ii. Support community resiliency by working with partners to shift the culture of alcohol use towards a culture of moderation iii. Mediate stakeholder and the public views to reframe heavy and binge alcohol consumption from an issue of individual choice to an issue that affects the community at large iv. Reduce harms associated with alcohol by promoting measures with community partners such as designated driver programs v. Advocate for the reduction of stigma associated with substance use Reorient health services: i. Address Social Determinants of Health - for example, advocate for community supports that promote optimal healthy growth and development in children and the achievement of critical milestones in the early years (upstream approach) 12

Chapter 2 Policy, Politics, and Power in Health Care

•

•

ii. Build broad awareness on the importance of access to mental health supports across the lifespan iii. Improve access for persons engaged in risky or hazardous drinking to brief behavioural counselling interventions to reduce alcohol misuse Develop personal skills: i. Promote access to treatment through awareness and use of self-screening tools that identify problematic alcohol use ii. Advocate for self-referral to local services iii. Promote low risk drinking guidelines iv. Promote abstinence among pregnant women Create supportive environments: i. Enable stakeholders and the public to reframe alcohol consumption from an issue of individual choice to an issue that affects the entire community ii. Encourage community partners to promote and offer alcohol free events iii. Participate in policy discussions related to regulatory frameworks such as the restriction of availability, advertising, labelling, price, prohibiting public consumption and conditions of sales

Canadian Research 2.1 1. Identify barriers to workplace integration of IENs. • Lack of organizational/senior commitment – priority of IEN/IEHP is not a priority, is not embedded in operational plans, link to the core priority of delivering high quality care is weak • Lack of senior leadership commitment to inclusive practices • Lack of leadership on part of Human Resources Dept to recruitment and retention of staff from diverse backgrounds • Lack of diversity within the employer’s workforce • Managers are not held accountable for working towards achieving targets/outcomes set by the organization • Differential strategies to support full transition of IEN into the Canadian nursing workplace have not been in place – often due to managerial concerns about treating IENs “equally” and not fully grasping the concept of “equity” • Nurse manager’s style of leadership is not supportive, participatory and strength-based • Inequitable access to professional development and leadership opportunities for IENs • Lack of recognition of how IENs contribute to nursing and quality of care e.g. platforms to share nursing experiences and expertise from international contexts are not available; IENs’ role as cultural and language interpreter are not acknowledged • Inadequate organizational policies and procedures (and related education) to:

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Chapter 2 Policy, Politics, and Power in Health Care

i. acknowledge and promote use of non-English/French language skills to address patient needs; ii. address racist and intolerant behaviours – nurse/staff to nurse/staff and nurse to patient and patient to nurse 2. What are the critical enablers of effective IEN integration?

•

opposite of those above in #1

3. What are the potential impacts of workplace diversity on health equity and community health nursing practice as whole?

•

When the nursing/health care workforce is ethno racially diverse, there is an overall responsiveness to client need as a result of: i.

Introducing various world views and interpretations of concepts of health and wellness ii. Openness to diverse points of reference in terms of treatment and healing, including alternative therapies and non-Western practices iii. Language barrier being reduced or eliminated especially when the primary nurse/team has the capacity to communicate directly with the client/family/caregiver in their language iv.

Cultural knowledge brokers and interpreters in house/on the interprofessional team serve to increase awareness and understanding of colleagues re. diverse cultures/practices v.

More appropriate/accurate assessment and care planning vi.

Increased effectiveness of health education vii.

Follow through by client/family/caregiver is more likely viii. Greater engagement of clients/family/caregivers due to cultural and linguistic access to processes for planning and evaluating programs/services

Individual Critical Thinking Exercises 1. List your core values for healthcare in Canada. How do your values compare with the values reflected in the five key funding criteria described in the Canada Health Act? • Five key funding criteria: comprehensiveness, universality, portability, accessibility, publicly administered 2. How would your life be different if health care in this country was provided based on ability to pay rather than need? .

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Chapter 2 Policy, Politics, and Power in Health Care

•

• • • • •

While hospital and physician-based care is covered under the Canada Health Act, many people living in Canada are experiencing the difficult decisions of having to pay or not for services such as home care, medications, dental and vision care, other allied health care services and mental health care.

People with many resources (a lot of money) would be “first in line.”

People with few resources would have to choose between paying for healthcare or other items in their budget.

People who could not pay would delay seeking treatment for health problems, potentially leading to failure in early case finding, and patients who are sicker when they finally seek treatment.

The first question asked in a healthcare facility might be: “Do you have insurance?”

Healthcare professionals would have to choose which system to seek employment from, potentially creating friction between the groups.

3. This chapter has shown that health policy decisions leave a legacy for generations.

Describe briefly one policy revision you would make in the areas of primary care, public health, and home care.

• • • •

Increase home care and social services for the elderly because of recognition that people live healthier lives in their own setting surrounded by familiar environments.

Discuss wait lists and explore effective models for managing them (see Rachlis’ Prescription for Excellence as a resource).

Discuss the role of nurse practitioners and registered nurses to increase access to primary care services.

The role of public health nurses has changed dramatically in many parts of the country over the last 20 years. Discuss whether those changes have been beneficial or a barrier to the health of individuals, families, and communities. Consider inequities across the country.

4. What examples can you describe of nurses’ work to close the health equity gap?

• • • •

.

based on community health assessment work with populations to address health equity issues support community groups and organizations to advocate for changes that address the social determinants of health through healthcare, education and other government systems bring information forward to team and management regarding issues impacting client and families’ ability to access healthcare work with provincial/territorial and national nursing and other health care organizations to develop policy tools to advocate for required system change

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Chapter 2 Policy, Politics, and Power in Health Care

5. What are some health problems in your community? How can you frame them as issues within a health policy context?

• Answers will vary 6. What opportunities have you encountered to promote the second phase of Medicare development?

• Examine political action activities and how healthy public policies are developed.

• Join professional and student professional organizations.

• Participate in calls to action from professional organizations.

• Participate in letter-writing campaigns to municipal, provincial, and national politicians, and for-profit and not-for profit organizations.

• Write letters to the editors of newspapers and magazines.

• Support/campaign for politicians who share the values and ideals of the Canadian healthcare system.

• Talk with classmates and laypersons about importance of the Canadian healthcare system.

7. Leadership development is an ongoing process. What ideas do you have to develop your leadership skills and knowledge?

• Volunteer to chair a committee at your workplace • Think of leadership roles you have played outside of nursing and the skills you developed, test them out in a clinical or team situation • Buddy with a colleague to take on a leadership role and commit to providing each other with support and feedback • Select and approach a mentor to assist you with leadership development • Take part in conferences and courses that support leadership development • Read about leaders in and out of nursing, both historical and modern-day leaders • Take the opportunity to discuss leadership issues with friends, family, and colleagues • Commit to several leadership development goals each year that are realistic and reachable Group Critical Thinking Exercises 1. On what values was the health care system founded? How do your own values fit with the societal values that are reflected in the five funding criteria described in the Canada Health Act? • • •

.

Have students identify their own values – is social justice important to them and what does it mean in terms of healthcare?

What principles, if any, would students add to the current five: comprehensiveness, universality, portability, accessibility, publicly administered Would they remove any?

16

Chapter 2 Policy, Politics, and Power in Health Care •

Which, if any, societal values that led to passage of the Canada Health Act have changed since 1984?

2. What are some of the solutions that you and your group can generate to address issues in Canada’s healthcare system? What role can CHNs play?

• • • • • • • •

Leadership in advocacy for change Advocacy for populations that are vulnerable, at risk or under-serviced Sharing stories of the people and communities we work with Supporting communities to speak out on their own behalf Working with communities to build capacity Understanding the Truth and Reconciliation recommendations for Action Publishing articles in peer-reviewed journals on promising practices and nursing success stories Incorporating social determinants of health and social justice principles in all settings

3. In an ideal world, create a health care system designed to provide the best care, to the most people, in the most costeffective manner. Describe the mechanisms for financing, allocation, and delivery. Compare and contrast this system with the current Canadian system.

• • • • • • • • •

Will it follow the guiding principles of the Canada Health Act? If not, what other principles will be followed? Consider the principles of Primary Health Care and social justice.

How is funding determined – population-based, “squeaky wheel,” blended funding models, funds allocated to individuals and families to let them self-determine spending needs, and/or percentage of GNP, ?

Who determines what services are available to what population?

Who makes allocation decisions?

Will delivery be public, private for-profit, or private not-for-profit? Consider blended models.

Will new healthcare provider categories be necessary and/or useful?

How will we determine cost-effectiveness?

How will the new system be evaluated?

What will be the mechanisms of accountability?

4. How can CHNs foster authentic relationships with community members to address health inequities?

•

.

Answers will vary

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Chapter 2 Policy, Politics, and Power in Health Care

Further Resources Daw, J. R., Morgan, S. G., Thomson, P. A., & Law, M. R. (2013). Here today, gone tomorrow: The issue attention cycle and national print media coverage of prescription drug financing in Canada. Health Policy, 110(1), 67-75.

Law, M. R., Daw, J. R., Cheng, L., & Morgan, S. G. (2013). Growth in private payments for health care by Canadian households. Health Policy, 110(2), 141-146.

OECD (2017), Health at a Glance 2017: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/health_glance-2017-en.

Pylypchuk, Y., & Sarpong, E. M. (2013). Comparison of health care utilization: United States versus Canada. Health Services Research, 48(2pt1), 560-581.

Stabile, M., & Thomson, S. (2013). The changing role of government in financing health care: An international perspective (No. w19439). National Bureau of Economic Research.

Tang, K. L., Ghali, W. A., & Manns, B. J. (2014). Addressing cost-related barriers to prescription drug use in Canada. Canadian Medical Association Journal, 186(4), 276.

Nadeau, R., Bélanger, É., Pétry, F., Soroka, S. N., & Maioni, A. (2014). Health Care Policy and Opinion in the United States and Canada (Vol. 17). Routledge.

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Chapter 3 Nursing Roles, Functions, and Practice Settings

Chapter 3: Nursing Roles, Functions, and Practice Settings Suggestions for Guest Speakers 1. Invite a Nurse Practitioner to discuss his/her roles and practice settings.

2. Invite a nurse working in a faith community nursing, forensic nursing, or military nursing capacity to describe his/her roles and responsibilities.

3. Ask a nurse in private practice (foot care, vaccination, home visiting, etc.) to describe her/his activities and the additional skills and training required for this type of work.

4. Have a panel of community health nurses discuss the similarities and differences of their roles (include a public health nurse and a home health nurse).

5. Have a teleconference with a nurse working at a telephone information line.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students to review the document “Public Health ~ Community Health Nursing Practice in Canada: Roles and Activities (4th edition) by the Canadian Public Health Association (2010). The document can be accessed at https://www.cpha.ca/sites/default/files/assets/pubs/3-1bk04214.pdf. After reviewing these descriptions, ask the students: Why do you think the CPHA uses the terms Public Health Nurse and Community Health Nurse synonymously? Were there any roles and/or activities that stood out for you? What statements were most memorable? Why? 2. Discuss the role of the “Nurse Entrepreneur.” Ask the students: Have you seen an area of practice where there is a need? Could a business be formed by a nurse that would meet that need?

3. Ask the students to take out a piece of paper and a pen. Tell them that they will have five minutes to write down all of the nursing roles in the community that they can think of (NP, forensic nurse, street nurse, etc.). At the end, ask one student to write all of his/her answers on the board. Next, another student will add the ones that she/he had that were missed and so on until all of the original ideas are on the board. You could have a prize of a school mug or a book for the student who thought of the most roles.

4. Ask the students if they have ever been involved with or provided care in a home health role. If so, what was the goal of the client in that situation? Were there nurses involved?

What was the role of the nurse? How might being in the setting of a client’s home change

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Chapter 3 Nursing Roles, Functions, and Practice Settings the nurse-client relationship? Ask the students who have had experience to lead a small group to create a poster listing the goals, roles, and impact on the care.

5. Ask the students to consider the following fictitious (but accurate) job description: Primary Care Nurse Practitioner - Fredericton, NB Responsible and accountable for the comprehensive assessment of patients and clients including diagnosing diseases, disorders, and conditions. Initiates treatment including healthcare management, therapeutic interventions, and prescribes medications. Provides professional guidance to other health professionals and participates autonomously as a member of the interdisciplinary health teams making referrals to specialist physicians as appropriate.

Collaborates with clients and other health professionals to identify and assess trends and patterns that have implications for clients, families, and communities; develops and implements population and evidence-based strategies to improve health; and participates in policy-making activities that influence health services and practices. Participates in peer review and self-review to evaluate the outcome of the services at the client, family, community and population levels. Responsible for own professional development and maintaining competence in the position.

QUALIFICATIONS: Current applicable registration with the Nurses Association of New Brunswick. Completion of a Masters degree level nurse program. Minimum of 4 years recent, relevant clinical nursing experience or an equivalent combination.

Ability to perform the full scope of duties and responsibilities. Ability to apply knowledge of developmental stages, behavioral sciences, pathophysiology, psychopathology, and epidemiology to clinical diagnoses. Ability to apply knowledge of pharmacology, pharmacokinetics, and pharmacodynamics to prescribing and evaluating treatment responses.

Ability to communicate and collaborate with patients and families about health findings, diagnosis, treatment, self-care, and prognosis. Ability to collaborate, consult with and formally refer clients and patients to physicians and other health professionals when appropriate. Ability to critically assess and evaluate health research literature to determine best practices; ability to introduce education and evidence-based research. Ability to assess and recognize population health trends; ability to plan and implement strategies for population-based prevention and health promotion. Ability to implement and evaluate planned change. Ability to define the specific areas of practice and client population for whom the position is able to provide healthcare services. Ability to supervise others and evaluate the care they deliver. Ability to lead a team and work within a team. Ability to selfdirect, interact, and adapt effectively with other professionals in complex, dynamic situations. Ability to transfer knowledge, teach, coach, and mentor others. Ability to identify and respond appropriately to legal and ethical issues that may arise in patient care. Ability to

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Chapter 3 Nursing Roles, Functions, and Practice Settings self-assess performance and assume responsibility and accountability for own professional development, educational or consultative assistance when appropriate.

Salary range for a nurse practitioner is $80,000–$85,000 per year plus benefits.

Ask the students to discuss their thoughts about the range of skills and abilities required for this position. Do they think the salary is fair? How does this job description differ from a CHN, PHN, medical doctor, or home healthcare nurse?

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Ask the students to review the document “Public Health ~ Community Health Nursing Practice in Canada: Roles and Activities (4th edition) by the Canadian Public Health Association (2010). The document can be accessed at https://www.cpha.ca/sites/default/files/assets/pubs/3-1bk04214.pdf. After reviewing these descriptions, ask the students: Why do you think the CPHA uses the terms Public Health Nurse and Community Health Nurse synonymously? Were there any roles and/or activities that stood out for you? What statements were most memorable? Why? 2. Ask students to write a couple of paragraphs about their understanding of the role of the “Nurse Entrepreneur.” Ask the students: Have you seen an area of practice where there is a need? Could a business be formed by a nurse that would meet that need?

3. Ask the students to consider the following fictitious job description: Primary Care Nurse Practitioner - Fredericton, NB Responsible and accountable for the comprehensive assessment of patients and clients including diagnosing diseases, disorders, and conditions. Initiates treatment including healthcare management, therapeutic interventions, and prescribes medications. Provides professional guidance to other health professionals and participates autonomously as a member of the interdisciplinary health teams making referrals to specialist physicians as appropriate.

Collaborates with clients and other health professionals to identify and assess trends and patterns that have implications for clients, families, and communities; develops and implements population and evidence-based strategies to improve health; and participates in policy-making activities that influence health services and practices. Participates in peer review and self-review to evaluate the outcome of the services at the client, family, community and population levels. Responsible for own professional development and maintaining competence in the position.

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21

Chapter 3 Nursing Roles, Functions, and Practice Settings QUALIFICATIONS: Current applicable registration with the Nurses Association of New Brunswick. Completion of a Masters degree level nurse program. Minimum of 4 years recent, relevant clinical nursing experience or an equivalent combination.

Ability to perform the full scope of duties and responsibilities. Ability to apply knowledge of developmental stages, behavioral sciences, pathophysiology, psychopathology, and epidemiology to clinical diagnoses. Ability to apply knowledge of pharmacology, pharmacokinetics, and pharmacodynamics to prescribing and evaluating treatment responses.

Ability to communicate and collaborate with patients and families about health findings, diagnosis, treatment, self-care, and prognosis. Ability to collaborate, consult with and formally refer clients and patients to physicians and other health professionals when appropriate. Ability to critically assess and evaluate health research literature to determine best practices; ability to introduce education and evidence-based research. Ability to assess and recognize population health trends; ability to plan and implement strategies for population-based prevention and health promotion. Ability to implement and evaluate planned change. Ability to define the specific areas of practice and client population for whom the position is able to provide healthcare services. Ability to supervise others and evaluate the care they deliver. Ability to lead a team and work within a team. Ability to selfdirect, interact, and adapt effectively with other professionals in complex, dynamic situations. Ability to transfer knowledge, teach, coach, and mentor others. Ability to identify and respond appropriately to legal and ethical issues that may arise in patient care. Ability to self-assess performance and assume responsibility and accountability for own professional development, educational or consultative assistance when appropriate.

Salary range for a nurse practitioner is $80,000–$85,000 per year plus benefits.

Ask the students to journal about their thoughts and feelings as they read this job description.

What do they think about the range of skills and abilities required for this position? Do they think the salary is fair? How does this job description differ from a CHN, PHN, or home healthcare nurse?

Seminar Discussion Questions 1. Ask the students to consider their community placement and the population that they are working with. What are the roles that you have seen nurses at your clinical practice carrying out? How do you see the nursing roles change as you compare this practice setting to that in the acute care system? Is there an area that you would like to explore that uses your nursing skills in an entrepreneurial way? Read “Attributes of Quality Practice Settings for CHNs.” How does this description compare to your practice setting?

What are some other attributes of quality practice settings that you can think of?

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Chapter 3 Nursing Roles, Functions, and Practice Settings Case Study 1. From reading all the descriptions of roles of CHNs in this chapter, assess which one appeals to you in terms of the kind of nursing roles and functions described.

•

Varies based on each individual students’ preferences and life goals. Confirm that the role is a CHN role.

2. What nursing knowledge, skills, and attitudes are required from you if you were working in the various specialties?

•

Varies based on specialty chosen. Examples of knowledge and skills would include: for a public health nurse having knowledge of communicable/infectious diseases and injury epidemiology; theories related to population health response, disaster planning, implementation, and evaluation; understanding of policy influence on health responses and population health challenges; skills related to health surveillance and population-based health promotion interventions.

3. How would you prepare for practising in the community health nursing role you have chosen? What skill sets and theoretical knowledge would you review?

•

Complete baccalaureate degree and entry-to-practice licensure exam. Review CASN Public Health Nursing Entry-to-Practice Competencies, if choosing PHN and Canadian Community Health Nursing Standards of Practice. Identify mentors and role-models who can provide guidance for tendering the chosen role and/or specialization. Seek learning opportunities and clinical placements that are closely related to the areas of specialization. Skill sets and theoretical knowledge to be reviewed is dependent upon the nursing role or specialization chosen. Seek out, join, and actively participant in nursing specialty professional organizations.

Canadian Research 3.1 1. What health and safety concerns can you identify for a person seeking sexual services through the internet and for a sex worker providing services through the internet?

•

Some of the safety concerns that arise from this study include, exposure to sexually transmitted infections and other infectious diseases, risk for exposure to violence perpetrated by the person seeking sexual services, the sex worker, or other persons who may have a vested interest in the exchange of transactional sex, risks for potential prosecution.

2. Give an example from the Canadian community health nursing standards of practice indicating the relevance of this study to community health nursing practice.

•

.

The standards of practice that most directly relate to this research are Standard 1 – Health Promotion, Standard 2 – Prevention and Health Protection, and Standard 6 – Health and Equity. This study is relevant to the health promotion initiatives of 23

Chapter 3 Nursing Roles, Functions, and Practice Settings community health nurses who work with communities where people engage in these behaviours. It is also relevant to prevention and health protection, because it provides data that can inform interventions to address the health concerns of persons who engage in these behaviours. Additionally, it helps community health nurses identify risk behaviours that members of the community are engaging, which can allow nurses to engage more effectively to address the needs of this population. Studies of this nature also allow community health nurses to gain knowledge that can inform the development of interventions that can help members of this population gain access to the health services and enhance efforts to provide equitable distribution of health care resources to patient populations that are at increased risk for adverse health outcomes.

3. Why is research that explores the sex and gender differences and internet use patterns important for community health nursing?

• Community health nurses need to be aware of the literature that is available in terms of sex and gender differences so that we can identify if inequities exist in the literature and in the services that are offered to address the health of various groups.

Internet use patterns are also important to consider for sex and gender differences because issues of sex and gender may impact how, why, when, and if an individual seeks health care. If we are finding the internet use is more prevalent in one group over another, this may be due to barriers in access to face-to-face care. We can improve our interventions by trying to decrease barriers in access to face-to-face care and ensure that the information that is available online speaks to the health needs of different populations groups. This is also one way to improve access to care.

Individual Critical Thinking Exercises 1. Which area of community health nursing interests you most, and why?

•

Individual answers will vary

2. Identify five key roles or functions of community health nursing that work toward achieving a healthier community.

•

.

Teacher/educator: Having the ability to impart knowledge and skills with clients, families, groups, and communities is foundational to educating the public. Nurses teach clients and their families how to manage their illnesses or injuries; explain post-treatment home care needs; advise on diet, nutrition, and exercise programs; explain medication self-administration; and provide physical therapy. They provide education on breastfeeding, healthy child development, family health, community resources, injury prevention, sexual health, and infectious diseases.

They promote general health by educating the public on warning signs and symptoms of disease and ways to stay healthy. Nurses are also teachers/educators/mentors of new staff and nursing students.

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Chapter 3 Nursing Roles, Functions, and Practice Settings • • • • • • • •

Facilitator: Often in group settings (e.g., families, community groups, etc.), nurses act as facilitators to enable learning, to advocate for community issues, to achieve group goals, and to keep conversations flowing.

Primary health care provider: Nurses provide healthcare to clients to prevent illness and injury, and, promote health.

Planner: Whether planning care for a client/family or a program in public health, planning is critical to achieving desired goals and outcomes.

Policy developer: Policy development is an important strategy to influence decision makers toward health, and, ensure equal opportunities for health.

Advocate: Often nurses have knowledge of community resources or awareness of how various systems work and are well positioned to advocate on behalf of clients.

Presenter: Nurses often share knowledge and information in group settings.

Community mobilizer: CHNs and in particular PHNs working in a community can bring people together to mobilize on particular health issues.

Evaluator: To ensure that various interventions such as programs are effective, or health improvements are being achieved, it is important to undertake evaluations.

3. What personal characteristics would draw nurses toward community health nursing rather than hospital-based nursing?

•

Some of the personal characteristics that would draw nurses toward community health nursing include desire to function autonomously in community, interesting in shaping the health outcomes of entire populations, interest in engaging in policy development to improve the health of entire populations. Some personal characteristics that would draw nurses toward hospital-based nursing includes interest in providing care to patients with acute illness or injury or with acute exacerbations of chronic conditions or desire for more structure.

Group Critical Thinking Exercises 1. Create a concept map that interconnects the multiple roles and functions of nurses working in a variety of community health settings in their work with individuals, families, groups, communities, and populations to promote health.

•

The concept map would identify several of the roles of functions identified in previous questions that illustrates the interconnections between the various community health nursing settings and functions/roles with all the levels of clients (individuals, families, groups, communities, and populations). In addition, students could recognize the ways in which community health nurses engage constituents across all levels of health care delivery and other sectors.

2. Identify strategies to promote an understanding of community health nursing roles among nurses in other sectors.

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Chapter 3 Nursing Roles, Functions, and Practice Settings •

This is a group specific response, which should include examples strategies that equally value the important contributions of community health nurses and nurses working in other sectors, such as housing, social assistance, agricultural, or education.

3. Debate the merits of legislation similar to the Canada Health Act that would provide standardized community health nursing services across Canada.

•

Students would provide rationales for aspects of the legislation they are debating.

If they are advocating for new legislation, they should include considerations for how to improve health care access and equity to achieve the goals of the health care system related to community health nursing and promote health.

Further Resources Canadian Nurses Association. (2006). Towards 2020—Visions for nursing. Ottawa: Author. http://www.cna-aiic.ca/CNA/documents/pdf/publications/Toward-2020-e.pdf Canadian Nurses Association. (2007). Understanding self-regulation. Nursing Now, 21, 1-5. http://www.cnaaiic.ca/CNA/documents/pdf/publications/NN_Understanding_Self_Regulation_e.pdf.

Canadian Nurses Association. (2008). CNA’s preferred future: Health for all. A discussion paper. http://cna-aiic.ca/~/media/cna/page-content/pdf-en/preferred_future_webcast_e.pdf.

National Film Board’s film on Inner City Health in Toronto and a mental health nurse partnering with local police: filmmakerinresidence.nfb.ca/ RNAO’s Clinical Best Practice Guideline on smoking cessation on YouTube: http://www.youtube.com/watch?v=L99LxIVJWNM The Canadian Association for Parish Nursing Ministry (CAPNM) http://www.capnm.ca/ Alliance for Healthier Communities https://www.allianceon.org/who-we-are Canadian Association of Sexual Assault Treatment Centres (CASAC) www.casac.ca Canadian Forces – Nursing (Officer) www.forces.ca Canadian Nurses Protective Society www.cnps.ca Community Health Nurses of Canada www.chnc.ca

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Chapter 4: Public Health Nursing

Chapter 4: Public Health Nursing Suggestions for Guest Speakers 1. Invite a seasoned public health nurse (PHN) to discuss changes to the role over time.

2. Have a teleconference panel with PHNs from various provinces to discuss similarities and differences in their roles.

3. Invite a nurse historian to discuss the history of public health nursing in Canada.

Classroom Activities 1. Clarify any questions regarding information in the text.

Practice Application 1. Ask the students to review the document “Public Health ~ Community Health Nursing Practice in Canada: Roles and Activities” (4th edition) by the Canadian Public Health Association (2010). The document can be accessed at https://www.cpha.ca/sites/default/files/assets/pubs/3-1bk04214.pdf. After reviewing these descriptions, ask the students: What roles and/or activities do you think are specific to PHNs? Why? 2. Ask the students to access the case study in Example 1 from the following source: “Public Health Nursing Practice and Ethical Challenges” (CNA, 2006) https://www.cnaaiic.ca/~/media/cna/page-content/pdf-en/ethics_in_practice_jan_06_e.pdf?la=en.

Then ask students to reflect on the case study in small groups and discuss applications of CNA’s 2017 “Code of Ethics.” The Code can be accessed at https://www.cnaaiic.ca/~/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secureinteractive.pdf?la=en Specifically ask them to discuss which nursing values and ethical responsibilities from the Code they feel are relevant to Mr. Landry’s situation.

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat regarding information in the text.

Practice Application 1. Ask the students to review the document “Public Health ~ Community Health Nursing Practice in Canada: Roles and Activities” (4th edition) by the Canadian Public Health Association (2010). The document can be accessed at https://www.cpha.ca/sites/default/files/assets/pubs/3-1bk04214.pdf. After reviewing .

27

Chapter 4: Public Health Nursing these descriptions, ask the students: What roles and/or activities do you think are specific to PHNs? Why? 2. Ask the students to access the case study in Example 1 from the following source: “Public Health Nursing Practice and Ethical Challenges” (CNA, 2006) https://www.cnaaiic.ca/~/media/cna/page-content/pdf-en/ethics_in_practice_jan_06_e.pdf?la=en.

Then ask students to reflect on the case study in small groups and discuss applications of CNA’s 2017 “Code of Ethics.” The Code can be accessed at https://www.cnaaiic.ca/~/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secureinteractive.pdf?la=en Specifically ask them to discuss which nursing values and ethical responsibilities from the Code they feel are relevant to Mr. Landry’s situation.

Seminar Discussion Questions 1. Find a job description for a public health nurse or community health nurse in your province and at least two other provinces, ideally in different regions of Canada. Read them to the class.

Ask the students how the job descriptions vary and to what extent they think the public health nursing specific competencies are reflected.

Case Study 1. What core public health essential functions is the interprofessional team demonstrating in this situation?

• •

Disease and injury prevention in that they are ensuring that Matthew understands how to take his medication correctly.

Health promotion in accessing housing for Matthew, teaching him to shop for nutrition and affordable food, and also in forming an intersectoral committee, including target group members, to advocate for system changes to help individuals who are homeless and/or drug using.

2. Which public health nursing discipline-specific competencies does Heather demonstrate in this case study?

• • • • • • • .

All of them Knowledge derived from public health and nursing science; Skills related to assessment and analysis; Conducting policy and program planning, implementation, and evaluation; Achieving partnerships, collaboration, and advocacy; Promoting diversity and inclusiveness; Effective communication exchange; 28

Chapter 4: Public Health Nursing • •

Leadership capabilities; and Professional responsibility and accountability.

3. What public health nursing roles does Heather demonstrate in this case study?

•

Collaborator, Leader, Policy Formulator, Outreach worker, Service Provider, Health Educator, Capacity Builder, Community Developer, Facilitator

Canadian Research 4.1 1. What levels of prevention exist within the Nurse-Family Partnership program?

•

Primordial, primary and secondary levels of prevention exist. Lobbying for higher social assistance for mothers in the program would prevent impoverished living conditions (i.e., primordial prevention) that could otherwise enable risk factors for development of maternal or child health problems. Mothers in the program may learn parenting skills or food management from PHNs that would interrupt causal chains (i.e., primary prevention) of child behaviour problems or nutritional deficiency-related diseases from occurring. In the program PHNs may identify early signs (i.e., secondary prevention) of autism or attention deficit hyperactive disorder and make appropriate referrals (secondary prevention).

2. Identify at least two essential functions of public health that the PHN may be carrying out when engaging in the Nurse-Family Partnership program.

•

The six essential functions of public health (CPHA, 2010) are: i. health protection, ii. health surveillance, iii. population health assessment, iv. disease and injury prevention, v. health promotion, and, vi. emergency preparation and response.

The PHN would be carrying out health protection, health surveillance, disease and injury prevention and health promotion.

3. Explain how the PHN may have to assume the public health nursing role of outreach worker while engaging in the Nurse-Family Partnership program.

•

.

Table 4.2 outlines the Outreach Worker role and strategies that the PHN may assume under the function of population health assessment when working with women in the Partnership program. Student answers may vary.

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Chapter 4: Public Health Nursing Individual Critical Thinking Exercises Answers will be different based on the critical thinking of students. However, main points that would need to be part of the answers are below.

1. Consider the definition of public health presented in this chapter. Is there another component you think is critical to include in this definition?

•

•

Public health is most commonly defined as the organized efforts of society to keep people heathy and prevent injury, illness and premature death. It is a combination of programs, services and policies that protect and promote the health of all Canadians.

Other possibilities: it is not just the responsibility of the health sector.

2. Although the PHAC was established relatively recently, what other organizations in your province also contribute to public health?

•

The responses to this may vary and can include organizations such as municipal, regional and provincial health boards and government departments, emergency management offices, government departments that manage income support, housing, education among others, community-based organizations such as those for the homelessness, marginalized youth, social support, and numerous health related organizations such as for cancer, health disease, or specific disabilities.

3. How do you think PHNs may contribute to the work of the PHAC? • Individual responses will vary. Students should consider and incorporate the six essential functions of public health: i. health protection, ii. health surveillance, iii. population health assessment, iv. disease and injury prevention, v. health promotion, and, vi. emergency preparation and response 4. Why do you think it is important to have public health nursing discipline-specific competencies?

•

Individual responses will vary

Group Critical Thinking Exercises 1. Discuss what course concepts you have learned in class that relate to the public health nursing discipline-specific competencies.

• Answers will vary based on class content .

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Chapter 4: Public Health Nursing

2. What public health activities are you able to identify in the communities in which you live?

• Answers will vary based on context 3. What current events locally, nationally, or globally could benefit from critically examining the issues through a social justice lens? What role might PHNs play in addressing these issues?

• Answers will vary based on context.

Further Resources Barrett, A., Terry, D., Lê, Q., & Hoang, H. (2016). Factors influencing community nursing roles and health service provision in rural areas: A review of literature. Contemporary Nurse: A Journal for the Australian Nursing Profession, 52(1), 119-135.

Cusack, C., Cohen, B., Mignone, J., Chartier, M., & Lutfiyya, Z. (2017). Reorienting Public Health Nurses’ Practice with a Professional Practice Model. Canadian Journal of Nursing Research, 49(1), 16-27.

Porr, C. (2015). Important Interactional Strategies for Everyday Public Health Nursing Practice. Public Health Nursing, 32(1), 43-9.

Canadian Nurses Association: Public Health https://www.cna-aiic.ca/en/downloadbuy/population-health/public-health Canadian Public Health Association http://www.cpha.ca Community Health Nurses of Canada http://www.chnc.ca Public Health Agency of Canada http://www.phac-aspc.gc.ca

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Chapter 5 Home Health Nursing in Canada

Chapter 5: Home Health Nursing in Canada Suggestions for Guest Speakers 1. Invite an experienced home health nurse to discuss facilitators and challenges to the role 2. Invite various community members (pediatric patients, youth, older adults) to discuss their experiences working with home health nurses within a therapeutic relationship Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students to review the document “Home Health Nursing Competencies Version 1.0” (CHNC, 2010). The document can be accessed at https://www.chnc.ca/en/competencies. After reviewing these descriptions, ask the students: How might you relate the home health nursing competencies to the Canadian Community Health Nursing Standards of Practice?

Ideas for Self-Study and Distance Students 1. Ask students to review the PowerPoint slides.

Practice Application 1. Ask the students to review the document “Home Health Nursing Competencies Version 1.0” (CHNC, 2010). The document can be accessed at https://www.chnc.ca/en/competencies. After reviewing these descriptions, ask the students: How might you relate the home health nursing competencies to the Canadian Community Health Nursing Standards of Practice?

Seminar Discussion Questions 1. Find a job description for a home health nurse in your province. Read it to the class. Ask the students if they think the job description reflects the full scope of practice for a home health nurse, as discussed in the chapter. Why or why not? Are there any other roles that could potentially be incorporated into the job description? Why or why not?

2. Why is it important that clients have access to home health nurses? What impact do you think home health nurses have on the health care system in your province? What else do you think needs to be in place in order to deliver seamless care in the home health care setting?

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Chapter 5 Home Health Nursing in Canada

Case Study 1. If you were an HHN in Winnipeg and knew of this case, what CHCN Competencies might you have utilized in advocating for Jordan?

•

All of them

2. If Jordan had been allowed to be at home, what information from the health history would be important to consider when creating a nursing care plan?

• • • •

Jordon is a five-year old first nations boy (what is normal development of fiveyear old child?)

Jordon is a member of Norway House Cree Nation (what cultural supports do the family have or might wish to be part of care?)

Jordon suffers from Carey Fineman Ziter Syndrome (understanding the disease, symptoms, treatment, what care needs to be provided by nurse versus family, etc?)

First two years of his life in hospital (has this resulted in any developmental delay or behaviours?)

3. What key principles of the FNIHCC 10-year plan were violated in this situation?

•

The boy and his family were never able to leave the hospital because of disputes between the provincial and federal governments regarding who would pay for home care. This was despite the desire of the family to live at home in the community. Therefore, the following principles of the FNIHCC 10-year plan were violated: i. Holistic Wellness: Respectful of both traditional and contemporary approaches to healing and wellness ii. Community-centered: Delivered in consideration of community priorities iii. Accessible: Available to those with assessed need iv. Supportive: Supportive of individual, family and community

Canadian Research 5.1 1. What is the difference between nurse-led and a medical model approach to care?

•

.

Medical Model focuses on the physical aspect of care. This approach often focuses on the client’s symptoms, underlying disease or injury, diagnosis and the medical management of the condition through medication or surgical interventions.

33

Chapter 5 Home Health Nursing in Canada •

•

Nursing-Led Model is a holistic approach to care that includes multiple aspects that may have impact on health and wellness including: i.

Physical

ii.

Emotional/Mental Health

iii.

Social

iv.

Economic

v.

Religious

vi.

Cultural

Sometimes things such as inability to access or pay for nutritious food due to physical, language, emotional barriers may be predisposing factors for nutritious to conditions such as diabetes. As change may be a necessary part of the care plan, a holistic approach really need to be considered to identify the enablers and barriers to maintaining or improving health.

2. Since HHNs work in partnership with families, how do nurse-led home care programs benefit clients?

•

An approach that includes the family is one that supports working together in partnership and respect and valuing the contribution that they bring to the client’s care. As the nurse is usually in the home for such a limited period of time, it is important that the family has input into what care is possible and how it will be achieved. This is often a more realistic approach to care that considers the enablers and barriers of meeting care needs. This may include physical limitations of providing care for an older spouse, or their ability to manage activities such as medication management or performing tasks such as wound care.

3. State why “aging in place” is an important concept in today’s Canadian society.

•

.

‘Aging in Place’ means that people stay in their residence of choice as they age. In today’s health care system this is an important concept because home is where most people want to be. But it also means that there must be the supports necessary to keep people healthy and have a good quality of life. This may require additional supports from family, other home care providers or community resources for assistance with activities of daily living (ADLs) such as Meals on Wheels. It may also mean that modifications might be necessary for the home such as the installation of railings, ramps or assistive devices in the bathroom. Transfer to a nursing home or long-term care facility is required for people that require more hours of care or when having the client live on their own becomes unsafe. This means that the danger associated with being in the home are too great such as the risk of falls, medication errors, poor nutrition, social isolation, etc.

34

Chapter 5 Home Health Nursing in Canada Individual Critical Thinking Exercises 1. What are the advantages and disadvantages of care delivered in the home?

•

•

Advantages of providing care in the home: i.

Where the client wants to be ii.

Home environment lends to nurse-led care with family support iii. Easier for family to have client at home versus going to hospital on a regular basis iv.

Care can be modified to meet each client and family’s individual needs v.

Care can be adapted to meet each client and family’s schedule vi.

Nurse can see the realities of the home environment including emotional, social, cultural supports required Disadvantages of providing care in the home: i.

Family caregivers suffer from ‘burnout’ ii.

Home may not be conducive to providing care; for example, perhaps the only bathroom is on the second floor and the client is unable to do stairs, the bath or shower may not be accessible iii. Some families are not able to cope with the care required by the client; this may further lead to expenses if families chose to purchase more home care services iv.

If a palliative situation, some families feel uncomfortable with dealing with death and dying at home

2. What do you think the “lived experience” would be for people and their families living at home with a chronic disease such as diabetes?

•

•

The “lived experience” for people and their family living at home with a chronic disease such as diabetes can be difficult as people have to implement changes into their usual way of living. For example, for a person and their family living with diabetes this may mean learning about the disease, it’s impact on the body and some of the activities of daily living that will be needed. This could include the need for closer monitoring of the client’s overall health condition as diabetes has an impact on the eyes, CV system and circulation and sensation especially in the extremities such as hands and feet.

To manage diabetes on a daily basis may mean the family has to learn about checking blood sugars, taking medications, changes to diet and emergency responses when blood sugars are too low. The condition may also have an impact on the family dynamics as the client requires more care and attention, and additional time may be needed away from work or school to attend required doctor’s appointments and educational sessions.

3. What mechanisms would you require for professional development in home health nursing?

.

35

Chapter 5 Home Health Nursing in Canada •

What is different about HHN is the mechanism in which care takes place; this requires a person and family centred approach that allows for a partnership with the client and family to assist them to identify their goals and care needs, as well as the ‘tasks’ that are required. It also means that you need to learn how to work effectively with other health care providers to develop a comprehensive care plan and to identify the community resources available in your area that can support people to stay at home. As a newly graduated nurse, you would require knowledge and skills to be able to independently care for clients in the home. If you attended a university that had a strong community nursing course, you might be able to learn some of the knowledge during your program. This would be combined with required courses that such as physical assessment, pharmacology, communication skills, disease processes, etc. For new graduates and experienced nurses who would like to make a switch to HHN, most home care organizations provide ongoing learning and a mentorship program that allows for gradual movement from dependent to independent practice. There is also a Canadian Nurses Association specialty certificate course in Home Health Nursing that provides the specialized knowledge and skills required.

Group Critical Thinking Exercises 1. It has been a ‘perfect world’ for the last 6 months! What are some of the things that have changed in the work life of an HHN in home care? As a group, then choose the single most important change.

• In home care, a perfect world would consist of: respect and valuing of the HHN role; ability for the HHN to fully utilize their scope of practice; ability to work collaboratively with other members of the health care team; ability to refer clients and their families to the support programs that they require; funding that would allow for more home care for clients and their families; a National Home Care Strategy that would provide more consistent services for Canadians; funding that would allow for coverage of health care supplies such as dressings, compression stockings, medications, etc.

2. From the changes possible in question 1, what led your group to choose the one you did?

• Answers will vary 3. Based on your understanding of the significant factor you chose in question 2, how will the change affect the health outcomes of clients in the home? How does it impact the HHN’s provision of care?

•

.

Answers will vary

36

Chapter 5 Home Health Nursing in Canada Further Resources Gruneir, A., Forrester, J., Camacho, X., Gill, S. S., & Bronskill, S. E. (2013). Gender differences in home care clients and admission to long-term care in Ontario, Canada: A population-based retrospective cohort study. BMC geriatrics, 13(1), 48.

Jacobs, J. C., Lilly, M. B., Ng, C., & Coyte, P. C. (2013). The fiscal impact of informal caregiving to home care recipients in Canada: How the intensity of care influences costs and benefits to government. Social Science & Medicine, 81, 102-109.

Markle‐Reid, M., Browne, G., & Gafni, A. (2013). Nurse‐led health promotion interventions improve quality of life in frail older home care clients: Lessons learned from three randomized trials in Ontario, Canada. Journal of Evaluation in Clinical Practice, 19(1), 118-131.

Canadian Nurses Association. Home care. https://www.cna-aiic.ca/en/on-the-issues/better-health/community-health-care Canadian Home Care Association http://www.cdnhomecare.ca/ Government of Canada. Home and continuing care http://healthycanadians.gc.ca/health-system-systeme-sante/services/home-domicile/indexeng.php Ontario Home Care Association. Home care nursing in Ontario http://www.homecareontario.ca/docs/default-source/HHR/hc-nsg-in-ontario---mar-2011---finalrev.pdf?sfvrsn=8 Victorian Order of Nurses http://www.von.ca/

.

37

Chapter 6 Advocacy, Ethical, and Legal Considerations

Chapter 6: Advocacy, Ethical, and Legal Considerations Suggestions for Guest Speakers 1. Ask a lawyer who works in the health field to visit, Skype, or phone conference with the students.

2. Invite a nurse who has worked through an ethical challenge or legal issue to speak to the class.

3. Ask a member of an ethics committee to visit the class and discuss issues related to CHN and ethical research.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students the following questions: Have you ever experienced moral distress? If you were to bring up a point of moral question and find that you were facing unfair discipline, who could you go to for assistance (union, ethics committee, managers, nurses’ associations)? If it were still in use today, how might the original Nightingale Creed influence the way that you practice?

2. Think, Pair, Share: Ask the students to consider the four principles for ethical decision making (harm principle, least restrictive or coercive means, reciprocity, and transparency). Instruct the students to journal about a time that they observed one of the principles being followed or not followed. Ask them to write about what happened, how the situation was or could have been improved by following the principles. Ask the students to discuss what they have written with a partner. Invite students to discuss what they shared with the larger group.

3. Ask the students to read Example 1 from the document, “Public Health Nursing Practice and Ethical Challenges” from the CNA (2006). http://cna-aiic.ca/~/media/cna/pagecontent/pdf-fr/ethics_in_practice_jan_06_e.pdf.

Applying the Code of Ethics, ask the students to consider how the values of safe, competent care, health and well-being, choice, dignity, and justice apply to the case studies described. What are some of the legal and ethical issues that may be in conflict for Nadia? What is her responsibility to the client? What is her responsibility to the community?

4. Ask the students to consider the following case about infamous historical figure, “Typhoid Mary.”

.

38

Chapter 6 Advocacy, Ethical, and Legal Considerations Mary Mellon was an Irish immigrant cook. Between 1900 and 1907, she infected dozens, if not hundreds of New Yorkers with typhoid fever through her puddings and cakes. At least one person that she served died. She left each place of employment when families fell ill. Despite knowing that she was a carrier of typhoid, Mary continued to work as a cook. She was eventually tracked down through epidemiological detective work and was quarantined for life.

Ask the students to consider the issues that might have influenced Mary’s decision to put others at risk (economic necessity, fatalism, resentment of the host culture, etc.).

Ask the students to consider people who knowingly put others at risk today (people who knowingly spread HIV, other STIs, TB, those who work while sick with influenza).

What should be the consequences? Who should enforce them?

5. Ask students to consider how the principle of reciprocity applies to each of the two cases above. The reciprocity principle indicates that if a public action is warranted, social entities, such as a public health department, are obligated to assist individuals in meeting their ethical responsibilities.

Ideas for Self-Study and Distance Students 1. Clarify any questions about the information from the text via online or phone conversations.

Practice Application 1. Ask the students to answer the following questions as a critical reflection: Have you ever experienced moral distress? If you were to bring up a point of moral question and find that you were facing unfair discipline, who could you go to for assistance (union, ethics committee, managers, nurses’ associations)? If it were still in use today, how might the original Nightingale Creed influence the way that you practice?

2. Think, Pair, Share: Ask the students to consider the four principles for ethical decision making (harm principle, least restrictive or coercive means, reciprocity, and transparency). Instruct the students to journal about a time that they observed one of the principles being followed or not followed. Ask them to write about what happened, how the situation was or could have been improved by following the principles. Ask the students to discuss what they have written with a partner. Invite students to discuss what they shared with the larger group.

3. Ask the students to read Example 1 from the document, “Public Health Nursing Practice and Ethical Challenges” from the CNA (2006). http://cna-aiic.ca/~/media/cna/pagecontent/pdf-fr/ethics_in_practice_jan_06_e.pdf.

Applying the Code of Ethics, ask the students to consider how the values of safe, competent care, health and well-being, choice, dignity, and justice apply to the case studies described. What are some of the legal and ethical issues that may be in conflict for .

39

Chapter 6 Advocacy, Ethical, and Legal Considerations Nadia? What is her responsibility to the client? What is her responsibility to the community?

4. Ask the students to consider the following case about infamous historical figure, “Typhoid Mary.”

Mary Mellon was an Irish immigrant cook. Between 1900 and 1907, she infected dozens, if not hundreds of New Yorkers with typhoid fever through her puddings and cakes. At least one person that she served died. She left each place of employment when families fell ill. Despite knowing that she was a carrier of typhoid, Mary continued to work as a cook. She was eventually tracked down through epidemiological detective work and was quarantined for life.

Ask the students to consider the issues that might have influenced Mary’s decision to put others at risk (economic necessity, fatalism, resentment of the host culture, etc.).

Ask the students to consider people who knowingly put others at risk today (people who knowingly spread HIV, other STIs, TB, those who work while sick with influenza).

What should be the consequences? Who should enforce them?

5. Ask students to consider how the principle of reciprocity applies to each of the two cases above. The reciprocity principle indicates that if a public action is warranted, social entities, such as a public health department, are obligated to assist individuals in meeting their ethical responsibilities.

Seminar Discussion Questions 1. Ask the students to consider their community placement and the population that they are working with. What are some of the ethical issues that they are encountering? Are the nurses in their placement area displaying excellence in the areas identified in the CHNAC’s Standards of Practice? How are the students’ roles impacting the standards?

2. What are some of the current or potential legal issues where the students are working?

Are there safeguards in place to protect the staff, students, and clients? Who facilitates/enforces them?

3. Why are ethic/legal issues in healthcare so important? How do they compare to other disciplines?

Case Study 1. What ethical and legal issues are raised by this situation?

•

.

This situation raises concerns related to client boundaries and accountability. Jane has established a nurse-client relationship with Anthony to whom she is legally and ethically responsible. She has not, and should not, establish a professional relationship with the other two siblings, except perhaps in an emergency situation. To 40

Chapter 6 Advocacy, Ethical, and Legal Considerations provide care to the others could confuse boundaries and could compromise her care to Anthony.

2. What sociopolitical factors situate these issues?

•

This situation may not have arisen if Susan had had a higher socio-economic status or a partner with whom she could share childcare. She then would likely not have needed to make the babysitting request. In addition, because nursing is associated with the caring work of women, it may have been easy for Susan to assume that Jane could take on the work of babysitting.

3. How could Jane help Susan in ways that do not violate professional and ethical standards?

•

Jane could help Susan by referring her to local social service agencies. She could assist Susan to identify other sources of childcare assistance, e.g. family, neighbours, etc.

Canadian Research 6.1 1. What values can conflict when nurses believe a client should no longer live at home?

• The primary conflict is between promoting the health and well-being of a client and promoting and respecting their informed decision making. Nurses have been socialized to protect their clients, but this may conflict with their clients’ decisions to ‘live at risk’.

2. What stereotypes might lead a CHN to believe that a client cannot remain at home?

• Stereotypes, particularly of seniors, may lead a CHN to believe that clients do not have the capacity to make decisions about their care, including where they would like to live.

When clients resist the decisions of CHNs or family members it is important that CHNs do not automatically attribute these to stereotypes.

3. What skills are required to address conflict?

• Establishing empathic relationships with clients and their families is central to the practice of CHNs so that they can understand their perspectives. Excellent listening and mediation skills are also helpful along with a sound knowledge of ethics and law.

Individual Critical Thinking Exercises 1. How are power and ethics related in community health nursing?

• •

.

Need to examine ethical issues and who is has power in each issue. Is this power actual or perceived and how is it used?

What power do nurses have in the community? How can this be used to promote social justice? Nurses can use their power to promote social justice, advocate for 41

Chapter 6 Advocacy, Ethical, and Legal Considerations

•

individuals and groups, empower individuals and groups and facilitate access and equity.

What power do nurses have in influencing the relationship between socio-economic status and health? Nurses can use their power to lobby government and influence healthy public policies specific to the underlying determinants affecting the health of populations.

2. What aspects of community health nursing bring about social control? Can these be ethically justified? How? •

Examples of such aspects include health promotion, illness and injury prevention, and health protection. They bring about social control by making it impossible, difficult or just uncomfortable to refuse to participate. Examples include testing and regulation of food and drugs, vaccinations, no-smoking bylaws, speed limits, seat belt laws, etc.

These activities can be ethically justified if the good created or harms prevented are greater than harms produced. For example, mandatory vaccinations limit the liberty of individuals and physically harm some (moral harm), but they greatly prevent morbidity and mortality (moral good).

3. What ethical responsibilities must the community nurse consider when working with dying clients?

•

CHNs must consider the client’s rights to die with dignity, free of pain, surrounded by family and friends and in the setting of their choice. It also important to consider decisions re: life-sustaining treatments, including CPR, cultural and religious practices, and advance directives. Some clients may also be eligible to receive MAID.

Group Critical Thinking Exercises 1. Identify a group in your community that experiences inequities that constrain their ability to meet their health needs. Discuss strategies that would promote social justice.

•

Consider the ten attributes of social justice as defined by the CNA. How do each of these attributes lead to potential strategies for the group that is being considered?

What limitations do these strategies have? Consider the differences between acting alone or as a group to promote social justice.

2. Ask each group to write down their definition of health and then share these with the group. How are these definitions similar and different? How do they reflect different values?

• •

.

After all group members write their definitions of health, share these with the group.

How are these definitions similar and different? How do they reflect different values?

After discussion about the definitions, consider how a definition of health might influence CHN practice. Are some definitions more sensitive to socio-political nature of health? Are some definitions more sensitive to social control issues?

42

Chapter 6 Advocacy, Ethical, and Legal Considerations •

How does a CHN ascertain the client’s definition of health? What are the implications when a client’s definition of health and a CHN’s definition of health differ?

3. Identify a nursing leader in your community who is promoting social justice. How is this person accomplishing this?

• • •

Use examples from the chapter to get started.

Consider nurses who are not well known, a fellow student, a clinical preceptor, a nursing instructor.

How is that person regarded in the community - how do other nurses relate to that person/group?

Further Resources Canadian Bioethics Society http://www.bioethics.ca/ Canadian Nurses Association https://www.cna-aiic.ca/en Community Health Nurses Association (CHNAC) www.chnc.ca Dalhousie University, Department of Bioethics http://bioethics.dal.ca/ Medical Assistance in Dying, https://www.canada.ca/en/health-canada/services/medicalassistance-dying.html McGill University, Biomedical Ethics http://www.mcgill.ca/biomedicalethicsunit/ Quality End-of-Life Care Coalition of Canada http://www.qelccc.ca/ University of Alberta, John Dossetor Health Ethics Centre http://www.ualberta.ca/BIOETHICS/ University of Manitoba, Centre for Professional and Applied Ethics http://umanitoba.ca/ethics_centre/ University of Toronto, Joint Centre for Bioethics http://jcb.utoronto.ca/ The W. Maurice Young Centre for Applied Ethics, University of British Columbia, http://www.ethics.ubc.ca/

.

43

Chapter 7 Theoretical Foundations of Community Health Nursing

Chapter 7: Theoretical Foundations of Community Health Nursing Suggestions for Guest Speakers 1. Ask a seasoned registered nurse to visit, Skype, or phone conference with the students to discuss the evolution of community health nursing theories.

2. Invite a nursing professor with expert knowledge in community health nursing theories to discuss the importance of applying theory to community health nursing practice Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Review Table 7.2 with students. Ask them to discuss similarities and differences of the theories presented with any theories they may have learned in previous courses related to acute care.

2. Review Table 7.3 with students. Ask them to select 3-4 conceptual models and discuss in hypothetical terms how these may be used in 3-4 community health practice areas outlined in Chapter 3.

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Ask students to review Table 7.2. Ask them to critically reflect on similarities and differences of the theories presented with any theories they may have learned in previous courses related to acute care.

2. Ask students to review Table 7.3. Ask them to select 3-4 conceptual models and discuss in hypothetical terms how these may be used in 3-4 community health practice areas outlined in Chapter 3.

Seminar Discussion Questions 1. Review Table 7.5 with students. Ask students to discuss why it is important to apply the three middle range theories to community health nursing practice. What might the application of each middle range theory look like?

.

44

Chapter 7 Theoretical Foundations of Community Health Nursing

Case Study 1.

How would you ensure you are prepared to develop a relationship with a palliative patient?

•

2.

Answers will vary.

In addition to providing direct care to Jim, how would you support the family?

•

3.

Answers will vary.

How will you support Jim to live with hope, recognizing that you have limited time to spend given your heavy caseload?

•

Answers will vary.

Canadian Research 7.1 1. What are some of the challenges facing a CHN to practising from an equity perspective?

•

Answers will vary

2. What would support a CHN in using a population health approach to address the social determinants of health reflected in Jason’s story?

• •

Being able to work to full scope of practice Answers will vary

3. How could a practice model such as the one developed through this research be used to encourage reflection and dialogue on values and concepts important to community health nursing practice and research?

•

Answers will vary

Individual Critical Thinking Exercises 1. The Canadian Public Health Association (CPHA, 2010) states that “The public/community health nurse combines knowledge from public health science, primary health care (including the determinants of health), nursing science, and the social sciences” (p. 8). Given this statement, what aspects of nursing science do nurses bring to the practice of community or public health nursing?

•

.

Key public health concepts that contribute to the practice of public health nursing include “social justice, a population focus, reliance on epidemiology, health promotion and prevention, the greater good [we use the term common good], and 45

Chapter 7 Theoretical Foundations of Community Health Nursing

long-term commitment to community” (Keller, Strohschein, & Schaffer, 2011, p.

251). In addition, concepts such as health equity, determinants of health, capacity building, a strengths-based approach, caring, cultural safety, collaboration, and others are important for CHN in Canada (CHNC, 2011; CPHA, 2010).

2. In order to enhance cultural safety, it is important for health care providers to reflect on and consider their own values, beliefs and biases. Reflect on the influences in your life that might shape your approach to client care.

•

Includes beliefs about health, fairness, accessibility, factors that influence health and wellbeing. The role and responsibilities of the individual, family, community and society. Your own culture and family of origin and other influences on your core values and beliefs.

3. Some nurses believe that theory is not relevant to nursing practice. What do you think about this statement, and why? What factors contribute to this belief about the relevance of theory to practice?

•

Influenced by - the lack of appropriate theory, lack widespread use of theory guided practice, lack of research about theory use and development. Lack of examples of where use of theory and the outcomes. Much of the guidance for community health nurses working in the post Ottawa Charter era has come from theories in other disciplines. Many community health nursing scholars have argued that, if community health nursing involves the nursing of communities, in addition to nursing individuals and families, then unique, explicit community health nursing theory must be developed for use in practice. They argue that specific nursing theory will facilitate practice activities and assessment of outcomes that are consistent with stated definitions of community health nursing.

4. What kind of theory might you use as a CHN working with a family with multiple health problems? What would support you in the use of that theory?

•

Answers will vary.

5. When a PHN provides immunizations to an individual, how does this contribute to population health? What is one model that helps to explain this?

•

.

The (Intervention Wheel) model is population based. This means that at all levels of practice, even the individual level, interventions are carried out in service of improving population health. Individual level practice involves changing knowledge, attitudes, practices and behaviour. It considers families as a context and influence on individual level change. Community level practice includes changing community norms, attitudes, and practices.

46

Chapter 7 Theoretical Foundations of Community Health Nursing

Group Critical Thinking Exercises 1. Some portions of the population tend to experience greater health inequities than others; for example, First Nation populations or families living in poverty. Discuss with your group how a postcolonial perspective might help you to view this situation differently •

A postcolonial perspective encourages us to look at how continuities from the past shape the present context of health and health care. It encourages us to have a better understanding of historical influences on the current experiences of those for whom we provide care, allows us to appreciate the lasting consequences of colonization on identity, race, and health. Postcolonial theory urges us to challenge our taken for granted assumptions through self-reflection, and to explore the forms of oppression at play within any given nurse-client or nurse-community interaction.

2. Discuss how a social ecological view might influence health promotion activities related to improving childhood immunization rates in a small community.

•

Answers will vary.

3. Using critical social theory, brainstorm and then discuss strategies you would use to address Jason’s situation. How would you go about advocating for policies that would help to address preventable injuries in Jason’s community (i.e. what would be your first steps)?

•

Critical social theory is one perspective that has been used to inform work with population groups who have been disadvantaged by social circumstances and populations who are “under threat”. Using this perspective would require CHNs to work not only with individual clients and families, but collaboratively with other sectors to influence public policy and address the structural and systemic determinants of health. In Jason’s situation one can see that the simple act of attending to his leg wound alone misses the underlying factors that led to his injury in the first place. Asking the ‘why’ questions illuminates various social and community issues. This provides an opportunity for CHNs to engage with local policies and services to work towards improvements benefitting the larger community.

Further Resources Arora, S. (2015). Integration of Nursing Theories in Practice. International Journal of Nursing Science Practice and Research, 1(1), 8-12.

Alligood, M. R. (2013a). Nursing theory: Utilization & application. Elsevier Health Sciences.

Alligood, M. R. (2013b). Nursing theorists and their work. Elsevier Health Sciences.

.

47

Chapter 7 Theoretical Foundations of Community Health Nursing

Butts, J. B., & Rich, K. L. (2013). Philosophies and theories for advanced nursing practice.

Jones & Bartlett Publishers.

Fawcett, J., & Desanto-Madeya, S. (2012). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories. FA Davis.

.

48

Chapter 8 Health Promotion

Chapter 8: Health Promotion Suggestions for Guest Speakers 1. Ask a nurse that works in a primary care centre to visit your class.

2. Have a group of nurses who work on issues of social justice, related to community health speak to the students in a panel format.

3.

Invite a nurse advocate to visit, Skype, or teleconference with your students.

4. Invite a nurse who is working on an up-stream intervention to discuss his/her work.

5. Invite a CHN who has been a part of a public health social marketing campaign (smoking cessation, seat belts, etc.) to speak to the class.

6. Invite a representative from an advocacy group (e.g., a Breast Cancer or Heart Disease prevention group) that looks at health promotion from the behavioural, biomedical, or socio-environmental (or a combination) approach to health to speak to the class.

7. Ask a representative from your region who is working on “Healthy Communities” to visit, Skype, or phone conference with the students about funding for up-stream, midstream, and down-stream efforts.

Classroom Activities 1. Discuss information from the text and clarify any questions.

Practice Application 1. Ask the students to create a poster outlining the “up-stream” and “down-stream” concept using an example from community health practice (cervical cancer, heart disease, TB in prisons, etc.).

2. Ask the students to consider the smoking cessation program as described in the “Tools of Change” case study found at http://www.toolsofchange.com/en/case-studies/detail/185 Ask the students the following questions: Who was the target population for the intervention? What could be done further up-stream from this intervention? What would an example of smoking prevention further down-stream be?

3. Show the satire video found at: http://www.youtube.com/watch?v=LO5XC9i_I1g What was the message that the comedian was getting across? What underlying feelings of victim-blaming might the population be feeling? Does this affect the effectiveness of the health enhancement activity?

.

49

Chapter 8 Health Promotion

4. Think, Pair, Share: Ask the students to reflect on their own personal definition of health and on what they base their definition on (the WHO, experience, readings, etc.) for three minutes. Next, ask them to share with a partner what they were thinking. Finally ask students to volunteer some of their thoughts with the larger group.

5. Use the following handout to encourage students to decipher between down-stream, midstream, and up-stream efforts to prevent atrial fibrillation.

According to the Public Health Agency of Canada, atrial fibrillation, while normally not lifethreatening, is a risk factor for stroke. When the heart is functioning normally, the upper chambers, called atria, emit an electrical signal triggering the heart to pump blood throughout the body. Atrial fibrillation occurs when the electrical signal is not consistent and causes irregular and rapid contractions.

Some risk factors, such as age and gender, cannot be modified by clients. With assistance from CHNs, others risk factors can. Complete the chart below with the potential actions that nurses can engage in to assist clients and populations in making modifications to decrease risk at an up-stream, mid-steam, or down-stream level.

Risk Factors for Atrial Fibrillation and Up-Stream, Mid-Stream, and Down-Stream Actions that CHNs Can Initiate Risk obesity

Potential CHN Actions (up-stream, mid-stream, or down-stream) - Advocate for and volunteer at a community garden where organic food is grown and distributed (up-stream) - Initiate a heart health club where members go for walks, and discuss healthy recipes, lifestyle, etc. (mid-stream) - Provide fruits and vegetables at your workplace (down-stream)

smoking

lack of physical activity

.

50

Chapter 8 Health Promotion

Risk

Potential CHN Actions (up-stream, mid-stream, or down-stream)

hypertension

diabetes

thyroid disease

sleep apnea

6. Ask the students to read the article, “Swimming Upstream: Access, Health Outcomes, and the Social Determinants of Health” by Arlene Bierman and James Dunn. The article can be found at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1484628/# Ask the students to answer the following questions: • •

What do the authors have to say about the impact that social determinants have on health?

What do the authors have to say about the relationship between social determinants and race, as they relate to health?

What do the authors have to say about intervention at the level of the patient versus at the societal level?

Describe the Expanded Chronic Care Model.

What is meant by “prescription for food,” and how does it relate to the current healthcare system?

The lead author on this paper is a Canadian medical doctor. How might the lens of the article have differed were it written by a CHN?

• • • •

.

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Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Ask the students to create a poster outlining the “up-stream” and “down-stream” concept using an example from community health practice (cervical cancer, heart disease, TB in prisons, etc.).

2. Ask the students to consider the smoking cessation program as described in the “Tools of Change” case study found at http://www.toolsofchange.com/en/case-studies/detail/185 a. Ask the students the following questions: Who was the target population for the intervention? What could be done further up-stream from this intervention? What would an example of smoking prevention further down-stream be?

3. Show the satire video found at: http://www.youtube.com/watch?v=LO5XC9i_I1g What was the message that the comedian was getting across? What underlying feelings of victim-blaming might the population be feeling? Does this affect the effectiveness of the health enhancement activity?

4. Think, Pair, Share: Ask the students to reflect on their own personal definition of health and on what they base their definition on (the WHO, experience, readings, etc.) for three minutes. Next, ask them to share with a partner what they were thinking. Finally ask students to volunteer some of their thoughts with the larger group.

5. Use the following handout to encourage students to decipher between down-stream, midstream, and up-stream efforts to prevent atrial fibrillation.

According to the Public Health Agency of Canada, atrial fibrillation, while normally not lifethreatening, is a risk factor for stroke. When the heart is functioning normally, the upper chambers, called atria, emit an electrical signal triggering the heart to pump blood throughout the body. Atrial fibrillation occurs when the electrical signal is not consistent and causes irregular and rapid contractions.

Some risk factors, such as age and gender, cannot be modified by clients. With assistance from CHNs, others risk factors can. Complete the chart below with the potential actions that nurses can engage in to assist clients and populations in making modifications to decrease risk at an upstream, mid-steam, or down-stream level.

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Risk Factors for Atrial Fibrillation and Up-Stream, Mid-Stream, and Down-Stream Actions that CHNs Can Initiate Risk obesity

Potential CHN Actions (up-stream, mid-stream, or down-stream) - Advocate for and volunteer at a community garden where organic food is grown and distributed (up-stream) - Initiate a heart health club where members go for walks, and discuss healthy recipes, lifestyle, etc. (mid-stream) - Provide fruits and vegetables at your workplace (down-stream)

smoking

lack of physical activity

hypertension

diabetes

thyroid disease

sleep apnea

.

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6. Ask the students to read the article, “Swimming Upstream: Access, Health Outcomes, and the Social Determinants of Health” by Arlene Bierman and James Dunn. The article can be found at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1484628/# Ask the students to answer the following questions: • •

What do the authors have to say about the impact that social determinants have on health?

What do the authors have to say about the relationship between social determinants and race, as they relate to health?

What do the authors have to say about intervention at the level of the patient versus at the societal level?

Describe the Expanded Chronic Care Model.

What is meant by “prescription for food,” and how does it relate to the current healthcare system?

The lead author on this paper is a Canadian medical doctor. How might the lens of the article have differed were it written by a CHN?

• • • •

Seminar Discussion Questions 1. Ask the students to reflect on what health is for them. How might their view of health impact the way that they learn and practice community health nursing?

2. Ask students to describe which concepts of health are most evident in their clinical practice setting (medical model, systems, laypersons). Invite the students to describe how the social determinants of health affect the community that they are working in. What determinants have they observed that are not modifiable? What could be modified? What activities are the students involved in that influence health? Where do their actions fit in to the different streams of health intervention?

3. Ask students to describe how they see the need for Primary Healthcare Reform in their community health setting. How does the need to reform universal coverage, service delivery, public policy, and leadership impede the goals of primary healthcare in your setting? What can nurses be doing to influence change in that setting? What can nursing students/instructors be doing? How might someone advocate for primary healthcare reform for the community served by the student’s placements? How might optimum health look for the people served by the student's community health placement?

4. What might interventions further up-stream look like for the health goal that their community health placement is trying to achieve? Who would need to be involved in a partnership to build up-stream capacity for health to reach these goals?

5. What is the role of social justice in community health nursing? How do you see social justice issues playing out in your community placement? Are there aspects of care that could be met, but are currently not met with your client population? Whose responsibility is it to advocate for change. .

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Case Study 1. What information do you already know and what additional information do you need to obtain about the determinants of health affecting this family?

You already know that this is a first-time mother, 17 years old who had very little contact with the health care system prior to giving birth; that she is receiving social assistance so is likely living in poverty, and has no phone. You know that her address is located in a low-income neighbourhood, and the mother is alone with her infant in a tiny one-bedroom apartment on the third floor of a poorly maintained building without an elevator. What is the urgency of the rent situation, is she in immediate danger of eviction? Additional information you’d need to obtain would include whether the infant’s father is involved, and whether that is a healthy or unhealthy relationship for the mother. What are the mother’s social support networks, and what are her social environments like? Does she know her neighbours? Does she have any relationships with extended family, if she no longer has her family of origin? Exploring the mother’s personal coping skills would be important, as well as her thoughts and fears about being a mom. You could explore what prevented her from having contact with the health care system while pregnant. Brainstorm other determinants of health that should be included in an assessment of this situation.

2.

Give specific examples of one or more health promotion strategies that you as the CHN could use at the individual, family, or community level to address each of the following determinants of health affecting this family: a. income and social status b. social support networks c. personal health practices and coping d. healthy child development e. access to health services f. Culture g. Race Health promotion strategies could include any that would help this mother gain a sense of control over and improve her own and her infant’s health, using a broad understanding of health as a state of physical, mental and social well-being. In addition to mobilizing social assistance or other resources to help her meet her urgent immediate financial needs, examples of health promotion strategies could include helping this mother to assess and mobilize her social supports; providing education to her on infant needs (including nutritional needs, growth and .

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development) and expected infant behaviour; helping her to assess for changes to her financial situation and her family’s needs now that she is a mother; helping her assess the safety of her physical environment (e.g., apartment, building, tobacco smoke exposure); providing access to or mobilizing resources to help her to provide the best possible environment for herself and her infant (such as milk programs, clothing and food banks, transportation assistance and others).

Assess her interest in connecting with immigrant support and services such as a local immigrant women’s association that provides counselling, mentoring and support related to racism/discrimination.

3. What knowledge, skills, or attitudes does a CHN require in order to effectively promote the health of this family?

A crucial starting point for a CHN to be able to work with this mother would be to develop a rapport and trust with her. Partner with her. Explore what motherhood means to her. Work from a position of cultural safety to understand her lived experience, explore and understand what is meaningful to her and explore what resources would be appropriate and safe, from her perspective. What barriers has she experienced? Assess what her priorities are, where she is at and what she would like to accomplish. If you start your work by addressing her priorities first you will be more likely to develop a relationship in which she values your input, and her expertise from her own lived experiences along with your CHN expertise can be combined for positive outcomes. Key CHN relationship development skills would include using active listening, warmth, genuineness, respect, a non-judgmental approach, and unconditional positive regard. Using genuine praise for the mother’s health promoting actions and accomplishments and working from a strengths-based perspective are important.

Canadian Research 8.1 1. What were key components of the heart health promotion intervention that were successful, and why were they successful?

Key components of the heart health promotion intervention that were successful included those that arose from incorporating Indigenous processes and ways of knowing. Of particular importance was using Talking Circles as the main process for group discussion and group learning. This included the NPs and the women participating in a process that honoured and shared each person’s wisdom, rather than employing a Western biomedical didactic teaching approach. Success was related to the flexibility shown by the NPs to modify the process and to partner with the women; demonstrating cultural safety.

2. How can Indigenous ways of knowing inform Western practise to provide a culturally safe model to promote heart-healthy activities among Indigenous women?

As demonstrated in the research pilot project, the initial intent of the non-Indigenous NPs was to didactically deliver heart health promotion information to improve the Indigenous women participants’ cardiac risk factors. Through the Talking Circles the NPs learned they needed to change their teaching approach to be less didactic and more holistic as they learned more about .

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Indigenous teaching perspectives. This evolved to become a more culturally safe model for decreasing cardiac risk factors as it employed fostering connections, relationship development, spirituality and traditional Indigenous learning methods; addressing power differentials in a manner that honoured the collective wisdom and partnership of the participants.

3. Using the PHPM as a guide, with a group of fellow students discuss potential interventions to support this population of women beyond the pilot project intervention.

Potential intervention suggestions should focus on continuing the partnership with the Indigenous women, employing culturally safe practice where the women set the direction for continuing and/or developing new interventions that are relevant, timely and meet the needs of the population as described by them. The PHPM offers multiple levels upon which action can be taken; which should be used to assist in determining which level(s) an issue is arising from and what action strategies would be most effective to address that issue.

Individual Critical Thinking Exercises 1. Prior to reading this chapter, what did the term “health promotion” mean to you? Has your initial interpretation changed, and if so, how?

Reflect on how your definition of health promotion has changed. Many people’s initial understanding of health promotion is really more closely aligned with health education; however, the breadth and scope of health promotion is much larger than simply health education. How might your current definition of health promotion influence which strategies you might use with a community?

2. You are a CHN in an Indigenous community where there appears to be an increasing number of children with noninsulin dependent diabetes mellitus. Describe an upstream approach to community health promotion in this situation.

Taking an upstream approach requires CHNs to identify all the compounding factors that influence the growing numbers of children with NIDDM. This is often completed by taking a social determinants of health perspective. Considering the determinants would allow CHNs to identify root causes of an issue and then decide where to focus their attention, based on the information obtained. Using the social determinants of health as your framework, some questions you might want to ask could include the following: Income and social status • What is the average income of the parents of the children in this community?

• Based on their income, are families able to afford healthy food? What is their access to healthy food?

• Based on income levels, are families able to pay for extracurricular activities, such as sports? What is their access to activities?

Social support networks • What does the social support of the average family look like? .

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• • •

Do parents have infrastructures in place to support the children in the neighbourhood participating in sports (e.g., car pooling, child care, healthy snack committee, etc.)?

Do children encourage each other to participate in physical activity and healthy eating?

Is there a community centre in the neighbourhood? o Does the community centre offer a community garden program? o Does the community centre offer sports for children? o Does the community centre offer healthy cooking classes?

Education • Does the school offer physical education classes?

• What messages (through curriculum or otherwise) do students learn at school about physical activity and healthy eating? What behaviours do teachers role model?

• Does the school have a cafeteria; if so what foods are offered, and how accessible is junk food (high fat, sodium, sugar, poor nutritional quality)?

How could the nutritional value of the food be improved upon? Are any traditional foods offered? What food or drinks are offered in snack machines? Is junk food used as a reward, in any context?

• Are there any sports teams in the school that children may join? How much would it cost? Are there subsidies for families?

Employment/working conditions • What type of employment are parents involved in?

• Are there workplace benefits or education offered that support physical activity and/or healthy eating?

• What time do parents and/or older children return home and is there sufficient time to prepare healthy meals daily?

Social environments • What messages do children and families obtain about healthy eating and physical activity from social media (facebook, twitter, etc.)

• What messages do children and families obtain about healthy eating and physical activity from traditional media outlets (television, radio, etc.)

Physical environments • Are there any affordable grocery stores in the neighbourhood?

• Are there any playgrounds in the neighbourhood?

• Are children encouraged to go out and play, either at home or at school, weather permitting?

Personal coping skills and health practices • Are children involved in meal planning?

• What types of foods do children look for when they are hungry? .

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•

What do children eat on a regular basis?

Healthy child development • Are children and their families aware of Canada’s food guide and do they use it for meal planning?

• Are families involving children in meal planning and lunch-making?

Health Services • What message are the students getting about healthy eating and physical activity from the school nurse?

• What supports are in place for the school nurse to address the increasing issue of NIDDM in children? Which school staff members are also concerned, that she or he might partner with to look at possible actions to take?

Culture • Are foods prepared in a traditional way? How is food cooked?

• What types of food would you find in the homes of families?

3. Visit the website of your provincial/territorial nursing association. Search for policy or position statements on PHC. Look for descriptions of activities that influence health care reform for Indigenous communities. Identify opportunities for CHNs to participate in the initiative. Reflect on how you can become involved.

There isn’t a specific answer to this question. It depends on what policy or positions statements are available from the professional association in your jurisdiction. What activities have you found your association involved in that may influence health care reform? What active role is your association taking on?

Group Critical Thinking Exercises 1. Discuss your answers to Individual Critical-Thinking Exercise 1 with one or more partners. How do your responses compare? What factors influenced your original understanding of health promotion? How are these different from those of your partners?

Refer to the answer to question #1 in Individual Critical Thinking Exercises and adapt your group answers to this question. Compare your answers with your partners’ answers – how do you understand the differences and the similarities? Have a group discussion to brainstorm health promotion strategies with your partners.

2. What is the definition of health promotion that the WHO uses, and why is this the definition that CHNs use?

.

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WHO definition of health promotion is: “Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but, goes beyond healthy life-styles to well-being.”

(WHO, 2009a, p. 1). CHNs use this definition of health promotion as it is the most inclusive, widely recognized and widely used definition (it is the one that Canada was involved in writing see the Ottawa Charter), and, is the definition that CNA and the Community Health Nurses of Canada use. It is also the definition that has provided direction for health promotion practice that uses the principles of PHC, empowering strategies and uses relationship building and other key components of CHN practice.

3. With a partner, interview a CHN in your community. Ask the following questions: What does the term “health promotion” mean to you? What are the main health issues in your area? Describe some of the health promotion activities in your practice. What are the barriers to engaging in health promotion activities? Analyze the responses with your partner. How would you summarize this CHN’s approach to health promotion?

Reflection should include an analysis of the CHN’s definition of health promotion and how she/he adapts this to working with a community. Are the main health issues aligned with the health promotion activities in the practice she/he describes? If not, discuss some reasons why there might not be a close alignment. Reflection should include identifying the barriers and thoughts on how to address those barriers. Did she or he discuss social justice or equity explicitly as a component of practice, or was it implicit, or missing entirely? What might this mean for that CHN’s practice?

Further Resources Baumann, A., Valaitis, R., & Kaba, A. (2009). Primary healthcare and nursing education in the 21st Century: A discussion paper. Toronto: Nursing Health Services Research Unit.

Health Canada. (2005). Primary Healthcare Transition Fund (PHCTF) Summary of Initiatives.

Ottawa: Health Canada Minkler, M. (Ed.), (2004). Community Organizing & Community Building for Health, Second Edition. New Brunswick, NJ: Rutgers University Press Nutbeam, D., & Harris, E. (2004). Theory in a nutshell: A practical guide to health promotion theories. Second Edition. Sydney: McGraw-Hill.

O'Neil, M., Pederson, A., Dupere, S., & Rootman, I. (2007). Health promotion in Canada: Critical perspectives. Toronto: Canadian Scholars' Press Inc.

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Poland, B., Green, L., & Rootman, I. (2000). Settings for health promotion: Linking theory and practice. Newbury Park, CA: Sage Publications.

Pederson, A., O’Neill, M., & Rootman, I. (2007). Health promotion in Canada: Provincial, national and international perspectives, second edition. Toronto, ON: Canadian Scholars Press.

Raphael, D. (2008). Social Determinants of Health: Canadian Perspectives, second edition.

Toronto, ON: Canadian Scholars’ Press.

Shortt, S., Hwang, S., & Stuart, H. (2005). Homelessness and health: A policy synthesis on approaches to delivering primary care for homeless persons. Kingston, ON: Center for Health Services and Policy Research, Queens University Wilson, R., Shortt, S. E. D., & Dorland, J. (2004). (Eds.). Implementing primary care reform— Barriers and facilitators. Montreal, QC: McGill-Queen’s University Press.

Canadian Council on Social Development www.ccsd.ca The Canadian Health Network www.phac-aspc.gc.ca/chn-rcs/index-eng.php Canadian Nurses Association https://www.cna-aiic.ca/en Health Canada Publications www.hc-sc.gc.ca/ahc-asc/pubs/index_e.html Health Promotion: Capacity Checklists www.usask.ca/healthsci/che/prhprc/programs/finalworkbook.pdf The Canadian Public Health Association www.cpha.ca Tools of Change http://www.toolsofchange.com/en/home/ World Health Organization Publications www.who.int/pub/en/ World Health Organization: Social Determinants of Health http://www.who.int/social_determinants/en/ Health Nexus http://www.healthnexus.ca Unnatural Causes: Is Inequality Making us Sick? http://www.unnaturalcauses.org/podcasts.php

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Chapter 9 Race, Culture, and Health

Chapter 9: Race, Culture, and Health Suggestions for Guest Speakers 1. Ask a CHN who works predominantly with refugees/immigrants to visit your class.

2. Invite a client who has worked through challenges with stereotyping to speak to your group.

3. Ask a client who is new to Canada to describe his/her experiences with your class.

4. Invite, Skype, or teleconference with a nurse who has carried out a transcultural nursing assessment.

Note to instructor: It is important not to ask students to represent their entire cultural group. For example, asking a First Nation student to speak for their entire culture is not appropriate. They can obviously speak from their own perspective, if they want to, but they should not be called upon to speak for what all First Nations people think, do, or believe.

Classroom Activities 1. Discuss information from the text and answer questions.

Practice Application 1. In small groups, ask students to explore the concept of culture, its various definitions and interpretations.

2. Ask the students to complete a community cultural assessment on the community they are working with for their clinical placement using the questions in Table 9.2.

3. Using the information provided in the case study, ask the students what strategies they would use to ensure they were practicing community health nursing in a culturally safe way.

4. Using your academic institution as a sample community. How might cultural diversity at your institution add to the learning environment? Are voices from various cultural background heard when decisions are made? How might alliances across different cultures be facilitated?

5. Have the students create a small family tree going back 3–4 generations and examining why people in their family immigrated to Canada. Ask the students group themselves by continent around the room. For example, people whose most recent ancestor emigrated from Europe would be together in one corner, Asia in another, etc. Next, you could ask the students to move to a different area of the room to represent the reason that their ancestor immigrated to Canada (economic reasons, lack of freedom, security, etc.). Next, .

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Chapter 9 Race, Culture, and Health ask the students to reflect on some of the challenges that may have affected their health.

What might CHNs at the time have done to assist them to achieve better health? Create a list of actions that the CHNs might have carried out.

6. Ask students to search the Statistics Canada website for the most recent information about the regions of the world immigrants to Canada come from. Ask students to find similar information for their specific province/city/community. Compare the current national cultural breakdown to what you found in your province/city/community. Ask the students to answer the following questions: How might the distributions of region of birth affect people’s response to community health initiatives? Are there specific cultural barriers that you have observed in your community?

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Ask students to explore the concept of culture, its various definitions and interpretations in written form.

2. Ask the students to complete a community cultural assessment on the community they are working with for their clinical placement using the questions in Table 9.2.

3. Using the information provided in the case study, ask the students what strategies they would use to ensure they were practicing community health nursing in a culturally safe way.

4. Using your academic institution as a sample community. How might cultural diversity at your institution add to the learning environment? Are voices from various cultural background heard when decisions are made? How might alliances across different cultures be facilitated?

5. Have the students create a small family tree going back 3–4 generations and examining why people in their family immigrated to Canada. Ask the students group themselves by continent around the room. For example, people whose most recent ancestor emigrated from Europe would be together in one corner, Asia in another, etc. Next, you could ask the students to move to a different area of the room to represent the reason that their ancestor immigrated to Canada (economic reasons, lack of freedom, security, etc.). Next, ask the students to reflect on some of the challenges that may have affected their health.

What might CHNs at the time have done to assist them to achieve better health? Create a list of actions that the CHNs might have carried out.

6. Search the Statistics Canada website for the most recent information about the regions of the world immigrants to Canada come from. Try to find similar information for your specific province/city/community. Compare the current national cultural breakdown to .

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Chapter 9 Race, Culture, and Health what you found in your province/city/community. Ask the students to answer the following questions: How might the distributions of region of birth affect people’s response to community health initiatives? Are there specific cultural barriers that you have observed in your community?

Seminar Discussion Questions 1. Ask students to reflect on the strength of cultural competence that they observe in their community health setting. Are there opportunities for improvement? How have they observed/experienced stereotyping in the past? What can you as nurses be doing to influence change in a culturally insensitive environment? What can you as nursing students/instructors be doing? How might you advocate for awareness of cultural diversity? How might you advocate for Indigenous cultural safety?

Case Study 1. How do nurses develop stereotypes of FNMI peoples in Canada?

Please keep in mind that these answers are only a beginning point for discussion.

Nurses develop stereotypes in many ways, including: • Their nursing education (lack of representation of diverse groups in textbooks and other learning materials, faculty, clinical instructors, and staff); • Lack of knowledge about Indigenous Canadians histories in Canada (e.g. Indian Residential Schools, genocide, and environmental racism); • The Media’s stereotypical representations of Indigenous peoples in Canada, for example— stereotypes that are not, in any way, supported by the evidence (e.g. Missing and Murdered Indigenous women are all “prostitutes”).

2. How do nurses learn (or not learn) about the historical contexts of FNMI peoples in Canada?

Please keep in mind that these answers are only a beginning point for discussion.

Although there are important initiatives in progress, there is currently no national mandate to include Indigenous history in curricular materials for primary and secondary education in Canada. There is no Canada-wide professional practice obligation for Registered Nurses to practice cultural competence or cultural safety, which includes a detailed examination of Canada’s history.

3. How can you, as community health nursing students, act to embed cultural safety in your classroom and clinical learning?

Please keep in mind that these answers are only a beginning point for discussion.

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•

• •

Nursing students can act to embed cultural safety in their curriculums through: a) working with their nursing student leaders (e.g. nursing society) to make the case for cultural safety education, and, presenting this case to nursing faculty and administrative bodies who have the power to change curricula in this nursing schools.

Nursing students can act to embed cultural safety in their curriculums through: a) working with their nursing student leaders (e.g. nursing society) to make the case for cultural safety education, and, presenting this case to nursing faculty and administrative bodies who have the power to change curricula in this nursing schools.

Educating Self and Others: Host “Lunch-and-Learn” gatherings where you screen ‘The danger of a single story’ and Indigenous cultural safety webinars and (See links in ‘Webinars, You Tube Documentaries’ below.

Acting for Change: Work with your student nursing society to promote cultural competence and cultural safety education in your nursing classes and in your community clinical areas.

Canadian Research 9.1 1. Where do nurses get the majority of their information about immigrants in Canada?

•

Answers will vary

2. Why do you think these negative stereotypes of immigrants persist in Canada, despite evidence to the contrary?

•

One of the main reasons that stereotyping and discrimination of immigrants continues to persist in Canada is because they are embedded in Canadian culture.

•

We are all exposed, regularly and everyday, to negative stereotypes. Many of these stereotypes are about immigrants, particularly with the rise of ant-immigration sentiments in Europe and in North America.

There is a lack of education, including in nursing education, about the historical facts about immigration in Canada. This evidence clearly demonstrates that after only a few years of adjustment (sometimes very difficult) to their new country, large numbers of immigrants become productive members of Canadian society, including many who develop leadership roles.

•

3. How do you think these negative views of immigrants may impact their health status and their success in accessing health care?

•

.

As discussed in many of the chapters in this book, nursing care involves power dynamics in the therapeutic relationship. Since, as nurses, we are also exposed to many societal stereotypes of immigrant peoples, there is a danger that these stereotypes will cause us to discriminate in our nursing care (lack of action, or discriminatory action). It is important to underscore that nurses can discriminate in their care, whether or not they recognize their participation in this discriminatory care.

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Chapter 9 Race, Culture, and Health •

Even if we have taken steps to educate ourselves about stereotyping and discrimination, it may be that many of our colleagues have not had the opportunity to engage in this kind of learning. In this case, our own care may be impacted by the discriminatory actions of others, especially if we are working in nursing teams, and/or working in collaborative practice with other professional practitioners.

Individual Critical Thinking Exercises 1. What implications does the Canadian Charter of Rights and Freedoms (Government of Canada, 1982) have on nursing practice when working with culturally diverse families?

Students not familiar with the Canadian Charter of Rights and Freedoms may benefit from a brief description of the law in order to provide context when reflecting on the answer.

The Charter: • Came into effect on April 17, 1982 and guaranteed the freedom of conscience, religion, thought, belief, opinion and expression.

• Gave every Canadian citizen the right to vote and to live and work in any province or territory.

• Provided the right to life, liberty, security and the right to the assistance of an interpreter if needed.

• Guaranteed that every person would be considered equal and given the right to protection without discrimination based on their race, national or ethnic origin, color, religion, sex, age or mental/physical disability. (See http://laws-lois.justice.gc.ca/eng/const/page15.html#docCont) • Identifies multiculturalism as a Canadian value.

• CHNs can refer to the Canadian Charter of Rights to guide their culturally appropriate professional approach and commitment to client care.

The Canadian Charter of Rights and Freedoms is a legal document that protects Canadian Citizens. Therefore, culturally diverse families have all of these rights according to Canadian law. It is essential for CHNs to know these rights, and to advocate when diverse families experience discrimination. Guide students to have a look at the Charter poster (readily available online) and encourage them to familiarize themselves with the equality rights section.

2. In your work as a public health nurse, you meet a family new to Canada at a community health fair. Communicating using very limited English, the parents tell you that money is very scarce, the mother is pregnant with her fifth child, the family does not have permanent residence status in Canada, and they are uncertain whether they will be allowed to stay. They are worried they will be deported to their country of origin. What community supports and services would you assist this family to access in order of priority, and why?

Individual responses will vary based on the services available in different provinces in Canada. However, you would try and link the family up with English as an additional .

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Chapter 9 Race, Culture, and Health language classes, employment and income assistance programs, and various social support services with your community.

3. How does culture influence health and illness within diverse communities? What roles do the social determinants of health and public policies play?

• • •

Moving to a broader level, students need to consider how diverse cultures within any community contribute to a wider community culture.

The reciprocal relationship between culture and health in communities is dynamic and multifaceted.

Culture shapes the use of community and/or societal health resources. The social determinants of health and public policies both reflect and shape communities’ cultures.

Group Critical Thinking Exercises 1. How would you go about gaining and demonstrating the skills and behaviours for culturally safe practice?

• • • • • • •

Self-reflection about your personal culture(s) and the culture of nursing Examining personal assumptions and values.

Entering into relationships as the learner Gaining skill in asking open-ended questions (e.g. practice cultural assessments) in order to avoid assuming or ascribing meanings and values to the client.

In collaboration with clients develop care plans that are congruent with the values of the client.

Include clients in the evaluation of nursing care. They are the people who will be able to tell you if the care you provided was culturally competent/culturally safe.

Include reflection and evaluation of the structures, systems, determinants of health and power relations that influence the lives of your clients and your nursing practice.

2. Are the members of your nursing class representative of your community’s population? Why or why not?

• • • •

What indicators will the class use to determine representation (ethnicity, race, language, religion, country of origin)?

Students will need to determine the makeup of the larger community and of the class.

Ask the students to identify the barriers to access (such as language, income, support services, discrimination) that would contribute to a non-representative class.

Ask the students to identify the supports, programs or values that contribute to a class representative of the community.

3. Discuss as a group the similarities and differences between your understandings of diversity and multiculturalism.

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Chapter 9 Race, Culture, and Health • • • •

This is group activity and it is probable that if students feel comfortable and respected, personal stories, experiences and understandings will emerge that reflect the current debates/tensions around these two concepts.

Diversity tends to be linked to cultural heritage, which is often seen as static or unchanging, and may reinforce differences between groups. Stress that diversity is much broader than cultural and/or ethnic heritage, including many fluid attributes.

Multiculturalism also often becomes linked to a static cultural heritage, which can be perceived as a celebration of values and traditions and/or a mechanism to preserve the power of the dominant majority by marginalizing those who are seen to be ‘cultural’.

Currently, the focus of multiculturalism is the integration of practices of diversity, tolerance, and respect for multiple ways of knowing and being, with issues of equity and social justice.

This is seen to benefit the entire population. Ask students if they think this is the case.

Further Resources IdleNoMore http://www.idlenomore.ca/ BlackLivesMatter https://blacklivesmatter.com/ Nova Scotia Department of Health. (2005). A cultural competence guide for primary healthcare professionals in Nova Scotia. http://healthteamnovascotia.ca/cultural_competence/Cultural_Competence_guide_for_Primary_ Health_Care_Professionals.pdf Etowa, J. (2015). Spirituality and Self-Reclamation: A response to nursing on the margins of the Profession. GSTF Journal of Nursing and Health Care, 2(2). 78-86.

Park, J., Tjepkema, M., Goedhuis, N., & Pennock, J. (2015). Avoidable mortality among First Nations adults in Canada: A cohort analysis. Health Reports, 26(8), 10.

Puzan, E. (2003). The unbearable whiteness of being (in nursing). Nursing Inquiry, 10(3), 193200.

Vukic, A., Jesty, C., Mathews, V. & Etowa, J. (2012). Understanding race and racism in Nursing: Insights from Aboriginal nurses. International Scholarly Research Notices.

Webinars, You Tube Documentaries The Danger of a Single Story (Chimamanda Ngozi Adichie) https://www.youtube.com/watch?v=D9Ihs241zeg Indigenous Cultural Safety Collaborative Learning Series Webinars http://www.icscollaborative.com/webinars

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Chapter 10 Evidence-Informed Decision Making in Community Health Nursing

Chapter 10: Evidence-Informed Decision Making in Community Health Nursing Suggestions for Guest Speakers 1. Ask a nurse researcher who is studying issues related to community health nursing to visit the class.

2. Have a panel of nurse researchers who use different methods (participatory action research, randomized controlled trial, qualitative, etc.) speak to the class.

3. Interview, Skype, or teleconference with a nurse who attended a national or international conference related to community health nursing.

Classroom Activities 1. Ask students to review EIDM Essentials: Key issues in evidence informed decision making available for free from the National Collaborating Centre for Methods and Tools: http://www.nccmt.ca/learningcentre/EN/index.php 2. Clarify any questions about the information from the text.

Practice Application 1. Ask students to access a recent original research article available from PubMed Central that interests them. An example of an up-stream paper might be: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168671/ 2. Access the website www.health-evidence.ca in class. You will need to sign up free of charge. Click on the Search healthevidence.ca tab. Find an article to review and provide copies for students. An example might be Effectiveness of health promotion programmes for truck drivers: A systematic review (2015). Click on the tools tab. Download the Evidence Informed Decision Making (EIDM) Checklist and provide copies for students.

Discuss the utility of this tool and the potential application of the information to clinical practice. Ask students: Why might some practicing nurses not use evidence-informed practice? What would need to be in place for them to do so?

3. Access the article “Facilitating access to pre-processed research evidence in public health” by Paula Robeson, Maureen Dobbins, Kara DeCorby, Daiva Tirilis (2010) at http://www.biomedcentral.com/1471-2458/10/95. Ask the students what is meant by "pre-processed" and "pre-appraised." How might community health nurses access similar articles to facilitate evidence-informed practice? What might happen to the length of time it takes for research to be translated into nursing practice (currently 8–17 years) if they use pre-processed evidence?

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Chapter 10 Evidence-Informed Decision Making in Community Health Nursing 4. View the CBC video, “Life itself is a hazard”, say tobacco companies, Broadcast Date: July 28, 1963 from http://www.cbc.ca/archives/search/bc254ee0d79f31b62b7f23c1ec573c3b/. Ask the students to discuss what life might have been like for regular smokers in 1963 as they tried to decide whether smoking and cancer were related. What research study designs might have been used in order to identify a relationship between smoking and cancer?

Ideas for Self-Study and Distance Students 1. Clarify any questions about the information from the text via online or phone conversations.

Practice Application 1. Ask students to access a recent original research article available from PubMed Central that interests them. An example of an up-stream paper might be: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2586713/?tool=pmcentrez. Use the appropriate critical appraisal tool from Chapter 10 to appraise the article. Discuss the potential application of the information to clinical practice.

2. Ask students to access the website www.health-evidence.ca. Ask students to sign up free of charge. Ask students to click on the Search healthevidence.ca tab and find an article to review. An example might be Effectiveness of health promotion programmes for truck drivers: A systematic review (2015). Ask students to click on the tools tab and download the Evidence Informed Decision Making (EIDM) Checklist. Ask students to discuss the utility of this tool and the potential application of the information to clinical practice. Ask students to answer the following questions: Why might some practicing nurses not use evidence-informed practice? What would need to be in place for them to do so?

3. Ask students to access the article “Facilitating access to pre-processed research evidence in public health” by Paula Robeson, Maureen Dobbins, Kara DeCorby, Daiva Tirilis (2010) at http://www.biomedcentral.com/1471-2458/10/95. Ask the students what is meant by "pre-processed" and "pre-appraised." Ask students to answer the following questions: How might community health nurses access similar articles to facilitate evidence-informed practice? What might happen to the length of time it takes for research to be translated into nursing practice (currently 8–17 years) if they use preprocessed evidence?

4. Ask students to view the CBC video, “Life itself is a hazard”, say tobacco companies, Broadcast Date: July 28, 1963 from http://www.cbc.ca/archives/search/bc254ee0d79f31b62b7f23c1ec573c3b/. Ask the students to discuss what life might have been like for regular smokers in 1963 as they tried to decide whether smoking and cancer were related. What research study designs might have been used in order to identify a relationship between smoking and cancer?

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Chapter 10 Evidence-Informed Decision Making in Community Health Nursing

Seminar Discussion Questions 1. Ask the students to reflect on the practice that takes place in their community health setting. What do they base their health interventions on? Is there evidence that is driving CHN work in that setting? Are Do the CHNs have questions that that still need to be answered? Might there already be research performed on this area? How might the students access that information?

Case Study 1. Will you present this systematic review and relevant guideline you identified from it at your next committee meeting? How could this research evidence inform your next steps?

Answers will vary.

2. How did finding and using a systematic review in this scenario help to overcome some of the barriers to research use among nurses?

Answers will vary.

By reading a systematic review, the CHN in the scenario was able to get a more complete picture of the literature, both published and unpublished, compiled in a way that minimizes bias. This pre-appraised literature will save you time, money, and resources from doing the complete literature review yourself.

3. Let’s say you hadn’t identified a systematic review or a guideline in your initial search of PubMed, what are three other sources you could search to identify guidelines?

A few examples are: • Canadian Task Force on Preventive Health Care guidelines (https://canadiantaskforce.ca/) ▪ National Guideline Clearinghouse (https://www.guideline.gov/) ▪ National Institute for Health and Clinical Excellence (NICE) (https://www.nice.org.uk/) ▪ Registered Nurses Association of Ontario (RNAO) (http://rnao.ca/bpg/guidelines).

Canadian Research 10.1 1. Some people naively look at systematic reviews and see that many titles were discarded; in the example above, they found 10 studies of the initial 1,837 titles. They then claim that not all studies get used; large numbers get thrown out, making a systematic review not really a look at all the available research. How would you respond?

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Chapter 10 Evidence-Informed Decision Making in Community Health Nursing To conduct a search for a systematic review, a very broad search is done. That leads to “hits” that are not at all relevant to the question at hand; so the reduction in numbers from 1,8371 to 10 does not represent “throwing out” studies related to the review question.

2. Is this conclusion convincing – that eHealth technology can reduce postpartum weight? It is a clinically important change? Is it worth putting resources into e-health lifestyle interventions for postpartum women? Why or why not?

This outcome has the potential to be meaningful in terms of reducing weight for women in the postpartum period and could impact whether a woman enters subsequent pregnancies at a healthy weight. The review found that eHealth technologies targeting nutrition and physical activity (intervention) for postpartum women (population) could result in weight loss (outcome) of -2.55kg with the true effect ranging between 1.28 kg and 3.81 kg. There were only a small number of studies with small sample sizes so a pilot of this type of intervention in the community would need to be rigorously evaluated.

3. What would need to be considered before providing this type of intervention in the community?

Weight is a sensitive topic, health equity – not everyone has access to the internet, etc.

Additional ideas on p. 10 of the article by Sherifali et al.

Individual Critical Thinking Exercises 1. Pick an intervention that has been shown to be effective and discuss how you would plan to implement that practice change in a nursing agency or organization. (You could search www.healthevidence.org to find an effective intervention relevant to community health.)

What factors would you assess? What processes would you use?

• • • • • • • •

Use the intervention review in Canadian Research 10.1 as an example.

You might want to contact the authors of any of the articles that you plan to recommend to the committee to find out the exact protocol for the intervention.

You need to cost out the intervention protocol(s) to complete your data gathering (e.g. additional staff and/or training required, additional overhead costs, material costs).

Take all the results to the committee and present them, including the costs of implementation.

If the committee wishes, additional stakeholders may be invited to this meeting After discussion, the committee chooses to implement one of the protocols through selected areas of the nursing agency Discuss with the administration of those selected areas the best method of implementation.

Utilize a change process for implementation.

2. Answer the following using Figure 10.3 a) How many studies were involved in this meta-analysis?

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Chapter 10 Evidence-Informed Decision Making in Community Health Nursing There were four studies b) Which of those studies had statistically significant findings?

Two studies had significant findings - the first two have confidence intervals that do not cross 1. c) How would you interpret the result? Is the intervention effective? Is it statistically significant? Is it precise?

If you need help with interpreting the results of a metaanalysis to answer this question, review the brief video on understanding research evidence from the NCCMT called Forest Plots at www.nccmt.ca The Pooled Odds ratio is 0.88 (95% CI 0.71, 1.19). The odds ratio is on the side of 1 that favours treatment, and while the confidence interval is narrow (precise) it crosses 1, and therefore is not statistically significant.

3. In a study of an intervention to increase school students’ use of helmets when in-line skating, the intervention consisted of an in-school educational video plus free helmets, versus the video alone. The odds ratio for observed helmet use was 3.85 in favour of the video plus free helmets (CI 3.05 to 4.11). Was this a statistically significant result? Put the results into words using the odds ratio.

If you need help with interpreting an odds ratio, review the brief video on understanding research evidence from the NCCMT called How to Calculate an Odds Ratio at www.nccmt.ca.

The Confidence Interval of 3.05 to 4.11 is statistically significant because it does not cross 1 (the line of no difference for an odds ratio). To put the Odds Ratio of 3.85 into words: the group who got the video and free helmets were almost 4 times (3.85 times) more likely to be observed wearing their helmets than the group who got the educational video alone.

Group Critical Thinking Exercises 1. Select an article that evaluates an intervention relevant to community health nursing. Use the criteria in the box titled “Questions Used to Critically Appraise Intervention Studies (Treatment or Prevention)” to critically appraise the article and come to a decision about using the intervention in your own practice.

• Explanation of each of the elements of the critical appraisal is found in the chapter under the heading Critical Appraisal of Studies of Interventions 2. As in question 1, critically appraise a systematic review article using the criteria in the box titled “Questions Used to Critically Appraise Systematic Review Articles.”

• Explanation/clarification of the process is found in the chapter under the heading Critical Appraisal of Systemic Reviews • Example is found in Canadian Research 10.1 .

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Chapter 10 Evidence-Informed Decision Making in Community Health Nursing

3. As in question 1, critically appraise an article on qualitative research using the criteria in the box titled “Questions Used to Critically Appraise Qualitative Research Reports.” If it is a valid study, discuss what the study findings contribute to your understanding of the issue that was explored.

• A Text Box to support this question is provided in the chapter under Questions used to Critically Appraise Qualitative Research Reports • Explanation/clarification of the process is found in the chapter under the heading Critical Appraisal of Qualitative Research • Example of the critical appraisal is found in the Case Study.

Further Resources Cullum, N., Ciliska, D., Haynes, R.B., & Marks, S. (Eds.) (2008). Evidence-Based Nursing: An Introduction. Oxford: Blackwell.

Journals of Pre-Appraised Research Evidence-Based Nursing www.ebn.bmjjournals.com Evidence-Based Mental Health www.ebmh.bmjjournals.com Evidence-Based Medicine www.ebm.bmjjournals.com BMJ Journals Online www.bmjjournals.com BMJ Clinical Evidence www.clinicalevidence.org Cochrane Collaboration Health Promotion/Public Health Field www.vichealth.vic.gov.au/cochrane Cochrane Library www.thecochranelibrary.com Evidence-Based Nursing www.evidencebasednursing.com Health-evidence.ca www.health-evidence.ca McMaster Health Forum www.mcmasterforum.org/ McMaster Optimal Aging Portal www.mcmasteroptimalaging.org/ McMaster Plus ACCESSSS Smart Search plus.mcmaster.ca/macplusfs/ National Collaborating Centre for Methods and Tools www.nccmt.ca

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Chapter 11 Epidemiology

Chapter 11: Epidemiology Suggestions for Guest Speakers 1. Ask a nurse epidemiologist from the local health unit to visit the class and discuss issues related to community health.

2. Interview, Skype, or teleconference with a nurse epidemiologist who is working internationally.

3. Ask a representative from Statistics Canada to Skype or teleconference with the class.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Divide the students into three groups (or six groups and give out the same scenario to two groups, depending on the size of the class). Provide the students with the following information in a handout: Group One: Methicillin-Resistant Staphylococcus aureus http://www.phac-aspc.gc.ca/id-mi/mrsa-eng.php MRSA Kelsey is a 28-year-old patient at Stanton General Hospital in Yellowknife, NWT. He has just been discharged following surgery. Home IV services have been set up and a Home Health Nurse will be visiting him every other day to check on his incision. During one of his follow-up visits, Dave the Home Health Nurse notes that the surgical wound appears to be infected. Dave takes a swab of the site and sends it off for testing. It comes back positive for MRSA. - Describe what MRSA is and how it emerged.

- How might Kelsey have acquired it?

- What factors related to Kelsey’s condition may have made him susceptible to MRSA? - What environmental factors may have put Kelsey at risk for infection?

- What are some primary, secondary, and tertiary interventions that may reduce MRSA infection?

Group 2: Tuberculosis https://lung.healthdiary.ca/Guest/Product.aspx?IDS=yaQAZ%2f8w5Dph%2fsSJ8eILtw%3d%3d TB Tom is an inmate at Central Nova Scotia Correctional Facility in Halifax, NS. He has been feverish, coughing, and feeling generally run down. Tom is a smoker, is 60 years old, is HIV positive, and often has respiratory infections. He visits Kendra, the nurse practitioner at the infirmary who asks him to give three separate sputum samples. Kendra informs Tom that she is .

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Chapter 11 Epidemiology testing him for tuberculosis. A few days later, Kendra, calls Tom back into the infirmary to inform him that he has tested positive for the TB bacillus. She orders an X-ray and starts him on INH and rifampin.

- How might Tom have acquired TB? - What factors related to Tom and his health put him at risk for TB? - What environmental factors may have put Tom at risk for infection?

- What are some primary, secondary, and tertiary interventions that may reduce infection?

Group 3: Human Papillomavirus http://www.phac-aspc.gc.ca/std-mts/hpv-vph/fact-faits-eng.php HPV Alexandria is a 15-year-old girl from Toronto, ON. She is healthy, attending school and has not been sexually active. As a part of her regular check-up, she is told about a new vaccine that is available called Cervarix®. She is open to being vaccinated but her mother is concerned.

Alexandra’s mother asks the following questions: - What is HPV and why is it potential concern for Alexandria?

- At this time, it comes with a cost of more than $100 per dose and requires three doses. Should we wait until it is free?

- What are the potential risks of taking Cervarix®?

- Does getting the vaccine mean that she will be more likely to have unprotected sex?

- What are some ways (primary, secondary, and tertiary interventions) to reduce HPV infection?

2. Ask the students to create a poster labelling the host, agent, environment, and vector (if necessary) for MRSA, TB, and HPV.

3. Ask students to read the following article titled “Case control studies for outbreak situations” by Nelson, Brunette, & FOCUS Working Group available at: https://nciph.sph.unc.edu/focus/vol3/issue2/3-2Case-Control_issue.pdf.

Case-control studies In a case-control study, you ask both case-patients and controls about their exposures. You then can calculate a simple mathematical measure of association—called an odds ratio—to quantify the relationship between exposure and disease. This method does not prove that a particular exposure caused a disease, but it is very helpful and effective in evaluating possible vehicles of disease. .

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Chapter 11 Epidemiology

When you design a case-control study, your first, and perhaps most important, decision is who the controls should be. Conceptually, the controls must not have the disease in question, but should be from the same population as the case-patients. In other words, they should be similar to the case-patients except that they do not have the disease. Common control groups consist of neighbours and friends of case-patients and people from the same physician practice or hospital as case-patients.

In general, the more case-patients and controls you have, the easier it will be to find an association. Often, however, you are limited because the outbreak is small. For example, in a hospital, 4 or 5 cases may constitute an outbreak. Fortunately, the number of potential controls will usually be more than you need. In an outbreak of 50 or more cases, 1 control per casepatient will usually suffice. In smaller outbreaks, you might use 2, 3, or 4 controls per casepatient. More than 4 controls per case-patient will rarely be worth your effort.

In a case-control study, the measure of association you use is an odds ratio. When preparing to calculate an odds ratio, it is helpful to look at your data in a 2×2 table. For instance, suppose you were investigating an outbreak of hepatitis A in a small town, and you suspected that the source was a favourite restaurant of the townspeople. After questioning case-patients and controls about whether they had eaten at that restaurant, your data might look like this:

Case Patients Ate at Restaurant A?

Total

Controls

Total

Yes

a=30

b=36

66

No

c=10

d=70

80

40

106

146

The odds ratio is calculated as ad/bc. Ask the students to calculate the odds ratio. What does their finding mean? Ask them to consider some of the potential confounders of the finding.

Answer: The odds ratio for Restaurant A is thus 30 × 70 / 36 × 10, or 5.8. This means that people who ate at Restaurant A were 5.8 times more likely to develop hepatitis A than were people who did not eat there. Even so, you could not conclude that Restaurant A was the source without comparing its odds ratio with the odds ratios for other possible sources. It could be that the source is elsewhere and that it just so happens that many of the people who were exposed also ate at Restaurant A.

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Chapter 11 Epidemiology Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Ask the students to access the following websites and complete one or more of the scenarios (from PHAC, 2010): Scenario 1: Methicillin-Resistant Staphylococcus aureus http://www.phac-aspc.gc.ca/id-mi/mrsa-eng.php MRSA Kelsey is a 28-year-old patient at Stanton General Hospital in Yellowknife, NWT. He has just been discharged following surgery. Home IV services have been set up and a Home Health Nurse will be visiting him every other day to check on his incision. During one of his follow-up visits, Dave the Home Health Nurse notes that the surgical wound appears to be infected. Dave takes a swab of the site and sends it off for testing. It comes back positive for MRSA. - Describe what MRSA is and how it emerged.

- How might Kelsey have acquired it?

- What factors related to Kelsey’s condition put may have made him susceptible to MRSA? - What environmental factors may have put Kelsey at risk for infection?

- What are some primary, secondary and tertiary interventions that may reduce MRSA infection?

Scenario 2: Tuberculosis https://lung.healthdiary.ca/Guest/Product.aspx?IDS=yaQAZ%2f8w5Dph%2fsSJ8eILtw%3d%3d TB Tom is an inmate at Central Nova Scotia Correctional Facility in Halifax, NS. He has been feverish, coughing, and feeling generally run down. Tom is a smoker, is 60 years old, is HIV positive, and often has respiratory infections. He visits Kendra, the nurse practitioner at the infirmary who asks him to give three separate sputum samples. Kendra informs Tom that she is testing him for tuberculosis. A few days later, Kendra, calls Tom back into the infirmary to inform him that he has tested positive for the TB bacillus. She orders an X-ray and starts him on INH and rifampin.

- How might Tom have acquired TB? - What factors related to Tom and his health put him at risk for TB? - What environmental factors may have put Tom at risk for infection?

- What are some primary, secondary, and tertiary interventions that may reduce infection?

Scenario 3: Human Papillomavirus http://www.phac-aspc.gc.ca/std-mts/hpv-vph/fact-faits-eng.php HPV Alexandria is a 15-year-old girl from Toronto, ON. She is healthy, attending school, and has not been sexually active. As a part of her regular check-up, she is told about a new vaccine that is .

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Chapter 11 Epidemiology available called Cervarix®. She is open to being vaccinated but her mother is concerned. The mother asks a number of questions. Write out what answers you would give.

- What is HPV and why is it potential concern for Alexandria?

- Should they wait until it is free?

- What are the potential risks of taking Cervarix®?

- Does getting the vaccine mean that she will be more likely to have unprotected sex?

- What are some ways (primary, secondary, and tertiary interventions) to reduce HPV infection?

2. Ask the students to create a diagram labeling the host, agent, environment, and vector (if necessary) for MRSA, TB, and HPV.

3. Ask students to read the following article titled “Case control studies for outbreak situations” by Nelson, Brunette, & FOCUS Working Group available at: https://nciph.sph.unc.edu/focus/vol3/issue2/3-2Case-Control_issue.pdf.

Case-control studies In a case-control study, you ask both case-patients and controls about their exposures. You then can calculate a simple mathematical measure of association—called an odds ratio—to quantify the relationship between exposure and disease. This method does not prove that a particular exposure caused a disease, but it is very helpful and effective in evaluating possible vehicles of disease.

When you design a case-control study, your first, and perhaps most important, decision is who the controls should be. Conceptually, the controls must not have the disease in question, but should be from the same population as the case-patients. In other words, they should be similar to the case-patients except that they do not have the disease. Common control groups consist of neighbours and friends of case-patients and people from the same physician practice or hospital as case-patients.

In general, the more case-patients and controls you have, the easier it will be to find an association. Often, however, you are limited because the outbreak is small. For example, in a hospital, 4 or 5 cases may constitute an outbreak. Fortunately, the number of potential controls will usually be more than you need. In an outbreak of 50 or more cases, 1 control per casepatient will usually suffice. In smaller outbreaks, you might use 2, 3, or 4 controls per casepatient. More than 4 controls per case-patient will rarely be worth your effort. .

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Chapter 11 Epidemiology In a case-control study, the measure of association you use is an odds ratio. When preparing to calculate an odds ratio, it is helpful to look at your data in a 2×2 table. For instance, suppose you were investigating an outbreak of hepatitis A in a small town, and you suspected that the source was a favourite restaurant of the townspeople. After questioning case-patients and controls about whether they had eaten at that restaurant, your data might look like this:

Case Patients Ate at Restaurant A?

Total

Controls

Total

Yes

a=30

b=36

66

No

c=10

d=70

80

40

106

146

The odds ratio is calculated as ad/bc. Ask the students to calculate the odds ratio. What does their finding mean? Ask them to consider some of the potential confounders of the finding.

Answer: The odds ratio for Restaurant A is thus 30 × 70 / 36 × 10, or 5.8. This means that people who ate at Restaurant A were 5.8 times more likely to develop hepatitis A than were people who did not eat there. Even so, you could not conclude that Restaurant A was the source without comparing its odds ratio with the odds ratios for other possible sources. It could be that the source is elsewhere and that it just so happens that many of the people who were exposed also ate at Restaurant A. Case Study 1. What information would you require to calculate the incidence of HIV in Canada in 2016?

Incidence is calculated using the following formula:

Number of new cases of given disease in population in given time ( one year ) Average total population in same time We know that there were 2,344 newly diagnosed cases of HIV in 2016. The additional piece of information we would need to calculate the incidence rate is the average total population in Canada in 2016.

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Chapter 11 Epidemiology

2. What information would you require to calculate the prevalence of HIV in Canada in December 2016?

Prevalence is calculated using the following formula:

Number of people with given disease in given population at one point in time Total in given population at same point in time We know that the cumulative total to 84,409 cases since 1985. We need to know how many, of the 84,409 individuals living with HIV or AIDS since 1985 are still alive. The additional piece of information we would need to calculate the prevalence rate is the average total population in Canada in 2016.

3. What information would you require to calculate the specific mortality of HIV infection for men who have sex with men in Canada in 2016?

Specific mortality is calculated using the following formula:

Total deaths from a specific cause in a given year in a population ( subgroup ) Average number of population ( subgroup ) for the same year We know that the “men who have sex with men” exposure category continued to represent the largest number of all reported HIV cases in adults at 44.1%. However, this does not give us the information we require. We need to know the total number of deaths from HIV of men who have sex with men in 2016. We also need to know the average total number of men who have sex with men in Canada in 2016.

Canadian Research 11.1 1. How might you as a CHN, use this study in your community?

•

The first step for any CHN is to know the population you are working with, and what their concerns are. If your practice or area of influence includes persons of varying ethnic backgrounds, it would be important to a) examine the published risks for these groups for various health challenges, and b) incorporate increased screening where possible in interactions with individuals from these groups.

2. What kind of interventions might you consider if this were your population?

• • .

The CHN could plan social marketing and community events where some of these risks could be discussed, along with strategies to mitigate the risks.

If the risks are difficult mitigate, the CHN should also consider harm reduction strategies.

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Chapter 11 Epidemiology •

For this challenge – diabetes risk, it touches on many topics – nutrition, frequent screening, diet and exercise, etc. Interventions should be planned and implemented with student and teacher leadership.

3. How might you make those interventions culturally safe?

•

•

•

Again, this comes back to knowing your population. Do the different groups have varying opinions as to the level of concern for different health challenges? For example, many populations still expect that they will lose their teeth as part of aging, therefore they are less responsive to health education about dental hygiene.

Work with key informants of the various groups to ensure you are not violating traditions; e.g. talking about palliative care in the community, suggesting new gender roles in childrearing, or multi-faceted sex education could all be seen very positively or very negatively, depending on the mores of the community.

For this study, utilizing student leaders and popular faculty to assist with planning and implementation is very important. Culture is not only about ethnicity, but also age groups and gender. All need to be represented in the interventions.

Individual Critical Thinking Exercises 1. Select a health problem. Using Figure 11.2 as a guide, suggest five CHN actions for each of the five levels of prevention. Include actions for individuals as well as populations.

How might CHNs collaborate with other health professionals to implement the actions?

The following chart addresses the health problem of tuberculosis (TB).

Primordial Prevention

• • •

• •

Primary Prevention

• •

•

.

Lobbying the government to ensure that there are minimum housing standards Lobby the government to ensure that there are living wage standards which could address over-crowding Lobbying the government to ensure that prevention initiatives are part of policy and ingrained within various programs Exploring the funding pathways for healthcare for Indigenous versus non-indigenous populations Explore inequities around who gets TB very closely and address all root causes of the inequities

Education and development of health habits through early childhood centres, parenting classes, and primary grades Assistance with encouragement and provision of effective hygiene practices in shelters and other places where people live closely together (e.g., university residences) Maintaining strong social marketing techniques to inform public of the resurgence of TB 82

Chapter 11 Epidemiology •

Secondary Prevention

• • • • •

•

Tertiary Prevention

• • • • •

Quaternary Prevention

• • • • •

Inclusion of TB as a topic in the curricula of health professionals, including modes of transmission Support for TB testing where appropriate Support (including support for funding) for TB testing for workers exposed, as well as people at high risk Encouragement of individuals at risk with primary findings to complete follow-up testing Follow-up of persons on the contact lists of newly diagnosed individuals Close follow-up of persons who have been diagnosed with Ghon tubercles, and health education for these people to inform them of factors that will increase their risk Ensuring that treatment for TB is managed through provincial/ territorial health plans at low cost to the individual Recognition of the resistance of the bacteria – support for continuing the treatment as prescribed Encouragement of individuals to continue follow-up of their disease Appropriate infection control measures wherever the infected person works and lives Social services to assist with potential living and employment issues Counselling, to assist with psychological and relationship issues with the illness Ensure that those who are on specific medication are benefiting from medication in the intended ways Ensure that the adverse effects experienced by those on specific medications are addressed Put policies in place that guide when certain medical procedures need to be performed Evaluate the impact of treatment options to ensure that harm isn’t being done to particular population groups Ensure that those in decision making capacities are making treatment decisions in ethical ways

•

Some of the primordial, primary, secondary, tertiary, and quaternary prevention activities can be completed by the CHN as part of his/her workload. In other cases, the CHN must work with other health professionals, especially in the testing and treatment of clients. Finally, the CHN must work with health agencies and health policy and funding bodies to ensure the resources are available.

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Chapter 11 Epidemiology 2. Discuss the pros and cons of having national registries for disease process such as tumours, diabetes, and HIV/AIDS. Did your discussion differ according to the statistics available regarding incidence and prevalence? What about possible social stigma?

• • •

•

While epidemiologists and researchers may see national registries as a boon for accurate data, others may see them as an invasion of privacy.

The huge issue is who has access to the data, and how much detail do they have access to?

For those diseases where there is a social stigma, the fear of lack of privacy becomes even more important. While HIV/AIDS is an obvious stigma, type 2 diabetes may also be a stigma in terms of the assumption that lack of exercise and obesity are the major risk factors and, therefore, all persons with type 2 diabetes have these issues.

This becomes even more potentially problematic when we consider third party payments – many health insurance companies in the US, for instance, have only recently been forbidden from refusing insurance for any health issue they can link to a pre-existing condition – some people see national registries as contributing to this problem. Some healthcare professionals may refuse to treat a patient who does not change behaviour in the way that the professional believes is in the patient’s best interest. Such registries may contribute to standards that patients are expected to meet.

3. Why are infant and child mortality rates used as a measure of the health of a population?

Using the national and provincial infant mortality rates (www.statcan.gc.ca), what do you discern about provincial disparities? Are you surprised? What factors might influence the rates noted? Where might you go to find further evidence?

• •

•

•

High infant mortality (and to a lesser extent, child mortality) is usually considered a measure of unmet health needs and availability (or lack) of healthcare services. It may also be an indicator of less than optimal environmental conditions.

Infant and child mortality are also statistics that are widely used to compare countries in terms of health – if infants and children do not live to adulthood, there are significant repercussions for future generations. Countries that do not have healthy populations are frequently compromised economically and in other ways.

CHNs must look at the total infant and child mortality as well as stratified rates amongst segments of the population (e.g., majority and minority rates). Matching these rates with the broad determinants of health as experienced by these same population segments can assist the CHN to identify high risks to the populations.

Infant and child morbidity, especially when calculated for disease processes that are genetic in nature, may spur research for the future as well as counselling for the present.

Group Critical Thinking Exercises 1. Select a condition that you are familiar with (e.g., type 2 diabetes, asthma, heart attack).

From two different provinces’ health websites and the PHAC website, compare the mortality and morbidity rates for that condition. Are they similar or different? What factors might influence the rates in those jurisdictions?

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Chapter 11 Epidemiology • •

• •

Note: several of the provincial sites have changed since this book has gone to press; students may find the best comparative information on the Health Canada, Public Health Agency of Canada or Statistics Canada sites (see Additional Resources in chapter for URLs).

For example, diabetes: • Both provincial and international mortality rates for diabetes can be found at http://www.conferenceboard.ca/hcp/provincial/health/diabetes.aspx?AspxAutoDetectCoo kieSupport=1 Note that the provinces have different mortality rates for diabetes, as do other countries. Why do you think that the rates are different across the country?

Factors to examine could include age, gender, race, level, and type of immigration.

Are there disease processes where geographic location might influence the prevalence (e.g., multiple sclerosis)?

2. As a group, discuss the pros and cons of using an epidemiological approach to planning CHN actions.

Pros: • • •

Often provides clear evidence Data can often be compared and/or generalized Goals are often clear and measurable

Cons: • •

Difficult to work up-stream Difficult to demonstrate strong associations or causation with several determinants of health

3.

Physical activity is recognized as a protector of health for all people, regardless of age and current health status. Using the tables found at www.statcan.gc.ca (specific tables found at http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health77b-eng.htm and http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health78b-eng.htm), consider how you might design a national campaign aimed at increasing physical activity. Which groups would be most important to target? Why? •

•

.

When looking at the tables, I chose the table that offers percentages rather than number of persons engaging in physical activity. Note that one can then calculate the physically inactive from these data. It appears that an increased rate of the total population engaged in physical activity over the years in question, but decreased slightly in 2014. This could begin a discussion about trends vs a single point in time. Do the numbers vary much across the provinces? Why might that be? What about across the age groups? Note that males seem to have a higher percentage over time than females. Why is looking at multiple sites important?

For ideas look to the Participaction campaigns which were popular in various formats over the years. Remind students that research indicates it takes up to 7 years for “branding” in the general population – they need to look long-term.

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What are their targets in terms of statistics (e.g., increase in moderately active of 10%)? How will they augment the campaign with ensuring safety of and accessibility for the participants?

How will they target various age groups within the same campaign?

Further Resources B.C. Ministry of Health Services https://www2.gov.bc.ca/gov/content/data/statistics Alberta Health Ministry http://www.health.alberta.ca/newsroom/pub-health-statistics.html Saskatchewan Population Health Branch http://www.health.gov.sk.ca/population-healthto be updated - changing the website Manitoba Health, Public Health www.gov.mb.ca/health/publichealth/ Ontario Ministry of Health and Long-Term Care www.health.gov.on.ca Nova Scotia, Department of Health https://novascotia.ca/dhw/publichealth/ Prince Edward Island Health and Social Services https://www.princeedwardisland.ca/en/topic/health-and-wellness Newfoundland and Labrador Health Information System www.nlchi.nf.ca/ Canadian Institute of Health Information www.cihi.ca CCDR (Canada Communicable Disease Report) www.phac-aspc.gc.ca/publicat/ccdr-rmtc/ Centers for Disease Control and Prevention (U.S.) www.cdc.gov CDC Morbidity and Mortality Weekly Report (CDC—U.S.) https://www.cdc.gov/mmwr/index.html CDC National Center for Health Statistics (U.S.) www.cdc.gov/nchs

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Chapter 11 Epidemiology Health Canada www.hc-sc.gc.ca Public Health Agency of Canada www.phac-aspc.gc.ca Statistics Canada www.statcan.gc.ca/ World Health Organization Weekly Epidemiological Record www.who.int/wer

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Chapter 12 Communicable Diseases

Chapter 12: Communicable Diseases Suggestions for Guest Speakers 1. Invite a representative of a provincial/territorial organization working in communicable diseases to speak to the class ▪ Examples: British Columbia Centre for Disease Control http://www.bccdc.ca National Collaborating Centre for Infectious Diseases http://nccid.ca 2. Interview, Skype, or teleconference with a nurse who works in communicable diseases, overseas, at an international organization (such as the WHO), or with an Indigenous population.

3. Invite a nurse who works at an immunization or travel clinic to speak to the class.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. In groups of 5–7, instruct the students to create a poster answering one of the following questions (allow 10–15 minutes). To answer the questions, they can use any of the following sources of information: their own experience as a recipient, clinical experience, or from research that they do or you provide. Afterwards, ask a representative from each group to present the ideas to the larger group for discussion.

Questions: ▪ Group One - Discuss safety precautions that must be in place prior to immunizing anyone (Ana-kit availability, sharps disposal, etc.). How does immunizing a patient “in the community” differ from immunizing a patient in hospital?

▪ Group Two - What is the appropriate information to provide a child, parent, teacher, etc. regarding vaccines? Where do you access such information?

▪ Group Three - Describe the information that must be recorded following vaccination.

Who keeps that information? What might that information be used for (benefit to society, such as observing those who may be susceptible in the case of an outbreak, and benefit to patient)?

▪ Group Four - Outline the appropriate procedure for administering an IM injection. They may need to use their Fundamentals textbook for this.

▪ Group Five - Define “mature minor” in your jurisdiction. What are the implications of declaring someone (or not declaring someone) a mature minor to the CHN? Provide the students with the following information for this activity.

The National Advisory Committee on Immunization (NACI) has developed 16 guidelines for the most desirable immunization practices to assist CHNs and other healthcare providers in critically .

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Chapter 12 Communicable Diseases examining their standards of practice related to immunization. The guidelines noted in its Canadian Immunization Guide (PHAC, 2014d) are as follows: 1. Immunization services should be readily available.

2. Vaccine providers should facilitate timely receipt of vaccine and eliminate unnecessary prerequisites to the receipt of vaccines.

3. Vaccine providers should use all clinical opportunities to screen for needed vaccines and to administer all vaccine doses for which a vaccine recipient is eligible at the time of each visit.

4. Vaccine providers should communicate current knowledge about immunization using an evidence-based approach.

5. Vaccine providers should inform vaccine recipients and parents in specific terms about the risks and benefits of vaccines that they or their children are to receive.

6. Vaccine providers should recommend deferral or withholding of vaccines for true contraindications only.

7. Vaccine providers should ensure that all vaccinations are accurately and completely recorded.

8. Vaccine providers should maintain easily retrievable summaries of immunization records to facilitate age-appropriate vaccination.

9. Vaccine providers should report clinically significant adverse events following immunization (AEFI)promptly, accurately, and completely.

10. Vaccine providers should report all cases of vaccine-preventable diseases as required under provincial and territorial legislation.

11. Vaccine providers should adhere to appropriate procedures for the storage and handling of immunizing agents.

12. Vaccine providers should maintain up-to-date, easily retrievable immunization protocols at all locations where vaccines are administered.

13. Vaccine providers should be properly trained and maintain ongoing education regarding current immunization recommendations.

14. Immunization errors and immunization related incidents should be reported by vaccine providers to their local jurisdiction.

15. Vaccine providers should operate an immunization tracking system.

16. Audits should be conducted in all immunization services to assess the quality of immunization records and the degree of immunization coverage.

A number of factors are integral to meeting the guidelines, such as considerations for cold-chain management of vaccines for guideline 11. For example, the CHN needs to ensure that every vaccine administered is viable by virtue of having been stored in appropriate environmental conditions. This responsibility also extends to a vaccine that is provided to other immunizers, such as physicians.

CHNs must respond to questions and concerns of those being immunized or parents of children being immunized. For example guidelines 4, 5, and 13 refer to education for recipients/parents, informing of risks and benefits of vaccine, and maintaining ongoing education of current recommendations. They respond in a respectful and supportive manner to educate and alleviate concerns from all clients/parents, including from parents choosing not to immunize their children. .

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Although many healthcare providers may rely entirely on providing up-to-date information and education to non-immunizing parents and expect that the evidence will speak for itself, there is an equal responsibility to continue to provide a supportive environment when a decision is made not to immunize. For parents who are seeking information about immunization, accurate information from healthcare professionals is crucial. The healthcare provider must be genuinely knowledgeable about immunization, since parents making an immunization decision tend to be well-informed and will not tolerate half-thought-out explanations from healthcare professionals, including CHNs. In the case of parents who choose not to immunize, they need to be able to trust or believe in the healthcare professional’s expertise based on their demonstration of knowledge and willingness to seek answers or critically question alternative perspectives.

2. There are new, innovative ways of looking at disease control worldwide. Ask the students to read the following segment from the Scientific American Article (April, 2010) “Expert Systems Fight Poverty: Appropriate information and communications technologies, combined with community involvement, can save lives” by Jeff Sachs. Article available at: http://www.scientificamerican.com/article.cfm?id=expert-systems-fight-poverty.

▪

▪

▪

In the Kenyan village of Sauri, also part of the Millennium Village Project, Community Health Workers (CHWs) are pioneering the application of expert systems for malaria control. In the past, suspected malaria patients had to walk or be carried to a clinic, often miles away, have a blood smear read under a microscope by a trained technician and, if positive, receive a prescription. With clinics few and far between and with trained technicians and microscopes even scarcer, untreated, lethal malaria ran rampant.

In the new approach, CHWs visit households on the lookout for fevers that may signify malaria. They carry rapid diagnostic tests that examine a drop of blood for the presence of the malaria pathogen. Then they send an SMS (short service message) text with the patient’s ID and the test results. Seconds later an automated text response informs the health worker of the proper course of treatment, if any. The system can also send reminders about any follow-up treatments or scheduled clinic visits for the patient. The new system of malaria control includes insecticide-treated bed nets made to last for five years and a new generation of combination drugs based on a traditional Chinese herbal treatment, artemisinin.

This full set of tools constitutes a remarkably effective malaria-control system. Already a partial deployment of the system is reducing the malaria burden dramatically in several parts of Africa. Modest international financial support could greatly accelerate the deployment of the full system, and if it were scaled up throughout Africa, hundreds of thousands of lives could be saved annually at around $7 per person a year in the malariatransmission zones.

Ask students to consider how they might translate this innovation into their local settings.

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Chapter 12 Communicable Diseases Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Provide the students with the information below. Ask them to answer the questions that follow.

The National Advisory Committee on Immunization (NACI) has developed 16 guidelines for the most desirable immunization practices to assist CHNs and other healthcare providers in critically examining their standards of practice related to immunization. The guidelines noted in its Canadian Immunization Guide (PHAC, 2014d) are as follows: 1. Immunization services should be readily available.

2. Vaccine providers should facilitate timely receipt of vaccine and eliminate unnecessary prerequisites to the receipt of vaccines.

3. Vaccine providers should use all clinical opportunities to screen for needed vaccines and to administer all vaccine doses for which a vaccine recipient is eligible at the time of each visit.

4. Vaccine providers should communicate current knowledge about immunization using an evidence-based approach.

5. Vaccine providers should inform vaccine recipients and parents in specific terms about the risks and benefits of vaccines that they or their children are to receive.

6. Vaccine providers should recommend deferral or withholding of vaccines for true contraindications only.

7. Vaccine providers should ensure that all vaccinations are accurately and completely recorded.

8. Vaccine providers should maintain easily retrievable summaries of immunization records to facilitate age-appropriate vaccination.

9. Vaccine providers should report clinically significant adverse events following immunization (AEFI)promptly, accurately, and completely.

10. Vaccine providers should report all cases of vaccine-preventable diseases as required under provincial and territorial legislation.

11. Vaccine providers should adhere to appropriate procedures for the storage and handling of immunizing agents.

12. Vaccine providers should maintain up-to-date, easily retrievable immunization protocols at all locations where vaccines are administered.

13. Vaccine providers should be properly trained and maintain ongoing education regarding current immunization recommendations.

14. Immunization errors and immunization related incidents should be reported by vaccine providers to their local jurisdiction.

15. Vaccine providers should operate an immunization tracking system.

16. Audits should be conducted in all immunization services to assess the quality of immunization records and the degree of immunization coverage.

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Chapter 12 Communicable Diseases A number of factors are integral to meeting the guidelines, such as considerations for cold-chain management of vaccines for guideline 11. For example, the CHN needs to ensure that every vaccine that is administered is viable by virtue of having been stored in appropriate environmental conditions. This responsibility also extends to a vaccine that is provided to other immunizers, such as physicians.

CHNs must respond to questions and concerns of those being immunized or parents of children being immunized. For example, guidelines 4, 5, and 13 refer to education for recipients/parents, informing of risks and benefits of vaccine, and maintaining ongoing education of current recommendations. They respond in a respectful and supportive manner to educate and alleviate concerns from all clients/parents, including from parents choosing not to immunize their children.

Although many healthcare providers may rely entirely on providing up-to-date information and education to non-immunizing parents and expect that the evidence will speak for itself, there is an equal responsibility to continue to provide a supportive environment when a decision is made not to immunize. For parents who are seeking information about immunization, accurate information from healthcare professionals is crucial. The healthcare provider must be genuinely knowledgeable about immunization, since parents making an immunization decision tend to be well-informed and will not tolerate half-thought-out explanations from healthcare professionals, including CHNs. In the case of parents who choose not to immunize, they need to be able to trust or believe in the healthcare professional’s expertise based on their demonstration of knowledge and willingness to seek answers or critically question alternative perspectives. a. List safety precautions that must be in place prior to immunizing anyone (Ana-kit availability, sharps disposal, etc.). How does immunizing a patient “in the community” differ from immunizing a patient in hospital? b. What is the appropriate information to provide a child, parent, teacher, etc. regarding vaccines? Where do you access such information? c. List the information that must be recorded following vaccination. Who keeps that information? What might that information be used for (benefit to society, such as observing those who may be susceptible in the case of an outbreak, and benefit to patient)?

Seminar Discussion Questions 1. Ask students to consider the precautions taken to prevent communicable disease transmission at their clinical placement area. Are they aware of policies to prevent spread of respiratory illness (e.g., staying away when ill, masks, sharps containers, etc.)? What communicable diseases are the clients that you are working with at particular risk for?

Why? 2. Is there a plan in case of a pandemic in your setting? What might happen to the work among the clientele in the event of a serious outbreak of disease in the community? What might happen to the work among the clientele in the event of a serious outbreak of disease in that setting? What can CHNs, nursing students/instructors be doing to prevent .

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Chapter 12 Communicable Diseases transmission of disease in that clientele? Are there up-stream interventions that could be taking place (e.g., better nutrition, advocating against issues that lead to poverty or drug use, etc.)?

Case Study 1. Who is the index case?

•

The index case was the teacher who had been ill several weeks before and had been at each school that the children attended.

2. Would you do active surveillance or passive surveillance? Why? •

The CHN would do active surveillance in order to identify as many cases as possible since the probable source of the infection has been identified. Active surveillance in this situation would include informing all parents of students at the implicated schools to observe their children for symptoms of Pertussis and seek medical attention and testing for the child if symptoms present.

3. Outline the steps to control and manage the pertussis outbreak.

•

Recommend testing and treatment for any symptomatic individuals. Require exclusion from work or school for anyone who is symptomatic until a determined number of days after the initiation of treatment. Inform school officials, parents, and local physicians of the nature and extent of the outbreak and the reporting mechanism in place to report new cases.

Canadian Research 12.1 1. Why is it important to utilize an intersectoral collaborative approach when implementing the One Health Framework?

• • • •

The relationship between animals, humans and the environment are interconnected; Microorganisms that infect animals, can also infect humans.

With multiple sectors working together, better health outcomes can be achieved, rather than if each discipline worked in a silo.

Attempts by one sector alone would be unable to prevent or eliminate the problem. By working together, the origin of the disease could be targeted rather than focusing on just the treatment of the disease (shifting the response upstream)

2. What are some factors that are contributing to the increasing number and significance of zoonotic diseases?

•

.

Environmental changes: climate change, land use, and deforestation have provided new opportunities for diseases to pass to animals.

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Increased urbanization: more people are living in closer proximity to wild and domestic animals, which provides more opportunities for the transmission of zoonotic diseases.

Increased demand for food-animal production: opportunities to develop antimicrobial resistance, passing from animals to humans, due to inappropriate and excessive use of antimicrobials and the use of antibiotics to promote growth in animals.

Global travel and trade

3. What important clinical practice strategies can be implemented to combat the development of antimicrobial resistance?

• • • •

Improving infection prevention and control measures, including hand hygiene; Increasing immunization uptake for specific vaccines, i.e. influenza; Not over-using or over-prescribing antibiotics; Following treatment guidelines to effectively treat infections, particularly for bacteria with increased resistance (e.g. Neisseria gonorrhoeae, Mycobacterium tuberculosis)

Individual Critical Thinking Exercises 1. You are working in a downtown clinic that provides services to marginalized and vulnerable persons when a client presents with non-specific ailments. While completing his health history, the client reveals addictions to opioids and other substances, and that he has multiple sexual partners. Your recommendation is to have a full work-up for STIs. The client refuses. Discuss your nursing responsibilities.

•

Your nursing responsibility is to inform the client of the symptoms of STIs, the risk of untreated STIs including the potential long-term effects. The client should also be informed of the risk to sexual partners and the client’s responsibility to inform his/her sexual partners of possible infection. In addition, the nurse should discuss the risks associated with illicit drug use and the risks associated with drug using equipment. The nurse also has a responsibility to discuss the risk of blood borne infections, and symptoms and practices to avoid infection. The nurse should recommend blood test screening for Hepatitis B, C, and HIV, if the client has not already been tested or is not aware of his disease/immune status. In addition, if the client’s disease/immune status is known, the nurse should recommend immunization as required.

2. Refer to Question 1. The client’s HIV test shows a positive result. What should be your next steps?

•

.

Arrange a clinic appointment with the client to inform the client of the positive result. If pre-test counselling was provided to the client, provide post-test counselling and review with client any remaining questions from pre-test counselling. Complete contact tracing and inform client that sexual partners or persons who have shared drug using equipment will be contacted and offered testing. Ensure that the client has medical assessment and follow-up.

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3. You have been assigned a client who has active TB, who has been on treatment in her home country, and who has just arrived in Canada and does not understand English or the purpose of the treatment. How would you ensure an accurate nursing assessment for this client and how would you facilitate a supportive treatment environment for her?

•

You would arrange an interpreter for your client to ensure that the education and information provided to the client is understood and to ensure that you are able to complete an accurate nursing assessment. In addition, to ensure that the client is successful in their treatment regime you would institute directly observed treatment for this client.

Group Critical Thinking Exercises 1. Large numbers of immigrants come from regions where the prevalence of tuberculosis is high. This has resulted in the importation of a large burden of latent infection that can be expected to generate future active cases in aging immigrant populations. Discuss the implications for caring for the future active cases. Healthy public policy should be included in the discussion as opposed to local health authority policy.

•

The implications for caring for the future active cases include the recognition of symptoms as latent infection becomes active, the prevention of outbreaks in family members who have ongoing and long-term exposure to aging family members, the potential for drug resistant strains of tuberculosis as disease was imported or not treated appropriately in foreign countries, and delay in treatment due to language and cultural barriers.

2. AIDS can manifest after years of HIV-positive status; a positive HIV test may not occur until three months after the contact. Similarly, in tuberculosis, the skin test can be negative up to 12 weeks post-exposure, and the manifestations of the disease may occur sometime in the person’s lifetime. Discuss the implications of contact tracing for these two diseases.

•

.

Since HIV and tuberculosis are spread from person to person by very different modes, the implications for contact tracing are also very different. In the case of HIV, knowing that it is spread by blood or body fluid exposure, and the exposure could occur at any time after the person is infected, contact tracing is based on the risk and the CHN will recommend counselling and testing for anyone who is at risk of possible infection based on their exposure to an infected individual’s blood or body fluids. Whereas in tuberculosis, which is spread by exposure to respiratory secretions when the infected person is symptomatic and able to pass the organism to another person, contact tracing focuses on persons who may have been exposed to coughing, sneezing, or exposed to respiratory secretions during a procedure involving aerosolized treatment or invasive respiratory procedures. So despite the differences in these two diseases, contact tracing is based on the risk of exposure based on type of exposure.

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3. Emerging diseases, changes in antimicrobial resistance, and threats of terrorism with biological agents have heightened the awareness of surveillance needs worldwide. Since September 11, 2001, the threats of smallpox and anthrax have been in the media. Discuss the information needed to control the spread of smallpox •

The CHN needs to have knowledge about smallpox, the organism that causes smallpox disease, including how someone becomes infected with smallpox, the infectious period, how it is spread from person to person, what the treatment and control measures are for an individual case of disease, and how an outbreak is prevented and, if necessary, managed. The CHN needs to have information about smallpox vaccine, its availability, use, and indication for use.

Further Resources Butler-Jones, D. & Wong, T. (2016). Infectious disease, social determinants and the need for intersectoral action. Canada Communicable Disease Report, 42-Suppl 1:S18-20.

Moloughney, B.W. What can public health do to address inequities in infectious disease?

Canada Communicable Disease Report, 42-Suppl 1:S14-17.

Pan-Canadian Public Health Network. (2015). Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector. Ottawa: Minister of Health.

Also available at: https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/cpippclcpi/assets/pdf/report-rapport-2015-eng.pdf Professional Education Working Group of the Canadian Immunization Committee. (2008).

Immunization Competencies for Health Professionals. Ottawa: Public Health Agency of Canada.

Also available at: https://www.canada.ca/en/public-health/services/publications/healthyliving/immunization-competencies-health-professionals.html The Chief Public Health Officer's Report on the State of Public Health in Canada, 2013 – Infectious Disease – The never-ending threat. Ottawa: ON. Available at https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officerreports-state-public-health-canada/chief-public-health-officer-report-on-state-public-healthcanada-2013-infectious-disease-never-ending-threat.html Sachs, J. (2010). Expert Systems Fight Poverty: Appropriate information and communications technologies, combined with community involvement, can save lives. Scientific American.

Downloaded April 29, 2010 from: http://www.scientificamerican.com/article.cfm?id=expertsystems-fight-poverty Centers for Disease Control and Prevention (CDC). MMWR: Morbidity and Mortality Weekly Report: https://www.cdc.gov/mmwr/index.html

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Infection Prevention and Control Canada: https://ipac-canada.org/ Pan American Health Organization: www.paho.org/hq/ Public Health Agency of Canada (PHAC). CCDR: Canada Communicable Disease Report (monthly): https://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/ World Health Organization: Integrated Disease Surveillance Programme http://www.who.int/csr/labepidemiology/projects/surveillance/en/

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Chapter 13 Community Nursing Process

Chapter 13: Community Nursing Process Suggestions for Guest Speakers 1. Ask a nurse who works for your local health authority on community assessments to address the class on the process and outcomes of their work.

2. Skype, teleconference, or invite a nurse from your provincial centre for disease control to discuss community assessments with your students.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Access the document titled “Community in Action: A guide to effective projects” from Rotary International (http://ruralxchange.net/communitychange/community-assessmenttools-a-companion-piece-to-communities-in-action-a-guide-to-effective-projects/) Use the document as a guide for the following activity: Divide the students into groups of 4. Provide them with poster paper and coloured pens. Ask the students to observe Figure 13.5 Present–Future Drawing from their textbook. Direct the students to reflect on their present situation as a community (student loans, studying, lack of time for relationships, etc.) and what resources and constraints contributed to it, and to visualize how the future might appear (jobs, money, colleague relationships, free time, vacations, etc.). This tool allows the students to see where they want to go and to formulate mutual intervention goals and objectives.

2. Break the class into groups of 8. Print out the document: Community Assessment Tools (A companion piece to Community in Action: A guide to effective projects) http://ruralxchange.net/communitychange/community-assessment-tools-a- companionpiece-to-communities-in-action-a-guide-to-effective-projects/ 3. Ask each group to read and discuss an assigned community assessment activity. Provide the students with poster paper and pens to make notes on. Bring the group back together and have each group present the activity that they discussed.

4. Break the students up into groups of 8–10. Ask each group to choose a facilitator and a recorder who will make notes on the group’s responses. Ask the students to choose a community health issue that is important to them (availability of healthy food on campus, supports for students experiencing extreme stress, student dental benefits, etc.) that they would be comfortable discussing in a focus group setting. Provide the facilitator with the following handout to help guide the focus group process:

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Chapter 13 Community Nursing Process www.rotary.org (search for “Community Assessment Tools: A Resource for Rotary Projects).

Focus Groups are discussed on pages 6-7.

Focus Group Session Plan Objectives • Identify stakeholders’ opinions about specific community issues.

• Identify how stakeholders believe these community issues should be addressed.

Time 1–2 hours Preparation - Select a location that is both convenient and private for a small group discussion.

- Develop a list of concepts you wish to discuss. These could include issues that your group thinks might exist in the community, ideas for service projects, or people’s perceptions of existing community resources. Take some time to develop questions that will help guide your discussion and encourage participants to share their ideas.

- Arrange for another facilitator to record the focus group session or take notes of participants’ responses. At least one week before the event, invite 10–20 people to participate. Make sure they are representative of the community, don’t know one another or any of the facilitators, and can communicate effectively.

Materials • Name tags • Pens or pencils for each participant • Notebooks for each participant • Seats arranged in a circle facing one another • Recording equipment, if available • Refreshments • Gift or honorarium for participants Procedures 1. Welcome participants as they arrive, but avoid talking about the topic of the focus group. (5– 10 minutes) 2. After all the participants have arrived, introduce yourself and explain the purpose of your assessment. (5 minutes) 3. Begin with a warm-up question before moving on to the main issue. Ask each participant to answer and briefly summarize their responses. (10 minutes) 4. Introduce the main topic of discussion, and guide the discussion using your prepared questions. (15–30 minutes) 5. Allow each person time to answer. Listen carefully to their ideas, asking for clarification if needed but avoiding confrontations or debates.

6. Summarize the main points discussed, and, thank people for their participation. (10 minutes)

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Chapter 13 Community Nursing Process Ideas for Self-Study and Distance Students 1. Ask students to review the PowerPoint slides.

2. Have an on-line or phone chat about the information from the text.

Practice Application 1. Direct the students to read the document: Community Assessment Tools (A companion piece to Community in Action: A guide to effective projects) http://ruralxchange.net/communitychange/community-assessment-tools-a-companionpiece-to-communities-in-action-a-guide-to-effective-projects/ Ask students to consider each step in the process of facilitating a community assessment. Ask the students to consider what would be their first steps in their communities towards an assessment.

What resources would be needed? Who would fund the work? Who would be involved? What would be some of the strengths that they (as student nurses) bring to the process of conducting a community assessment? What might be some of the barriers?

Seminar Discussion Questions 1. Ask students to consider how community is defined in their community placement organization. Is there criteria for who can access services? Does the population served at the community health placement consider themselves to be a community? If so, what is that based on (age, gender, disease diagnosis, economic status, etc.)? What model or approach is used in the way that staff engage with the community that they serve (epidemiological, health promotion, etc.)? Are there on-going assessments of the needs of the community? If so, how are the assessments carried out? By whom?

Case Study 1. Who are the experts in identifying the local needs of a community? By priority, rank the areas that you feel would improve the health of this community and relate them to the determinants of health.

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While the CHN may be expert in nursing, members of the community are true experts in knowing about their own community needs through their lived experiences.

Superficial problems identified by community outsiders as top priority interventions may include: sanitation, poverty, housing, and crowding.

Community residents often list education and jobs are their top priority concerns. Education can help increase their opportunities for better paying employment and thereby income level.

It allows them to move out of the slum neighbourhoods.

To relate to the determinants of health, the following should be asked: ▪ Why are the children playing on the streets unsupervised? Why are they not in school? How safe are the children playing in this neighbourhood? Do they look healthy? (Health determinants: Education and literacy, healthy child development, 100

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▪

▪

income and social status, social support networks, physical environment, personal health practices, coping skills) What are the adults doing in the illustration? Why are they not working? Why are they unemployed? What do they do to pass time? Why? (Health determinants: Employment and working conditions, income and social status, social support network, physical environment, social environment) What do you think of the housing conditions and environment? Do you see equity in living conditions in this illustration? Why? (Health determinants: Income and social status, physical environment)

2. If you were a resident of this community, how would you feel if someone made judgments about your living situation? Why? What do you see as the priority area to improve the health of your community?

• •

Residents have pride and self-esteem and would rather be listened to rather than criticized or told what to do.

They have first-hand knowledge of their lived experiences. They know what works and what does not.

3. What data sources and data collection methods would you use to establish a community profile as depicted in this figure?

• • • •

People from their own community have the lived experiences. They are most aware of their resources, strengths, deficits, and needs.

CHNs’ expertise lies in their ability to mobilize the community toward a higher level of health functioning through community mobilization and empowerment.

Community residents must be accessed and listened to when gathering data needed to complete a comprehensive community profile.

Working together will allow them to better understand how the community functions as a whole and both subjective and objectives assessments of the community needs could be shared for community planning.

Canadian Research 13.1 1. Explain the benefits of using community engagement over digital communication or virtual meetings.

While community engagement may be a more time consuming and expensive activity than digital communication or virtual meetings, it allows participants to meet face-to-face as a group to brainstorm, share their values and interests and discuss their needs/priorities and find solutions to their issues raised. Face-to-face meetings can promote engagement that may foster new relationships and strengthen existing connections among the participants.

2. What might be the challenges of the methodology in this research study?

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a) Audio recording may be used in the meeting as it is a time-consuming process to transcribe the interactions and notes written on the sticky notes at the meeting. b) Given the number of participants at the meeting, focus-groups could be used instead of one big community meeting.

3. Explain when and why you would use community engagement when working with your community. Give examples.

Community dialogue is important to encourage public input into the planning process. To be cost effective, planning and strategies for any community interventions must be geared to identifying the priority community needs, their value systems, and what capacity/resources are available for implementation. Community engagement may be used in the following activities: hospital restructuring, merging of service agencies, mental health needs of teens (or any aggregates), prevention of opioids and drug use and misuse in the community, antipoverty strategies, implementing health care reform, prevention of elder abuse/wife abuse, managing cyber bullying, building accessible cycling paths in the community, Passing the law on physician assisted dying, etc.

Individual Critical Thinking Exercises 1. Why is it important for the nurse to provide care to the community?

• • • •

To better understand the health behaviours of the residents in their natural environments where they work, learn, play, and live.

To assess how and what impact various factors or system components in the community have on their clients’ health. This allows the nurse to then collaborate with various community stakeholders to improve these determinants of health.

To effect change by building and strengthening community capacity or resources through primary, secondary, and tertiary prevention as CHNs work with various aggregates, especially women, children, and marginalized or vulnerable groups.

To provide basic care for the community; to promote, preserve, and protect their health and to achieve equity in health for all.

2. How would you work with your community to identify their health needs and share their community experiences?

• •

First, identify formal and informal leaders in the community; work with them for coalition building and community mobilization.

Depending on the purpose and the available resources, plan a focus group or community for community dialogue and public participation. Encourage community members to discuss their health needs, share ideas, and learn from each other’s ideas and lived experiences.

3. In developing a health profile for a community, what assessment questions would you ask for each category of the community components? Where and how would you collect the needed data?

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•

•

A clear purpose of the assessment will guide the data collection process. This purpose should be supported by sound rationale. For example, why is there a need for developing a health profile in this community? Is the health profile for a specific group or for the overall community? Is the health profile for particular boundaries within the community or for the overall community?

Assessment questions may be developed for each category of the community assessment components as listed in the textbox (Guide to Community Health Nursing Process). Develop these questions with a focus on what, who, where, when, how, and why. Refer to Table 13.2 for types and sources of community data.

Group Critical Thinking Exercises 1. Discuss the benefits of community dialogue between CHNs and Indigenous populations or any other population groups.

It is important for the CHN to remember that each group or individual has its own distinct values, culture and beliefs. The CHN must learn about their clients’ world views and cultural practices and remain non-judgmental when working with them to attain their health goals.

For the Aboriginal people in particular, CHNs must make an effort to understand the roots of the many problems (such as alcoholism, suicide, addictions, etc.) they suffer are a result of the experiences when placed in residential schools. Similarly, when entering Canada, immigrants, migrants, and refugees also have many hardships such as loss of family members and family assets, violation of their human rights. CHNs use active listening and remain a learner to learn about their clients’ experiences, then provide the needed resources as needed.

Community dialogue encourages two-way communication among community members to share and discuss their experiences, lessons learned, problems, needs, visions, and goals.

Members engage in the discussions, exchange information, and become an open learning community and support for one another. When working with a population that the CHNs are not familiar with or when there is a need to introduce new information or resolve old community issues, community dialogue is an effective way for both parties to learn about each other’s cultures, needs, values, expectations, and reasons why differences exist. Once a common understanding is reached, mutual goals can be developed and community partnership for actions can be built.

2. In a group of two to four, spend about an hour visiting and talking to people in your local neighbourhood. Describe your community visit, and explain your impression about the felt needs, real needs, and wants of the community. (a) Formulate your nursing diagnoses and propose your actions (b) Discuss possible ways to engage your community to meet the identified health needs.

(2a) • Encourage students to use all their five senses when they perform the environmental scan.

• Encourage students to engage members of their community through interviews to explore and understand what are their real needs, felt needs, and wants. .

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Needs can be “felt” and “real.” Felt needs are what people feel are their biggest problems, concerns, or issues. Real needs are steps people can take to correct these. Wants are desires that go beyond the basic need.

Refer to Table 13.3 for formulation of community nursing diagnoses.

(2b) • Introduce yourself to the community (i.e., target group) by contacting the community stakeholders or by participating in their community functions, committees, or events.

• Clearly articulate your role and functions, the purpose of your involvement and what you need, what you can do for them, or what they can do for you. Remember that this is a twoway process and the community is the expert on the conditions they live in.

• Be open and inquisitive. Do the needed research so that you can critically analyze the data when collected.

• Keep the communication open. Keep your community informed throughout the process.

• Be a facilitator and help the community work through their problems, identify their priorities, and set out realistic plans that can be implemented. Help the community to identify their capacity and mobilize the resources they have in order to reach their goals.

• Involve the community to evaluate the outcomes. Do a de-briefing and learn from the experience for future development.

Further Resources Benbow, S., Gorlick, C., & Forchuk, C. (2016). Ontario’s Poverty Reduction Strategy: A Critical Discourse Analysis. CJNR, 48(3-4)., 100-109. Published online Dec. 16, 2016. Retrieved from https://doi.org/10.1177/0844562116684729 Cusack, C., Cohen, B., Mignone, J., Chartier, M. J., & Lutfiyya, Z. (2017). Reorienting public health nurse’ practice with a professional practice model. CJNR 49(1), 16-27. Retrieved from https://doi.org/10.1177/0844562116686003 Diem, E., & Moyer, A. (2015). Community and public health nursing: Learning to make a difference through teamwork. Toronto: Lippincott Williams & Wilkins.

Government of Canada. (2016, July 14). Health Canada and the Public Health Agency of Canada Guidelines on Public Engagement. Retrieved from https://www.canada.ca/en/healthcanada/services/publications/health-system-services/health-canada-public-health-agency-canadaguidelines-public-engagement.html?_ga=2.69704848.1876854603.1510884521121853921.1506561809 Norris, J. M., White, D. e., Newell, L., Mrklas, K., & Stelfox, H. T. (2017). How do stakeholders from multiple hierarchical levels of a large provincial health system define engagement? A qualitative study. Implement Sci., 12(1)98. doi: 10.1186/s13012-017-0625-5.

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Statistics Canada. (2016). Canadian community health survey, 2016. Retrieved from http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=3226 Canadian Public Health Association www.cpha.ca Canadian Institute for Health Information (CIHI) www.cihi.ca Public Health Agency of Canada www.phac-aspc.gc.ca

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Chapter 14 Community Health Planning, Monitoring, and Evaluation

Chapter 14: Community Health Planning, Monitoring, and Evaluation Suggestions for Guest Speakers 1. Ask a representative of the local health authority to visit to discuss planning, monitoring, and evaluation of community health programs.

2. Ask a program planner from a non-governmental organization to discuss the issues of planning, monitoring, and evaluation.

3. Ask a CHN who is working in a non-governmental organization to explain the impact of the planning, monitoring, and evaluation process on his/her practice.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Sample logic models are available on-line. Provide one to the students for discussion.

Note the development of a logic model consists of two planning stages, referred to as CAT (Components, Activities, and Target groups) and SOLO (Short-term Outcomes and Long-term Outcomes).

2. Ask students to find the article: Dwyer, J. J. & Makin, S. (1997). Using a program logic model that focuses on performance measurement to develop a program. Canadian Journal of Public Health, 88(6), 421-425. (The article can be found by copy and pasting the reference into google scholar). Ask students to read the article to understand the process for developing a program logic model. Ask students to develop a logic model based on the scenario below: The Scenario: The Sunshine Teen Resource Center found that many teens accessing their center would make poor choices about nutrition, hygiene, physical health, relationships, sexual health and substance abuse. Assuming that you have been working collaboratively with the community, please use the template below to develop a program to increase healthy decision making in youth who live in the Sunshine community.

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Sample logic models are available on-line. Provide one to the students for discussion.

Note the development of a logic model consists of two planning stages, referred to as .

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Chapter 14 Community Health Planning, Monitoring, and Evaluation CAT (Components, Activities, and Target groups) and SOLO (Short-term Outcomes and Long-term Outcomes).

2. Ask students to find the article: Dwyer, J. J. & Makin, S. (1997). Using a program logic model that focuses on performance measurement to develop a program. Canadian Journal of Public Health, 88(6), 421-425. (The article can be found by copy and pasting the reference into google scholar). Ask students to read the article to understand the process for developing a program logic model. Ask students to develop a logic model based on the scenario below: The Scenario: The Sunshine Teen Resource Center found that many teens accessing their center would make poor choices about nutrition, hygiene, physical health, relationships, sexual health and substance abuse. Assuming that you have been working collaboratively with the community, please use the template below to develop a program to increase healthy decision making in youth who live in the Sunshine community.

Seminar Discussion Questions 1. Ask the students to consider whether their community placement organization has a fiveyear (or similar) plan. How did they develop this plan? How is the work that goes on at your placement monitored? How do you know that the organization is having the desired effect on their clientele?

Case Study Questions 1. At what stage in the planning-implementation-evaluation cycle are Rachelle and her colleagues in their work at the outreach centre?

Rachelle and colleagues have ‘identified a problem or issue of concern’: an increasing proportion of young pregnant and parenting women needing access to mental health services.

They may decide to ‘conduct a formal situational analysis or assessment’ of the young women’s mental health service needs; or they could move directly to the stage of ‘considering possible solutions or actions to address the problem’.

2. Which community partners should be included in the planning-implementationevaluation cycle and how can Rachelle engage them?

Rachelle could suggest conducting a SWOT analysis (strengths, weaknesses, opportunities and threats) to engage community partners and to identify the internal strengths and weaknesses of the outreach centre programming and external opportunities and threats. The SWOT analysis could involve: a) meetings with personnel from agencies that provide mental health services to assess the potential for collaboration, b) key informant interviews with service providers who have implemented community based mental health services to determine potential barriers and

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Chapter 14 Community Health Planning, Monitoring, and Evaluation facilitators, and c) focus groups with the outreach centre staff and clientele to determine priorities.

3. Using a socioecological framework to guide your approach, what sources of literature and community data might help you develop an intervention plan?

In using a socioecological framework, one needs to consider literature and community data that describe individual, family, organizational and societal factors that may be influencing the problem; and intervention options that should be considered in program design. For example, etiological studies of mood disorders may help identify what individual and societal factors are contributing to the prevalence of mental health issues among teens who are pregnant. A review of organizational and policy and historical studies may reveal contributing meso-level factors such as stigmatizing practices among those working in health care and social services organizations; and macro- level factors such as changes to educational, social welfare and housing policies. Descriptive studies across different settings would help to identify whether these changing patterns of illness are being seen in similar settings. Consulting systematic and integrative reviews would help identify effective individual and community services that are targeted at female youth.

Canadian Research 14.1 1. How does poverty affect children living in low-income families?

Poverty is associated with a lack of school readiness among children and parenting stress.

2. What are the strengths and limitations of the research design used to assess the impact of this program?

Strengths of the research design include: the integration of community involvement, evidence, and theory in the intervention design, implementation and evaluation; surveys were used to quantitatively determine if changes in children’s language skills and parenting stress occurred over time; a multiple intervention design was employed to address the social determinants of health. Limitations of the research design include: a lack of qualitative data collection that would contribute understanding about how and why the observed changes occurred; sustainability of the program may not be feasible.

3. Were the evaluation measures used examples of output, outcome, or impact indicators?

The evaluation measures (parental stress, community life skills and self-esteem, and children’s language skills) were outcome indicators because they measured medium-term changes that can be attributed to the program.

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Chapter 14 Community Health Planning, Monitoring, and Evaluation Individual Critical Thinking Exercises 1. Your healthcare agency is collaborating with a community advocacy group to address escalating substance use among youth (ages 12 to 17). What are some of the underlying socioecological determinants of substance abuse in this age group?

Refer to levels of the socioecological determinants model in the chapter. Consider the factors at each level that may influence substance use among youth. Identify the types of information sources you would use to identify these influences at each level of the socioecological model.

2. Using the substance abuse problem above, what types of evidence would you assemble to support the development of the program plan and why?

Qualitative and quantitative research on substance use among youth may provide evidence of determinants. Consider examples of qualitative and quantitative evidence and the types of journals or reports where you would find both types of evidence. What audiences are you trying to reach with your program plan? What types of evidence might they find easiest to understand?

Would evidence that comes from studies of related problems be useful? For example, you might want to consider evidence from studies of tobacco control since tobacco is an addictive substance.

3. What are the strengths and weaknesses of each type of evidence you have selected for the substance abuse problem?

Consider the strengths and weaknesses of evidence arising from qualitative and quantitative sources and studies. How does each type of evidence help describe the underlying determinants and assist with the identification of strategies to address these determinants? Consider what kinds of evidence are needed to determine the reach and intensity of an intervention.

4. What are some examples of indicators you can use to assess the impact of the substance abuse program at the individual, organizational, community, and policy levels?

Indicators provide an indication of whether or not a program is making a difference. Structure indicators are those which suggest the program is being implemented. Are there educational sessions with clients, are training programs being run, are meetings being held to discuss policy options, are there stories about the program in the media? Process indicators concern changes in knowledge, attitudes, and practices. Consider examples at individual, family, community, and policy levels. For the youth, this might be increased awareness of the risks of addiction; for teachers this might be increased knowledge of what youth need to know about substance use; for the community this might be parents who are better informed about how to discuss substance abuse with their teens; for the community this might be more balanced media coverage of the substance abuse problem. Impact indicators refer to changes in health status, and changes in policy. Examples include a reduction in the proportion of teens who report initiating substance .

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Chapter 14 Community Health Planning, Monitoring, and Evaluation abuse and the establishment and enforcement of no-alcohol policies for teen dances. Consider both shorter-term and longer-term impacts as some may be achieved quickly while others may take a much longer time period to occur.

5. Identify a community health issue of interest. What are some examples of synergies that might be expected to occur between program strategies and community context?

Consider what is meant by the term synergy. How might the program strategies for your issue of interest be influenced by the community context? For example, does the community support efforts to address the issue? Are there other investments being made in the health problem? Is this an issue being addressed by the media? Are politicians or other leaders talking about the issue and efforts to address it? Are their suggestions for change consistent with the program strategies or are they in conflict with program strategies?

Group Critical Thinking Exercises 1. You are part of a team evaluating a childhood obesity program delivered through the local schools. What information would you need to develop a logic model for this initiative? Describe to the members of your team why it is important to spend time developing the logic model.

Review the structure for a logic model. Identify the information you require to complete the logic model structure: a) nature of the problem, b) underlying determinants, c) evidence of effective program strategies, d) indicators that can be used to assess change. Consider the advantages of a logic model: a) commonly used in health departments and increasingly a requirement of funding organizations, b) provides a structured way to assemble program information and to communicate same to community partners, and c) clearly identifies program components and their inter-relationships.

2. Locate a good example of a community health program plan that illustrates the integration of several different theories. Do these theories reflect different levels of a socioecological model?

Review the integrated theory examples on the multiple intervention toolkit website http://www.miptoolkit.com/ or identify the theories used to guide a multiple intervention program. Link each of the theories with the underlying determinants of the issue. Line up both the determinants and the theories with different elements of the socio-ecological model. What theories are prominent? Which levels of determinants are addressed by the program interventions but not explicitly guided by theory?

3. You have been asked to develop a multiple intervention program and evaluation plan to address homelessness among older adults. What community partners would you involve in this process and why? How would you get community partners involved?

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Chapter 14 Community Health Planning, Monitoring, and Evaluation What community partners already work with the homeless population or are directly or indirectly affected by homelessness? Consider sectors such as housing, the business community, social services, addictions, and health. Identify the mandate of the various community partners. Given their mandates, what outcomes would they be aiming to achieve in working with the homeless?

How might a multiple intervention program address the problems associated with homelessness?

Further Resources MIP Tool Kit http://www.miptoolkit.com/ Asthana S, & Halliday J. (2006). Developing an evidence base for polices and intervention to address health inequalities: The analysis of “public health regimes”. Milbank Quarterly. [cited 2007 Nov 23];84(3):577-603.

Riley B, & Edwards N. A primer on multiple intervention programs and some implications for a research agenda. CHRU & NBPRU publication No. M2009-1.

Galea S. (2007). Macrosocial determinants of population health. Springer Science.

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Chapter 15 Digital Health

Chapter 15: Digital Health Suggestions for Guest Speakers 1. Invite a representative of the local health authority to discuss the use of health informatics for public health initiative.

2. Interview, Skype, or teleconference with a nurse who lives in a remote community and accesses health information online or provides digital health care.

3. Invite a nurse who teaches health informatics to speak about the challenges and opportunities they face.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask students to imagine what life would be like as a student nurse, without the use of the Internet. Have them write out all of the ways their life would change on a piece of paper (give them 5 minutes). Ask them to share their thoughts with a partner (also 5 minutes).

Ask for volunteers to share what they leaned with the larger group.

2. Ask students to describe how the following nurses would currently use the Internet for their nursing practice. Also give examples of how students imagine that each nurse might expand the use of information technology to enrich their practice.

Community Health Nurse

Current Internet Uses

Imagined Future Internet Uses

A Community Health Nurse in a nursing station in Iqaluit, Nunavut A street nurse in downtown Toronto A diabetes nurse educator in Brandon, Manitoba A public health nurse in New Brunswick

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3. Ask students to read the Scientific American article “Expert Systems Fight Poverty: Appropriate information and communications technologies, combined with community involvement, can save lives” by Jeff Sachs. Article available at: http://www.scientificamerican.com/article.cfm?id=expert-systems-fight-poverty Ask the students to think about how cell phones have revolutionized CHNs’ ability to provide care in teams, while practicing in the community. Using the mind-map procedure found in Appendix A, brainstorm all of the ways that cell phones could be further used to improve coordination of services in the community.

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Ask students to imagine what life would be like as a student nurse, without the use of the Internet. Have them write out all of the ways their life would change on a piece of paper (give them 5 minutes). Ask them to share their thoughts with a partner (also 5 minutes).

Ask for volunteers to share what they leaned with the larger group.

2. Ask students to describe how the following nurses would currently use the Internet for their nursing practice. Also give examples of how students imagine that each nurse might expand the use of information technology to enrich their practice.

Community Health Nurse

Current Internet Uses

Imagined Future Internet Uses

A Community Health Nurse in a nursing station in Iqaluit, Nunavut A street nurse in downtown Toronto A diabetes nurse educator in Brandon, Manitoba A public health nurse in New Brunswick

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3. Ask students to read the Scientific American article “Expert Systems Fight Poverty: Appropriate information and communications technologies, combined with community involvement, can save lives” by Jeff Sachs. Article available at: http://www.scientificamerican.com/article.cfm?id=expert-systems-fight-poverty Ask the students to think about how cell phones have revolutionized CHNs’ ability to provide care in teams, while practicing in the community. Using the mind-map procedure found in Appendix A, brainstorm all of the ways that cell phones could be further used to improve coordination of services in the community.

Seminar Discussion Questions How is the Internet used at your practice placement area? What percentage of your clientele do you believe have access to the Internet? Is literacy an issue with your clientele? Are there other access issues when it comes to information technology? Have you as a student accessed the Internet to seek out health-related information this week? Was it useful? What was not useful and why? What is the risk of people accessing information/joining on-line support groups?

Case Study Questions 1. How accessible was your site?

•

Individual responses will vary

2. Which standards did it fail?

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Individual responses will vary

3. Consider how the website could be improved.

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Individual responses will vary

Canadian Research 15.1 1. How could nurses assist clients to use a navigation tool to access credible information relative to their needs?

One of the first issues of accessibility to credible health information is knowledge of where to find that information on the Internet. Since we know that patients tend to conduct their Internet searches in a limited fashion, and also use the first few hits that come up on the search engine, it is important to direct patients to credible resources. If the website has been well-designed according to the HON criteria, the navigation tool should be relatively easy to .

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Chapter 15 Digital Health use, internal links should be clearly identified, and the user should remain on the website when using the links. For those with disabilities, the ability to increase font size and sound is important: patients should be reminded to use these features. For those clients who are limited in their Internet skills, partnering with more confident family members or healthcare professionals can assist these individuals to use the site more confidently, thus contributing to their sense of control and empowerment in the search for information.

2. What assessments could nurses make to determine client or family limitations to the use of such a navigation tool?

Nurses can ask clients about their level of computer skill and their confidence in using the Internet effectively. Reading and comprehension skills are also important, and can be assessed informally by asking clients about their last completed grade in school. Because lack of computers or Internet connections in the home is one of the key barriers to Internet use for health information, an assessment of the client’s home equipment and his use of it is necessary, understanding that merely having a computer in one’s home does not mean the client actually uses it.

3. As a health equity issue, how could nurses support clients who lack computer literacy to use navigation tools to access high quality oncology information?

Clients who lack computer skills may need a coach who will sit with them while they use the Internet resource and gain confidence in using it. The nurse may also find that coaching the client allows for teaching about high quality websites and credible information on the Internet. In addition, while acknowledging client confidentiality, it may be possible to incorporate family members who have better skills or use volunteers who can also support the client in computer skills and navigation of the website.

Individual Critical Thinking Exercises 1. What criteria would you use to evaluate a health promotion intervention such as a smokingcessation website?

Community Health Nurses are often asked to review materials that clients have downloaded from various websites. At other times, CHNs may wish to refer clients to specific health promotion, screening, or informational websites. In all instances, CHNs must assess the quality of the information provided to clients through the Internet, whether clients access it themselves or CHNs access the information. Table 15.2 summarizes the following principles of the HON Code of Conduct (HONcode) for medical and health websites (Health on the Net Foundation, 2017): • information provided on the website is given by duly qualified healthcare professionals • information provided is intended to be complementary to the advice provided by the client’s health care professionals .

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confidentiality of data relating to clients or visitors to the website is assured information on the website is supported by references to data sources and the date of most recent updating of the website claims about the benefits or performance of specific treatments or services will be supported by appropriate evidence the authorship and sponsorship of the website including financial support will be clearly evident to visitors any advertising on the website will be presented such that it is clearly separated from the informational text of the website.

Internet users may determine if health-related websites have been certified by the HONcode by submitting a website URL to WRAPIN (WRAPIN, 2014) for confirmation of its HON status. The Health Summit Working Group added several other criteria (see Table 15.4), which are made available to Internet users in the form of the Information Quality Tool (The Health Summit Working Group (2017): • • • • • • • • • •

sponsoring agency logo and information are clearly displayed the purpose of the website is clearly stated content corresponds to intended purpose of the website evidence of editorial/content review is evident content is accurate, complete, and current appropriate links both internal and external are included on the website the website is easily navigated the information is well designed with a balance of text and graphics internal search capabilities are present within the website interactivity is encouraged, including exchange of information among users and the provision of feedback to the web designers/overseers.

In addition, assessment of the website would include an assessment of readability using an approach such as SMOG (McLaughlin, 1969) and the use of plain language to facilitate understanding (Canadian Public Health Association, 1999). Lastly, CHNs must assess the appropriateness of a website for the targeted population, recognizing the special needs of certain populations.

2. What would you need to consider when working as a community health nurse with a client who is visually impaired and wants to use the Internet?

Ensure that the person you are working with has access to the Internet and a computer where he or she can adjust their computer settings. Some simple adjustments to the operating system can be made to ease reading on the screen such as adjusting the contrast of the background from white to black with white text for people with light sensitivities. Other commonly used devices for the visually impaired include screen readers which read the text that appears on the screen, and screen magnifiers which simply magnify the size of the text.

OCR software can turn a printed page into electronic text for screen reading (Fichten, Barile & Asuncion, 2003). Simple adjustments can be made with most Windows operating systems to enhance accessibility by exploring the ‘Accessibility Options’ folder in the Control Panel .

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Chapter 15 Digital Health to adjust settings for hearing, vision, and mobility. You can always try these out on your own computer and then reset the configuration to normal settings. The Canadian Adaptech Network project website at Dawson College (http://adaptech.dawsoncollege.qc.ca/) provides ideas and resources to assist users with disabilities in using the Internet (Adaptech Research Network, 2006). The University of Washington also has a very useful online video that provides a good overview of numerous assistive technologies to assist people with disabilities at work and school. It is located at http://www.washington.edu/doit/Video/wt_dis.html 3. Discuss the merits and drawbacks of the HON code. Review the editorial and the response to it found in the Journal of Medical Internet Research by Eysenbach (2001).

HON certified websites are designed to meet certain ethical standards and criteria that aim to protect the public and healthcare professionals from misleading online heath information.

HON certification demonstrates “the intent of the website to publish useful, objective, and correct data.” However, HON cannot guarantee the content of a website at any given time.

This may be confusing to some. Although HON is the oldest and most used ethical code on the Internet, Eysenbach challenges its reliance on vulnerable second generation technology including a static logo that can be simply “copied and pasted by webmasters.” Eysenbach provides one example of a website abusing the HON Code logo. Examples such as this must first be discovered before they can be corrected. Eysenbach states that newer third generation technology, which uses a third party to generate a “dynamic logo,” would provide additional security and features such as time stamping and a link to up-to-date site status information. Also third generation technology would not be reliant on the cooperation of the health information provider. Eysenbach further questions the frequency with which websites displaying the HON Code logo are monitored by the HON organization and expresses concern that the public may be easily confused by the misrepresentation of the HON logo as an award by some websites. Health On the Net Foundation (2016) Retrieved from http://www.hon.ch/HONcode/Pro/ 4. What would you need to take into account when designing a web-based intervention for an older adult?

When designing a web-based intervention for a senior, at a minimum, the Priory Level One universal accessibility design standard must be met to ensure that the website is accessible and navigable to a wide range of people with disabilities and limitations. This standard guides developers to use clear text, alternate text tags on images, and contrasting background and text colours. There should be an option to increase the website font, or activate a talking feature if required. Additionally, external links should be relevant to the content of the site and users should be able to manoeuvre easily between pages of the website. Users should be informed when they are leaving the website by clicking on an external link. Interactivity with the website may also be an attractive feature and has been shown to enhance learning (Ramsey, Corsini, Peters, & Eckert, 2017). Graphics must not be overwhelming, or distracting. It is also recommended that only one paragraph per web page be presented (Ramsey et al., 2017), although this approach may also create navigation problems. .

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Website readability must also be considered. Websites should be written using plain language strategies at no higher than a grade 9 reading level. Although web designers have some basic guidelines from which to draw, online health information should be designed for the intended users. Design considerations may be disease specific. End-user insight is always an asset during early phases of iterative website design to avoid unforeseen usability issues.

5. How can technology help to empower individuals and communities?

Technology can empower individuals and communities by providing access to information.

Personal empowerment may be enhanced by the use of online health information resources.

Research has shown that access to health information on the internet may result in compliance with expert advice, self-reliance through individual choice, and social inclusion through the development of collective support (Lemire et. al., 2008). Communities, such as people with disabilities, may use technology to reduce the feeling of social isolation by contacting others who share in their experiences (McMaster Health Forum, 2014).

Community websites have also sparked public debate, mobilization, capacity building, and increased citizen participation in the promotion of a healthier community.

6. How would you determine if a health promotion website is appropriate for an Indigenous community with whom you are working?

Individual responses will vary 7. How would you explain privacy protections to a youth who is considering accessing your ethically designed health promotion website but is concerned that his identity will be apparent?

Individual responses will vary

Group Critical Thinking Exercises 1. Discuss what informatics core competencies you think a new graduate working in community health is required to have at a high level of proficiency? Use the Community Health Nurses Standards of Practice (Appendix A) to help you.

Community Health Nurses (CHNs) need to be competent in using a variety of sources to access data and research findings to promote health (Standard 1, p.10). The use of the Internet to locate credible information is a basic competency of all nurses and is especially emphasized for CHNs working with a varied client population in more independent practice.

Increasingly, CHNs have access to wireless devices for documentation and information access at the point of contact with clients.

A CHN “Collaborates with client to do a comprehensive, evidence informed, and strengthbased holistic health assessment using multiple sources and methods to identify needs, assets, .

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Chapter 15 Digital Health inequities and resources” (Standard 1). To this end, the CHN “Implements appropriate communication approaches such as social marketing and media advocacy to disseminate health information and raise awareness of health issues at individual and/or societal level” (Standard 1) . For a number of client populations, including youth and those who feel marginalized or stigmatized, the Internet has become a major source of health information. CHNs may refer clients to credible websites for health promotion or intervention strategies and thus need to be competent in assessing websites recommended for use by a variety of clients. In addition, a CHN “assists the client to make an informed decision in determining their health goals and priorities for action. ” (Standard 5, ). The CHN needs skill in accessing information or assisting clients to access information, both possibly involving use of the Internet. With the assistance of qualified webmasters, CHNs may be involved in the development of websites for a variety of purposes including health promotion, screening, or interventions. In this way, the CHN “helps the client to identify and access available resources to address their health issues” (Standard 5) and “seeks out reliable sources of available evidence from nursing and other relevant disciplines” (Standard 7).

A CHN needs to “promotes awareness of, and supports linkages to, appropriate community resources that are acceptable to the client (Standard 4).

Recognizing the preferences and skills of clients, CHNs may use the Internet as one of the means of addressing the needs of clients more effectively through screening, online support groups, information sites, or interactive self-assessment websites. At the very least, CHNs must have knowledge of how various client populations use the Internet and support clients in this use. One of the key uses of the Internet for many clients is for purposes of communication. Email has become indispensable as a means of contact with certain populations. For those populations that are potentially vulnerable, use of the Internet with select individuals may be a very useful outreach strategy for health promotion, intervention, and support.

A key professional competence is the ability to use “culturally safe communication strategies in professional relationships, recognizing communication may be verbal or nonverbal, written or graphic. Communication can occur via a variety of mediums” (Standard 4) The Internet has become a key source of information for CHNs, both provided locally within the agency or globally via the Internet. The ability to use the Internet for information retrieval and to assess the credibility of the information thus accessed is a key competency of a CHN. In summary, core ICT competencies for CHNs include accessing and processing information from the Internet; using Internet resources to promote health, screen for specific health issues, and provide online interventions; assessing online resources for credibility; supporting clients in their use of websites; communicating with clients and other healthcare professionals; and generating, managing, and processing relevant data for client care.

2. What trends do you anticipate in the use of the internet to promote health by youth, older adults, new immigrants, and disabled populations? What role could Web 2.0 technologies .

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• • • • • • •

With growth in use of the Internet in all populations and age groups, nurses should expect to see increased uses of the Internet to access health information overall.

With the aging population, clients will likely be looking for sites that address various sensory impairments.

With growing use of Web 2.0 technologies, we can expect to see more use of highly interactive health information sites that include features such as podcasting, streaming videos, and social networking tools (such as Facebook and MySpace).

Online health service delivery will likely increase (email counselling, online advice forums, etc.).

Sharing of health information between care providers is increasing and the electronic medical and health records will also become more prevalent.

As a result of early successes with online tailored messaging systems, such applications will likely increase for broader audiences and topics.

The growth of online social support groups continues; it is not clear when or if this trend will begin to level out.

3. Should nurses encourage their clients to join online social support groups? Why or why not?

Many North Americans are currently using social support groups as evidenced by their surge in numbers. Students can easily learn about this by investigating the types and numbers of Yahoo groups (http://groups.yahoo.com/) or Google groups. Royer, FernandezLambert, & Moreno (2013) found that online support groups are very effective, particularly when the participants may be experiencing stigma associated with their situations. The authors argued that studying naturally occurring self-help groups is difficult where participants self-select for the intervention. Also, studies of online social support groups typically include complex interventions (professional advice and counselling, online information resources, etc.) in addition to the groups, making it difficult to tease out the impact of the social support groups alone. Although this review identified no risks to participating in online social support groups, nurses should caution their clients that there have been risks reported of online aggression, hoaxes and spam, encouragement of suicide, and questions about quality of information. It would be prudent to encourage clients to discuss any questions that have been raised for them from their participation in online support groups and to promote the use of groups that are moderated by qualified health care professionals over un-moderated groups.

Further Resources Health on the Net Foundation. (2016). HON Code of Conduct (HONcode) for medical and health websites. Health on the Net Foundation. Retrieved from https://www.healthonnet.org WRAPIN. (2014). Worldwide online Reliable Advice to Patients and Individuals. European Project-IST-2001-33260. Retrieved from http://www.wrapin.org .

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Chapter 16 Maternal, Infant, and Child Health

Chapter 16: Maternal, Infant, and Child Health Suggestions for Guest Speakers 1. Ask a public health nurse who works with mothers and their babies to visit the class.

2. Ask a childbirth educator to visit and discuss his/her role in the public’s health.

3. Invite a nurse-midwife to speak to the class about his/her role. This interview can take place in person, via Skype, or teleconference.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Search for the following article on google scholar: Dykeman, S., & Williams, A. M. (2014). Agenda-setting for Canadian caregivers: Using media analysis of the maternity leave benefit to inform the compassionate care benefit. BMC Women's Health, 14(1), 1.

Ask the students to consider the impact of employment, benefits, current and future earnings, etc. on a couple or individual’s decision to have children. Discuss the article. Next, have them consider quietly for two minutes other determinants of people’s choice to become pregnant.

Ask them to write down their thoughts, allowing 5 minutes for this. Ask the students to then pair up and discuss what they thought. In the larger group, ask the pairs to contribute what they discussed. Make notes on the board to summarize the students’ thoughts and add your own.

2. Consider the following determinants of maternal, fetal, and infant health behaviours and practices, as described by the Public Health Agency of Canada website: http://www.phac-aspc.gc.ca/rhs-ssg/overview-apercu-eng.php List interventions that CHNs could advocate for or develop to impact the determinants:

Determinants of maternal, fetal, and infant health behaviours and practices

Potential Interventions

Rate of maternal smoking during pregnancy

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Chapter 16 Maternal, Infant, and Child Health Determinants of maternal, fetal, and infant health behaviours and practices

Potential Interventions

Rate of maternal alcohol consumption during pregnancy Rate of breast feeding Rate of low maternal education Rate of live births to teenage mothers Rate of live births to older mothers Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Search for the following article on google scholar: Dykeman, S., & Williams, A. M. (2014). Agenda-setting for Canadian caregivers: Using media analysis of the maternity leave benefit to inform the compassionate care benefit. BMC Women's Health, 14(1), 1.

Ask the students to consider the impact of employment, benefits, current and future earnings, etc. on a couple or individual’s decision to have children. Discuss the article. Next, have them consider quietly for two minutes other determinants of people’s choice to become pregnant. Ask them to write down their thoughts, allowing 5 minutes for this. Ask the students to then pair up and discuss what they thought. In the larger group, ask the pairs to contribute what they discussed. Make notes on the board to summarize the students’ thoughts and add your own.

2. Consider the determinants of maternal, fetal, and infant health behaviours and practices, as described by the Public Health Agency of Canada website: http://www.phac-aspc.gc.ca/rhs-ssg/overview-apercu-eng.php

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Chapter 16 Maternal, Infant, and Child Health List interventions that CHNs could advocate for or develop to impact the determinants: Determinants of maternal, fetal, and infant health behaviours and practices

Potential Interventions

Rate of maternal smoking during pregnancy Rate of maternal alcohol consumption during pregnancy Rate of breast feeding Rate of low maternal education Rate of live births to teenage mothers Rate of live births to older mothers Seminar Discussion Questions 1. Consider the clients who are served by your clinical placement organization. Do you believe that the issues that they currently face can be traced back to issues as far back as their first year of life (birth defect, FAS, parental support, parental income, education, etc.)?

2. Are any of the clientele that you serve pregnant? How does your organization respond to the needs of mothers and babies?

Case Study Questions 1. Which of the determinants of health would you want to consider in your community health nursing interventions?

•

.

Given that this mother appears to be socially isolated, as a CHN you would want to pay special attention to her social support networks. You would also want to explore her personal coping skills, as well as income and social status. Since she indicates that she relies on public transportation, you might want to explore other resources that she may be able to access for transportation.

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Chapter 16 Maternal, Infant, and Child Health 2. Based on your responses to question 1 above, what CHN interventions might you consider implementing?

•

The responses to this question may vary, depending on how the student responds to the previous question. One intervention could be to bring together the new mothers, based on the trend that you and your colleagues are observing, and form a social support group, where your clients may come together to discuss the challenges as well as successes that they are experiencing as new mothers in a new country.

3. Based on the perceived language barriers, how might you ensure that the messages you are trying to convey are received as intended?

•

You could try to reschedule the visit to take place when an English speaking family member is present. You could try to access translation services. You could try and convey messages in a group setting so that those in similar positions have an opportunity to discuss content to ensure that they are understanding the information the way it is intending to be understood.

Canadian Research 16.1 1. What suggestions might you have about how PHNs should approach relationship building with mothers who have LPIs? •

Perhaps PHNs can go to the hospital to begin the relationship building process. This way the PHN is aware of the teaching that the mom and family has received and ensures no conflicting information is given. The PHN could participate in the discharge teaching and then follow up in the home visit to promote continuity of care and seamless transition from hospital to community.

2. PHNs could interact with families with LPIs prior to discharge from hospital. What changes to the health care system in your region would you propose to ensure that the transition for families with a LPI is seamless from hospital to the community?

•

Responses may vary depending on the organization of LPI care both in postpartum units and in the community setting.

3. What do you think community health nurses need to advocate for, in terms of their practice settings, to ensure appropriate care is provided to families with LPIs? •

.

Perhaps having more time in each home visit to ensure the mother and family is supported with all of the challenges they are experiencing. Having more home visits than a term newborn infant would have would also be appropriate. It would make sense to have a specialized team of PHNs who focus on the care of LPIs in the community to ensure that the LPI, mother, and family are receiving the appropriate level of services and support for optimal health and wellbeing. It would also make sense to have the same PHN paired with a family for continuity of care.

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Individual Critical Thinking Exercises 1. Visit the Public Health Agency of Canada Healthy Pregnancy Guidelines online (http://www.phac-aspc.gc.ca/hp-gs/guide/index-eng.php) and compare the recommended guidelines to the resources that are being offered in your local area. Are there differences or similarities? Are there policies or programs in your area that offer unique guidelines based on the population that program or policy is trying to serve?

The answer will depend on where students are practicing and dependent on what population they are working with. For example, there may be cultural considerations found in some programs that are not considered within the Healthy Pregnancy Guidelines, or there may nutritional recommendations that women of a low SES cannot meet due to finances.

2. Why are immigrant and refugee women particularly vulnerable to negative mental health outcomes during the perinatal and postnatal period?

Immigrant and refugee women are particularly vulnerable to negative mental health outcomes during the perinatal and postnatal period due to social determinants of health such as inadequate social support, poverty and demanding gender roles which reduce a women’s self-esteem and perceived power. Factors such as vulnerable immigration status, food insecurity, lack of social support and a sense of not belonging in Canadian society put migrant women at higher risk for postpartum depression. Migrant women are also more likely to experience barriers to health care services exacerbated by language and gender-based cultural barriers than Canadian-born women.

3. What is reproductive justice? What are the resources in your community that would support a client to have access to reproductive justice? What gaps in services exist in your community and how could a CHN help to fill that void?

Reproductive justice is a term that is used to encompass reproductive rights and social justice.

Reproductive justice highlights that until women around the world have economic, political, and social power, they may not be able to make informed choices about the sexuality, relationships, and birth control for example. Reproductive justice highlights that there are many social, economic, and political barriers that women face in achieving their optimal health.

Students may find sexual health clinics, free in services at hospitals/community health clinics, services aimed at men and women of differing ages (teens programs, sexual health for seniors), sexually transmitted disease clinics that offer both testing and educations, sexual services offered in primary languages for immigrants, school health programs etc.

Gaps in services will be dependent on the region of Canada the students are located in, along with potential differences in services offered between rural and urban centres. Students may also

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Chapter 16 Maternal, Infant, and Child Health find gaps in services aimed at different age groups (i.e. no specific sexual health services for older adults).

Group Critical Thinking Exercises 1. Assume your group is a team of CHNs who have been asked to develop a health promotion drop-in program aimed at pregnant teens in your community. What four main topic areas would your group propose as essential for pregnant teens to know about?

What may be three barriers your program could face in engaging this population?

• • •

The answer to this question will depend on the community that the students are located in, however, potential answers may include: Four topic areas: smoking in pregnancy (smoking cessation in pregnancy/postpartum), substance abuse, continuing your education, teaching about infant care Barriers may include: lack of buy in by the teen girls, lack of time to attend, embarrassed to attend, may not be culturally appropriate for the ten to attend, lack of resources

2. Consider Table 16.5. Do you agree with the indicators that are being used to measure child well-being? Why do you think these indicators are being used? Discuss with your group any indicators you think should be added or removed and why.

•

Answers for this question will vary depending on the views of the individual students in the group. Responses should give reference to the social determinants of health.

3. Consider the concept of mothering. What responsibilities do CHNs have to ensure women have a positive self-image as mothers? What cultural influences in your communities shape the idea of a “good mother”? What barriers do women face in getting support for positive mothering education and support?

•

Answers for this question will reflect the background of the students and the location of the students within Canada. Student’s beliefs and experiences will shape this answer, as the idea of what is a ‘good’ mother may come from personal experiences. Responses should examine the influence of the mothers’ determinants of health, and potentially include an examination of the services available based on elements of the Canada Health Act (i.e. accessibility), and the fit of the services provided to the population within the community.

Further Resources National Aboriginal Health Organization (NAHO) –Midwifery publications: http://www.naho.ca/midwifery/midwifery-publications/Public Health Agency of Canada –

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Chapter 16 Maternal, Infant, and Child Health UNICEF – The State of the World’s Children Reports: http://www.unicef.org/sowc/ UNICEF – United Nations Convention on the Rights of the Child: http://www.unicef.org/crc/ Public Health Agency of Canada: Maternal and Infant Health: http://www.phac-aspc.gc.ca/rhs-ssg/index-eng.php University of Victoria, Early Childhood Development Intercultural Partnerships: Hook and hub: Coordinating program to support indigenous children’s early learning and development: http://www.ecdip.org/docs/pdf/WIPCE%20Hook%20and%20Hub.pdf National Aboriginal Health Organization (NAHO) (2009). Celebrating birth: First Nations and Metis approaches to mother and child care (video recording). Ottawa, ON: Author.

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Chapter 17 School Health

Chapter 17: School Health Suggestions for Guest Speakers 1. Invite a school nurse to speak to the class.

2. Interview, Skype, or teleconference with a nurse who is a member of the U.S. National Association for School Nurses, 1100 Wayne Ave, Suite 925, Silver Spring, MD 20910 1240-821-1130.

3. Invite a PHN who delivers immunizations to school children to speak to the class.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Read the following description of a day in the life of a community health nurse (CHN): A day in the life of a school-based CHN • 0830h - CHN checks her voicemail and finds a message from a school principal wanting to discuss a new kindergarten student with severe milk allergies. The CHN contacts the principal and arranges a meeting with the child’s teacher, parents, administration to discuss a child safety plan that will involve the classroom and entire school.

• 0900h - CHN arrives at School A where she meets with four grade 7 and 8 students who are members of the Student Parliament. Nutrition has been identified as an issue for the school and together they are working on activities to support their application for the Healthy Eating Champions Award offered through the Health Department to encourage schools in creating a supportive environment for healthy eating.

This small group wants to establish a Healthy Snack Tuck Shop.

• 1130h - While documenting in the teachers’ lounge the CHN is approached by a teacher who expresses concern about a student in her class who is cutting herself. The CHN provides a reference for the teacher to learn more about the issue and they plan to meet again to discuss this student further. The nurse is aware of a community support that might be helpful for referral if necessary.

• 1150h - CHN checks her messages at the Health Department and responds to a parent’s concern about her son’s diabetes.

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Chapter 17 School Health • 1300h - Healthy School Committee (HSC) meeting at School B where a committee of 2 parents, 18 students, 1 teacher principal, and the nurse are reviewing the results of a Healthy School Profile report and beginning to develop an action plan for the remainder of the school year.

• 1430h - The CHN stops at a coffee shop for a break on the way back to the office for a meeting with a colleague to prepare a report to the Board of Health. This report and presentation will profile a HSC’s work in creating an eco-friendly school.

•

1500h - Computer work to complete the report.

• 1600h - CHN checks email, responds to voicemail, and completes the daily activity tracking and mileage reports. She ensures that she has gathered materials to facilitate a small group session on self-esteem for grade 7 girls the next morning.

Activity: Consider the many skills that the school-based nurse must have. As a class, build a list of the skills involved in carrying out this single day’s work. List each of the people that she collaborated with. How might the CHN organize herself in order to keep so many “balls in the air”?

2. Find out what the role of the school-based CHN is in your neighbourhood. This can be accomplished by emailing or phoning a school or the public health unit in your jurisdiction. Describe the role to your class and ask them how the school-based CHN role might be expanded. Ask the students if they would like to see more practice that is consistent with socio-environmental and population health approaches? Why or why not?

If so, to whom could they advocate? Ask them to write a letter to the school board, MLA, or premier who is in a position to make changes for nurses working in school settings.

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1.

Read the following description of a day in the life of a community health nurse: A day in the life of a school-based CHN • 0830h - CHN checks her voicemail and finds a message from a school principal wanting to discuss a new kindergarten student with severe milk allergies. The CHN contacts the principal and arranges a meeting with the child’s teacher, parents, administration to discuss a child safety plan that will involve the classroom and entire school.

• 0900h - CHN arrives at School A where she meets with four grade 7 and 8 students who are members of the Student Parliament. Nutrition has been identified as an

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Chapter 17 School Health issue for the school and together they are working on activities to support their application for the Healthy Eating Champions Award offered through the Health Department to encourage schools in creating a supportive environment for healthy eating.

This small group wants to establish a Healthy Snack Tuck Shop.

• 1130h - While documenting in the teachers lounge the CHN is approached by a teacher who expresses concern about a student in her class who is cutting herself. The CHN provides a reference for the teacher to learn more about the issue and they plan to meet again to discuss this student further. The nurse is aware of a community support that might be helpful for referral if necessary.

• 1150h - CHN checks her messages at the Health Department and responds to a parent’s concern about her son’s diabetes.

•

1200h - Lunch

• 1300h - Healthy School Committee (HSC) meeting at School B where a committee of 2 parents, 18 students, 1 teacher principal, and the nurse are reviewing the results of a Healthy School Profile report and beginning to develop an action plan for the remainder of the school year.

• 1430h - The CHN stops at a coffee shop for a break on the way back to the office for a meeting with a colleague to prepare a report to the Board of Health. This report and presentation will profile a HSC’s work in creating an eco-friendly school.

•

1500h - Computer work to complete the report.

• 1600h - CHN checks email, responds to voicemail, and completes the daily activity tracking and mileage reports. She ensures that she has gathered materials to facilitate a small group session on self-esteem for grade 7 girls the next morning.

Activity: Ask the students to consider the many skills that the school-based nurse must have.

Have them create a list of the skills involved in carrying out this single day’s work. Include each person that she collaborated with. Describe how the CHN might organize herself in order to keep so many “balls in the air.” Describe some methods, resources, and tools that she could use to keep herself organized and on task.

2. Find out what the role of the school-based CHN is in your neighbourhood. This can be accomplished by emailing or phoning a school or the public health unit in your jurisdiction. Describe the role to your class and ask them how the school-based CHN role might be expanded. Ask the students if they would like to see more practice that is consistent with socio-environmental and population health approaches? Why or why not?

If so, to whom could they advocate? Ask them to write a letter to the school board, MLA, or premier who is in a position to make changes for nurses working in school settings.

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Chapter 17 School Health Seminar Discussion Questions What are the issues with school-aged children/youth at the organization where you are carrying out your clinical placement? Consider your own school experience. Were there nurses working at your school? What did you see them doing? What might they have done that would have been meaningful to your school experience? Are there nurses who work at the educational institution that you are currently studying at? What is their role? What could further roles be?

Case Study Questions 1. When creating an interest to work together it is important to recognize what the focus of action will be and how others perceive it. How can the school-based PHN be sure that there is support for this collaborative action from the community, other organizations, and the individuals who are to benefit most by it?

•

Community development is a process where community members come together to take collective action and generate solutions to common problems. Community wellbeing (economic, social, environmental and cultural) often evolves from this type of collective action being taken at a grassroots level. With a community development approach, the school-based PHN values inclusiveness, participation, and cooperative action.

•

It takes time. It is important to build a common understanding of what will be done, why it is being done and the expected benefits.

CHNs can take a community development approach, similar to capacity building discussed in previous chapters. Part of this can include completing a community assessment to identify the community’s strengths. Community members should be involved in all parts of this work to ensure representation and build relationships. During this process leaders and potential champions could be found who can work with the community to identify priorities of the communities, and how various resources could be leveraged. Plans and action strategies can be developed with the community. Once implementation takes place, CHNs can work with the community to evaluate the interventions.

2. Name two ways the Indigenous School Health Framework (NCCAH, 2010), provided in this chapter, is reflected in the approach taken by the SHN in the example.

•

.

The nurse in the case study demonstrated respect for foundational principles in the Indigenous School Health Framework.

1) Inter-connectedness and Relationships: in developing the program for opioid addiction (suboxone availability plus grief counselling and other psychosocial interventions) the nurse recognizes that the health, social and educational issues that were most relevant to the students in her school had connections to loss of culture and identity as a result of being away from home communities. Students’ home communities reflected possible breakdowns in cultural relationships as reflected in the self-medication, high rates of addiction, youth mental health crises and suicides.

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Chapter 17 School Health 2) Self-reliance and Collective Ownership: to be successful in expanding the treatment for opioid addiction to 22 sites in northern communities, the nurse recognizes that the members of Indigenous communities are the experts with respect to knowing their needs and aspirations for their Indigenous students. They have the ability to mobilize and bring about change because of the strength of their culture, communities, families and organizations.

3. Community capacity influences readiness for community action. Define community capacity in the context of this school health case study.

The characteristics of Indigenous communities that affect their ability to identify, mobilize, and address social and public health problems through “Different ways of knowing (concepts and other sources of knowledge)” and include such examples as • “health is not simply a possession but rather a set of relationships with the land, tribe, family and ancestors, • learning is embedded in a cultural construct and way of being, • community ownership and control ensure knowledge uptake and sustainability, • collective approaches of sharing – wealth, possessions, property and shared accountability –build interdependencies, • environmental and social relationships create bonds of stewardship and responsibility, • future orientation/sense of history is a part of continuous orientation which requires a sense of role model and relationship with generations past, present, and future, . . .” (NCCAH, 2010, p. 24).

The set of assets or strengths and resilience factors Indigenous populations bring to the cause of improving community quality of life (culturally, collectively, and individually). See NACCH (2010), pp. 25-26.

Canadian Research 17.1 1. What are some of the unique features associated with providing health services in schools?

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•

School-aged populations are by and large healthy and so schools are an ideal setting for health promotion. Health literacy is informally and formally learned in schools.

•

Eliminates students’ barriers to access by being offered on school premises.

•

Schools provide a setting in which individually-focused as well as community-focused interventions can be provided using a broad range of interventions as described in the 2010 CPHA publication: Public Health~Community Health Nursing in Canada: Roles and Activities.

•

Schools provide an opportunity to simultaneously work with individuals (staff, students, and parents), families or groups and neighborhoods while focusing on the larger picture of the community or population.

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•

Schools provide opportunities for surveillance, early detection and early intervention.

Crisis intervention may also be required depending on the health situations.

•

Schools can facilitate interprofessional practice with social workers, mental health and youth workers, school psychologists.

2. From the findings discussed, what might explain the differences or similarities among the three jurisdictions in this study?

• • • • •

The country’s value systems and general orientation toward publicly funded or privately funded health care services.

Limited access to primary care services could influence decisions about the type of services available in schools.

Funding is the most common barrier reported by all 3 countries. Funding of school health services may fall to school districts rather than the health care system. This is the case in U.S. All 3 countries reported similar concerns regarding a lack of understanding and valuing of a school nurse’s role and responsibilities.

All jurisdictions experienced challenges in providing nursing leadership to facilitate whole school health promotion initiatives because the nurse’s time was focused on surveillance, health education, infection control, vaccinations and staff education in the case of the Australian and Canadian jurisdictions whereas in the U.S. school nurses focused their time and energy on primary care services such as medication administration, health education and promotion, staff education, counselling, referrals and networking.

3. How might provincial and national nursing leadership help SHNs in Canada to perform within the scope of practice identified in Table 17.2 (on page 342)?

•

Provincial/territorial nursing associations need to advocate with ministries of health and education for the creation of protocols that identify minimum expectations of practice for public health nurses in schools or, alternatively, establish standards of practice for public health nurses working in school settings. The Ordre des infirmières et infirmiers du Québec has created Standards of Practice for nurses working in school health.

For additional information, read Healthy schools, healthy children: Maximizing the contribution of public health nursing in school settings (available at http://www.chnig.org/healthy-schools-healthy-children-maximizing-contribution-publichealth-nursing-school-setting/) C.N.A. and PHAC could support research and demonstration projects that use public health nurses working to full scope of practice in schools or in school-based nurse-managed clinics. C.N.A. has endorsed the document, Healthy schools, healthy children: Maximizing the contribution of public health nursing in school settings. C.N.A. and the .

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Chapter 17 School Health Community Health Nurses of Canada could also engage in advocacy with federal and provincial/territorial governments to secure funds for such initiatives.

Individual Critical Thinking Exercises 1. What are the main assumptions underlying comprehensive school health work, in particular work with school health committees?

• • • • • •

Addresses health in a broad and holistic way Recognizes that the school community “knows best” regarding what the issues are and the potential actions that would be appropriate All stakeholders are involved especially students, parents, school staff, and those who care about the health and learning of children and youth School-based PHN provides guidance and resource support as needed and draws on the expertise of the community Structure and process are grounded in health promotion, empowerment, meaningful youth and parental involvement and engagement When formulating a plan to address health issues, the action team should identify strategies or activities within each of the four component areas to achieve a degree of comprehensiveness that is more likely to have meaningful impact on the school community.

2. Think of a school you attended in your past, and identify an issue that you believe would have benefitted from a CSH approach. Devise a comprehensive action plan.

Consult the following websites for common health issues that are being addressed using CSH. Pan-Canadian Joint Consortium on School Health http://www.jcsh-cces.ca Canadian School Health Community http://www.canadianschoolhealth.ca Canadian Best Practices Portal: Promoting the Health of School-aged Children http://cbpp-pcpe.phac-aspc.gc.ca/?s=school+health&post_type=interventions Centre for Addiction and Mental Health: Best practice guidelines for mental health promotion: children and youth https://knowledgex.camh.net/policy_health/mhpromotion/mhp_childyouth/Pages/default. aspx Public Health Agency of Canada. Health Behaviour in School-Aged Children (HBSC) findings are published in national and international reports. http://www.phacaspc.gc.ca/hp-ps/dca-dea/prog-ini/school-scolaire/behaviourcomportements/publications/index-eng.php

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Chapter 17 School Health How to use a CSH Approach: • If there is not a School Health/Healthy School Committee or Action Team in place, then the PHN needs to gain commitment of the school. The PHN meets with the principal to discuss Healthy Schools and determine whether there is sufficient interest and support for the implementation of the initiative. The principal and the nurse develop a plan to inform the school community (e.g., the PHN can present the process to the students, staff, school council/student parliament, and to the Home and School Association.

Information can be sent to parents and students can be informed by school staff or the nurse, school newsletter, or during an assembly).

• Form a Healthy School Committee or Action Team – this team is composed of representatives from the administration (i.e., principal or vice-principal), school staff, parents, teachers, students, the nurse, and interested members of the community. This committee assesses the strengths and areas of need in the school and develops an action plan to address the issues identified.

• The Action Plan needs to be shared with the entire school community and may become part of the school’s growth plan or improvement plan.

3. How might a PHN in a school promote the health of families who have disadvantaged children in the school, such as newcomer children, Indigenous children, or children living with disability?

•

Promoting Family Fun nights that are inclusive, embrace diversity, and universal design in for accessibility of families whose children have disabilities.

• Promoting physical activity campaigns involving whole families, e.g., Walk to School, Turn off the Screens • Multicultural food and dance events (connect with Newcomer organizations and First Nations and Inuit communities to plan appropriately) • Traffic safety and bicycle safety rodeos/education days • Parenting education with the provision of child care services so that parents can attend • Group-oriented health education or support groups for parents experiencing particular health concerns, e.g., Quit Smoking groups, self-development groups, sessions on how to talk to your children about sex (provide appropriate resources for newcomer children who may be from communities that do not discuss sex, sexual health Indigenous children – how elders are incorporated into teachings for children, for children with disabilities resources to assist parents).

• Review, Implement, Adjust, and Celebrate: Evaluation of the school’s progress is important 4. What are the benefits of a CSH approach for students, teachers, and the entire school community?

This approach assists in reaching students and promoting health within and beyond the classroom. It not only benefits the students, but school staff, parents, and families as well.

This approach encourages the development of values, skills, and actions that will help students grow and succeed.

• Benefits for Students – students get along better with peers, teachers, and parents; .

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•

•

•

develop health literacy skills including critical thinking, problem solving, and effective communication (IUHPE, 2013); improved physical fitness, health attitudes and skills, and resiliency to stress; benefit from their parents’ participation in school effort (Physical and Health Education Canada, Quality School Health Checklist, 2009).

See International Union for Health Promotion and Education [IUHPE]. (2008).

Promoting health in schools: From evidence to action. http://www.iuhpe.org/images/PUBLICATIONS/THEMATIC/HPS/EvidenceAction_ENG.pdf Benefits for Staff – more school spirit; higher morale; lowered absenteeism; a more positive school environment with less vandalism; less time addressing student health needs; improved job satisfaction; less tobacco use among staff and improved physical fitness.

Benefits for the School Community – complements the school improvement process and safe school initiatives by increasing the protective factors in the school, such as parental and community support; establishes links to important services and resources in the community; enhances partnerships and communication within the school community; parents and community members gain knowledge about local health issues; parents benefit by taking part in their children’s education; community groups benefit by having student groups involved in community activities; workplaces can expect better educated and more productive employees.

5. Analyze your level of comfort, knowledge, and skill base in facilitating a CSH approach.

What would increase your comfort, knowledge, and skill with the structure and process?

•

Start by becoming familiar with the array of online resources to support the comprehensive school health approach: Joint Consortium for School Health http://www.jcsh-cces.ca The Joint Consortium for School Health (JCSH) plays an important role in strengthening federal–provincial/territorial cooperation and inter-ministerial coordination to promote the wellness and achievement of children and youth in the school setting. A number of resources are available on the website including the Healthy School Planner, Positive Mental Health Toolkit and Youth Engagement Toolkit and Substance Use Toolkits.

Canadian Best Practices Portal: Promoting the Health of School-aged Children http://cbpp-pcpe.phac-aspc.gc.ca/?s=school+health&post_type=interventions An official website of the Public Health Agency of Canada that provides data, systematic reviews, guidance and strategies to plan programs for school-aged children and youth.

Over 100 articles on a variety of health topics are provided.

Centre for Addiction and Mental Health http://www.ementalhealth.ca/index.php?ID=10295&m=record A Canadian research facility and hospital that provides a searchable data base of addiction related materials for adults and children and youth. Website provides a number of brochures and clinical guidelines including best practice guidelines for mental health promotion: children and youth

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Chapter 17 School Health Global School Health Initiative http://www.who.int/school_youth_health/en/ This website provides a number of technical reports and resources to support those who are advocating and /or implementing school-based and youth-focused prevention initiatives in the global community.

Public Health Agency of Canada. Health Behaviour in School-Aged Children (HBSC) is a school based survey administered every 4 years. It captures health related information from youth ages 11 to 15 years of age. Canada has participated since 1989-90. http://www.phac-aspc.gc.ca/hp-ps/dca-dea/prog-ini/school-scolaire/behaviourcomportements/publications/index-eng.php • • • •

Talk to a PHN who is assigned to schools and shadow him/her for a few days.

Observe a Healthy School Committee in action addressing an identified issue.

Read about healthy school success stories.

Consider the skills required of a PHN and what skills you might need to enhance: development of effective working relationships with the community as client (note: relationships with community partners occur within a complex, changing, and often ambiguous environment); core nursing skills of mutual respect, caring, listening, assessing, enabling, empowering; skills working with groups such as facilitation and consensus building; assessing and planning interventions with individuals, groups, and the entire school community that address the broader determinants of health; engagement strategies such as health promotion campaigns that achieve quick success, thereby encouraging buyin; creativity in working with students at various levels of development.

Group Critical Thinking Exercises 1. Imagine a high school has a sudden increase in the number of teens becoming pregnant, or imagine an elementary school is experiencing a high incidence of cyberbullying. Describe how you would work with the school community to assist it to address this issue.

Pregnant teens • Mobilize a group of concerned individuals including guidance counsellors, social workers, teachers, parents, and students • Conduct focus groups with the teens to gain insight into their situation and concerns • Address this issue using the 4 components of Comprehensive School Health: − Teaching and learning: Provide health education/health fairs on pregnancy prevention; integrate issue into safe partying campaigns; ensure teachers are adequately prepared to cover curriculum material (could offer a Train-the-Trainer in-service to teachers) − Partnerships and services: Provide sexual health services in the school or neighbourhood; promote the availability of guidance and chaplaincy services as applicable; Collaborate in setting up on-site child care and parenting services so teens can continue their education and receive support in their early parenting years

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Chapter 17 School Health − Supportive social and physical environment: Train sexual health peer leaders to work with younger students and create a prevailing social norm supportive of healthy relationships and reduced pregnancy rates; healthy sexuality promotion through student-led health fairs and positive health messaging − Healthy school policies: administration is supportive of sexual health curriculum; inclusive policies that facilitate or enable pregnant teens to feel welcome to complete their education High incidence of cyber-bullying • Convene a meeting of school administration, staff, parents, teachers, and students to discuss issue • Address this issue using the 4 components of Comprehensive School Health: - Supportive social and physical environment: Involve students in creating classroom and school code of behaviour including the use of electronic devices; school staff distribute Positive Tickets to students who demonstrate positive behaviours in the school yard and classroom; train older students in leading games and activities during recesses; encourage school to purchase bags/bins of balls, skipping ropes, etc. for use outside during recesses; ensure adequate lighting in all corridors; ensure supervision of out-of-the-way areas where bullying and cyber-bullying could occur - Teaching and learning: Ensure teachers are fully in-serviced on cyber-bullying; consider an awareness campaign for developing caring relationships among the students - Healthy school policy: school implements safe school policy; administration follows up immediately on cyber-bullying incidents for school-related issues that may occur outside of the usual school day.

- Partnerships and services: Bring in a specialist from the school board or community to do more extensive work with bullies who use the social media platform and victims of cyber-bullies.

2. Review current provincial or territorial legislation to determine what health services are provided in schools.

-

-

.

Resiliency Initiatives http://www.resiliencycanada.ca/ Search Institute http://www.search-institute.org/ School Connectedness: Strategies for Increasing Protective Factors Among Youth https://www.cdc.gov/healthyyouth/protective/school_connectedness.htm Scales, P.C. (1999). Reducing risks and building developmental assets: Essential actions for promoting adolescent health. Journal of School Health. 69(3), 113-119. https://doi.org/10.1111/j.1746-1561.1999.tb07219.x Compare intrinsic (internal) strengths/assets with extrinsic (external) strengths/assets and examine how PHNs can contribute to both categories.

PHN can provide parenting classes to enhance communication and support from parents and ensure they set reasonable boundaries and expectations for their child.

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-

PHN can work with school health committee in creating a supportive school climate, a safe school, and a school that sets reasonable boundaries and expectations for students.

PHN can work with school health committee to build caring relationships between students and adults in the community, and to ensure students have positive adult role models.

PHN can run support groups for youth to encourage supportive peer relationships and positive peer influence and enhance self-esteem.

PHN can work with school health committee to create an appealing after-school program of constructive activities in school or community.

PHN can work one-on-one with students to build internal strengths.

PHN can support teachers in teaching resistance skills and conflict resolution skills and in promoting character development school-wide.

PHN can support school health committee in its work so students in the whole school community feel they have a voice and some personal power in the school.

3. In developing a health profile for a school community, what assessment questions would you ask for each component of CSH? What methods might you use for various stakeholders: students, parents, teachers, administration, and community members?

Supportive social and physical environment • How does this school promote healthy living outside the classroom? What else could be done?

• How does this school encourage tobacco-, alcohol-, and drug-free living? What else could be done?

• How does the school encourage students to get along with each other?

• Is this school a happy, positive place to learn and play? Why? Why not?

• Are teachers, parents, and students valued partners with school administration in decision-making?

• What are you most concerned about in your school?

• What is the best thing about your school?

• What are your concerns about the physical environment of the school?

• Is the school safe and healthy inside and outside the building? Do you have any suggestions?

• Picture your school five years from now. What would you like to see? How would you do this?

Teaching and Learning • Does your school implement the provincial/territorial curriculum?

• How is health information communicated between school and home?

• Are teachers adequately prepared to provide the health and physical education curriculum?

• What do students learn about health inside the classroom? Outside the classroom?

• Are students actively engaged in learning or passive recipients of health information?

Partnerships and Services • What services are available to assist students and their families? .

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What people are available in the school to help you stay healthy and happy?

How does your school manage health concerns and/or injury at the school?

What agencies or organizations from the community are involved in the school?

Is the school aware of public health services and programs that are available to the school?

Healthy School Policies • What policies are in place to help students and their families feel connected to the school?

• What are the rules for upholding and modeling respectful behaviour?

• Does the school follow policies that contribute to the physical and emotional safety of all students and staff?

• How are the students learning and social needs accommodated in the school, including those with exceptionalities?

To develop a health profile of a school community, what methods might you use for various stakeholders: students, parents, teachers, administration, and community members?

For all stakeholder groups, variations of the following methods could be used: − School generated open-ended questionnaires, or formal questionnaires and survey available from Ministry of Education websites, PHE Canada, School Health Planner, Alberta Healthy Schools Wellness Fund and public health departments. − Focus groups for different grade levels of students; for parents, staff and community members. − Town hall meeting involving representatives from all stakeholder groups. − Key informant interviews.

4. A high school administrator wants to find ways to prevent substance use and abuse among the school’s students. What are your first three steps, and why? Who will you involve?

• •

• • • •

.

Check epidemiological and research reports to determine prevalence of drug use in community Assess current learning needs of students, parents, and teachers • Identify current teaching and learning opportunities that are available to students, teachers, and parents (e.g., formal health curriculum, training for teachers and parents) and resources/toolkits related to substance use from JCSH. Retrieve from http://www.jcsh-cces.ca/index.php/resources/tools-toolkits Consult with local police and drug and addiction workers regarding the current drug scene in the community and areas of risk Consult with public health department and other community agencies regarding programs and services in the community Conduct focus groups with youth regarding their perceptions of drug use in their community—prevalence, reasons youth engage in substance use and abuse, suggestions to ameliorate the situation Establish a working group involving youth and relevant stakeholders to organize an awareness campaign and other activities.

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Chapter 17 School Health 5. Discuss the meaning of a “strengths-based approach” and how a school-based PHN could operationalize this in working with students and schools.

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-

-

RNAO Enhancing Healthy Adolescent Development Best Practice Guidelines (revised 2010) http://rnao.ca/bpg/guidelines/enhancing-healthy-adolescent-development - Hammond, W. and R. Zimmerman. (2012). A Strengths-Based Perspective. http://shed-thelight.webs.com/documents/RSL_STRENGTH_BASED_PERSPECTIVE.pdf Gottlieb, L. N. (2013). Strengths-based nursing care: Health and healing for person and family. New York: Springer Publishing. Retrieve from https://doi.org/10.1111/nuf.12011 Instead of conducting a “needs assessment” in a school, a PHN could, in collaboration with a school health committee, conduct a “strengths and needs assessment” or “situational assessment.” This is a basic premise of community development, that all groups or communities have some strengths that can be built upon.

In working with individual students, the PHN would not only focus on the student’s problem that brought them to the nurse, but also on their strengths-based and identifying when the problem does not occur. This is a solution focus and strength-based focus. It encourages the student to identify their strengths and “what works” and do more of what works and less of what doesn’t work.

Additional Activity Brainstorm what populations of young people have any of the pre-requisites to health impinged upon and then brainstorm how they are affected. We have started the activity. (see Ottawa Charter for Health Promotion https://www.canada.ca/en/public-health/services/healthpromotion/population-health/ottawa- charter-health-promotion-international-conference-onhealth-promotion.html) Pre-Requisites to Health (Ottawa Charter, 1986)

Populations Affected

Peace

Refugee Children,

How Affected

Children fleeing domestic violence Shelter

Precariously Housed/Homeless Children Indigenous Children

Education

‘Dis’Abled Children, Institutionalized Children, Indigenous Children

Food

.

Impoverished Children,

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Children living on or near toxic lands

Sustainable Resources

Indigenous Children, Impoverished Children ‘Dis’Abled Children

Social Justice & Equity

Indigenous Children, Trans Youth

Further Resources Canadian Joint Consortium on School Health www.jcsh-cces.ca Canadian School Health Community www.canadianschoolhealth.ca Centre for Addictions and Mental Health http://www.camh.ca/fr/hospital/Pages/home.aspx Communities and Schools Promoting Health www.safehealthyschools.org National Aboriginal Collaborating Centre: Indigenous School Health Framework https://www.ccnsa-nccah.ca/docs/health/RPT-FrameworkIndigenousSchoolHealth-TagalikEN.pdf First Nations Caring Society https://fncaringsociety.com/shannens-dream http://www.manyhandsonedream.ca/themes/ International: http://www.mentalhealthpromotion.net/?i=promenpol.en.promenpol-tool-kit

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Chapter 18 Family Health

Chapter 18: Family Health Suggestions for Guest Speakers 1. Ask a Home Health nurse or Public Health Nurse to visit and discuss the role of a CHN working with the family.

2. Ask a family member of a client who has received home visits from a CHN to discuss their experience.

3. Ask a community nurse who provides palliative care to share their experiences with issues of family involvement. Inquire about CHN competencies required working with family during difficult times.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask students to reflect on the last opportunity they had to interact with a client regarding his/hers care. How was the family involved? How might they have worked to involve the family more? Ask students to journal about how they might have included the family for a more effective plan of care.

2. Have interactive activities planned such as case studies and role playing. Review major concepts/theories with the students.

3. Ask the students to make a videotape of a mock interview with a patient using the family visit summary and information from the text. Provide them with feedback on their verbal and non-verbal language.

Summary of Family Visit Content Stage of Family Visit Planning for the visit

Actions for Role-play Connect via phone (introduction, discuss and negotiate purpose, and schedule a visit) Build the relationship with the client and family Ask questions to understand the family’s current level of knowledge on the health issues, their past history of approaches to resolve issues, and identify the family’s desired approaches

During the first visit

.

Reintroduce self, restate the agreed upon purpose of the visit, and present identification

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Chapter 18 Family Health Engage the family in “small talk” then review confidentiality and duties/roles/expectations Ask reflective circular questions.

You could also include some of the following questions: 1. How can I be most helpful to you and your family (or friends) during this visit and follow up visits with regards to your care?

2. What has been most and least helpful to you and your family with past healthcare experiences?

3. What is the greatest challenge facing your family right now?

4. With which of your family members or friends would you like us to share information if any? Who would you like us not to share information? (Indicates alliances, resources, and possible conflictual relationships) 5. What do you need to best prepare you or your family for ___________?

6. Who do you believe is suffering the most in your family right now?

7. What is the one question you would like to have answered during this visit? I may not be able to answer this question at the moment, but I will do my best or will try to find the answer for you.

8. How have I been helpful to you today? If not, what could I have done differently?

After the visit

Mutually develop a plan of care for short and long term health goals Record the assessment data, the plan of care, the implementation of the interventions, and evaluate progress towards the goals

1. Look at the following care plan example: Concern: Client not achieving optimum nutrition Observations

Client is 10 lbs underweight and reports dissatisfaction with current diet

Family members involved

Food preparers: Sue (daughter), Kevin (grandson)

Strengths

The whole family articulates a desire to learn more about preparing a “kidney diet”

Interventions

Attend the kidney clinic once a week for three weeks for counselling with nutritionist

.

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Chapter 18 Family Health Concern: Client not achieving optimum nutrition Goal

Client receiving cost-effective, palatable kidney protective meals regularly

Objectives

After 3 weeks of visiting kidney clinic nutritional counselling, family members will be able to articulate what is involved in providing a kidney-friendly diet and where to obtain further information and resources Client will report receiving food that is satisfying

Method of nurse/family contact Home visits Resources needed

Transportation to kidney clinic, recipe books (library)

Evaluation

Reports from kidney clinic based on lab results, feedback from client and family, weight gain in client by 10 lbs

Consider and list some of the obstacles the client and nurse might face if they were to attempt to make a plan of care without involving the family. How might they influence the concern of poor nutrition and the need for a very specific diet for an elderly person, who is dependent on family members for their meals?

1. Create a care plan based on the mock family home visit using the following template: Concern #1: New mother needing breast feeding support Observations

New mom having difficulty with breastfeeding. Newborn not gaining adequate weight.

Family members involved

Grandmother, newborn, mother, friend

Strengths

Mother is determined to breast feed and has support.

.

Concern #2:

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Goal

PHN would ask mother what’s working for her and what she would like to focus on during the visit. Observe breast technique. Weigh newborn.

Support breast feeding of a new mother and optimize newborn weight gain.

Objectives

At the end of the visit: .

Mother feels comfortable contacting PHN for continued breastfeeding support.

Mother feels more relaxed, empowered and confident with her breastfeeding plan.

Grandmother and friend state that they are able to be supportive of mother’s plan Mother demonstrates effective latching and breastfeeding technique.

Newborn regains birth weight loss and achieves steady weight gain.

Evaluation

Mother feels more confident and reassured about her breastfeeding plan.

Family members are supportive of the mother Newborn has appropriate weight gain and effective breastfeeding latch.

Ideas for Self-Study and Distance Students Practice Application 4. Ask students to reflect on the last opportunity they had to interact with a client regarding his/hers care. How was the family involved? How might they have worked to involve the .

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Chapter 18 Family Health family more? Ask students to journal about how they might have included the family for a more effective plan of care.

5. Have interactive activities planned such as case studies and role playing. Review major concepts/theories with the students.

6. Ask the students to make a videotape of a mock interview with a patient using the family visit summary and information from the text. Provide them with feedback on their verbal and non-verbal language.

Summary of Family Visit Content Stage of Actions for Role-play Family Visit Planning Connect via phone (introduction, discuss and negotiate purpose, and schedule a for the visit) visit Build the relationship with the client and family Ask questions to understand the family’s current level of knowledge on the health issues, their past history of approaches to resolve issues, and identify the family’s desired approaches During the Reintroduce self, restate the agreed upon purpose of the visit, first visit and present identification Engage the family in “small talk” then review confidentiality and duties/roles/expectations Ask reflective circular questions.

You could also include some of the following questions: 9. How can I be most helpful to you and your family (or friends) during this visit and follow up visits with regards to your care?

10.

What has been most and least helpful to you and your family with past healthcare experiences?

11.

What is the greatest challenge facing your family right now?

12.

With which of your family members or friends would you like us to share information if any? Who would you like us not to share information? (Indicates alliances, resources, and possible conflictual relationships) 13.

What do you need to best prepare you or your family for ___________?

14.

Who do you believe is suffering the most in your family right now?

15.

What is the one question you would like to have answered during this visit?

I may not be able to answer this question at the moment, but I will do my best or will try to find the answer for you.

16.

How have I been helpful to you today? If not, what could I have done differently?

.

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Chapter 18 Family Health Mutually develop a plan of care for short- and long-term health goals After the visit

Record the assessment data, the plan of care, the implementation of the interventions, and evaluate progress towards the goals

2. Look at the following care plan example: Concern: Client not achieving optimum nutrition Observations

Client is 10 lbs underweight and reports dissatisfaction with current diet

Family members involved

Food preparers: Sue (daughter), Kevin (grandson)

Strengths

The whole family articulates a desire to learn more about preparing a “kidney diet”

Interventions

Attend the kidney clinic once a week for three weeks for counselling with nutritionist

Goal

Client receiving cost-effective, palatable kidney protective meals regularly

Objectives

After 3 weeks of visiting kidney clinic nutritional counselling, family members will be able to articulate what is involved in providing a kidney-friendly diet and where to obtain further information and resources Client will report receiving food that is satisfying

Method of nurse/family contact Home visits Resources needed

Transportation to kidney clinic, recipe books (library)

Evaluation

Reports from kidney clinic based on lab results, feedback from client and family, weight gain in client by 10 lbs

Consider and list some of the obstacles the client and nurse might face if they were to attempt to make a plan of care without involving the family. How might they influence the concern of poor nutrition and the need for a very specific diet for an elderly person, who is dependent on family members for their meals?

.

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2. Create a care plan based on the mock family home visit using the following template: Concern #1: New mother needing breast feeding support

Concern #2:

Observations New mom having difficulty with breastfeeding.

Newborn not gaining adequate weight.

Family members involved

Grandmother, newborn, mother, friend

Strengths

Mother is determined to breast feed and has support.

Interventions PHN would ask mother what’s working for her and what she would like to focus on during the visit. Observe breast technique. Weigh newborn.

Goal

Support breast feeding of a new mother and optimize newborn weight gain.

Objectives

At the end of the visit: .

Mother feels comfortable contacting PHN for continued breastfeeding support.

Mother feels more relaxed, empowered and confident with her breastfeeding plan.

Grandmother and friend state that they are able to be supportive of mother’s plan Mother demonstrates effective latching and breastfeeding technique.

Newborn regains birth weight loss and achieves steady weight gain.

.

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Mother feels more confident and reassured about her breastfeeding plan.

Family members are supportive of the mother Newborn has appropriate weight gain and effective breastfeeding latch.

Seminar Discussion Questions 1. Consider the client population at your community placement. How are families included in decisions concerning their care around care/treatments intervention? How are the issues of confidentiality addressed especially in light of electronic medical records (EMR)? Are families that meet the expectations of the staff treated differently from those who do not? Do the clients whose families meet the expectations of the staff receive different treatment from the staff?

2. In pairs, ask the students to conduct mock interviews to practice and hone their interviewing skills. Ask them to provide receive feedback on their verbal and non-verbal language.

Concern #1: Client not achieving optimum nutrition

.

Concern #2:

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Case Study Questions 1. What are the priorities for this family visit?

• •

Identify various ways that the family is coping with the challenges experienced Identify if the family requires any external resources and their openness to explore these

2. What would a strengths-based approach include with this multigenerational Indigenous family?

• •

Identify all of the resources currently available to the family and how they may leverage these differently to meet their needs Identify various cultural norms within their community and identify what resources they can leverage

3. What does cultural safety mean within the context of working with Indigenous families in their homes and community?

• • .

The family decides what the priority is for them at this point in time That the family leads the conversation about what they think they need to improve their situation.

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Canadian Research 18.1 1. Discuss your thoughts on the level of family nursing addressed in this study.

•

Individual responses will vary

2. What social determinants of health would you want to examine?

•

Individual responses will vary

3. What policies within public health should be addressed?

• •

Individual responses will vary Policies regarding home visiting in terms of who must get a home visit and how many home visits someone receives ought to be addressed.

Individual Critical Thinking Exercises 1. Draw your family genogram and ecomap. Describe the roles of family members, the quality of the intra-family relationships, and the strengths of your family.

•

Encourage students to consider all ‘family’ members and the role that each member plays within the family. Guide students to consider each family member’s particular strengths and how these strengths affect the family’s functioning.

2. Identify some factors that make a family vulnerable. ● Health services may be limited and/or there may be barriers to access. ● Working conditions may be dangerous, low-paying, and/or without extended health benefits for coverage of prescription drugs, dental care, and eyeglasses. Unemployment rates may be high. Parents of families immigrating to Canada may have difficulty finding employment comparable to that held in their country of origin. Employment in Canada may not reflect their educational level and/or previous work history. ● Social support networks can be strengthened or challenged in various communities. ● Biological and genetic risk factors may affect the health of families. ● The support and nurturance of healthy child development is a significant function of families. ● Lack of education, literacy, or language barriers ● Difficulty with relationships, history of abuse .

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●

Lack of social support.

3. Describe a crisis experience in your family and the family resilience factors that assisted

your family to cope with the crisis.

•

Encourage students to identify how their particular family copes with stress or crisis situations. What helped their family survive the adversity or hardship? How did the family mobilize any resources?

4. Compare your beliefs about your family with those of a romanticized or stigmatized

family.

•

Encourage students to explore their own values and beliefs about what constitutes a family. What are their thoughts about these stereotypes?

5. What impact could your values and beliefs about family have on your nurse-family

relationships?

•

Encourage students to examine how their own personal values and beliefs affect their attitudes and their interactions with families. How do ‘judgements’ or ‘opinions’ about what constitutes a ‘good’ family affect your motivation to care for a family?

Group Critical Thinking Exercises 1. Differentiate between viewing the family as client and the family as context. Drawing on your experiences, provide an example to illustrate each concept (family as client and family as context).

•

The family as context was the traditional focus of nursing. The individual was in the foreground and the family was in the background.

The family as client views the entire family as the unit of care.

When the family is the client, the nurse concentrates on both the individual and the family simultaneously.

The family as client brings the family into the foreground and the individual moves to the background.

The nurse assesses each family member and provides care for all family members when the family is client.

• • • •

2.

Reflect on your biases regarding people outside the cultural group you identify with. How might your biases and stereotypes influence the way you assess a family?

•

.

Group responses will vary based on the conversations had

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Chapter 18 Family Health 3. Describe an approach to the assessment of a family for each of the CCHN standards: promoting health, building capacity, building relationships, facilitating access and equity, and demonstrating professional responsibility and accountability. Provide concrete examples to illustrate the application of each standard in family nursing.

•

Review the description of each standard. What would the standard ‘look like’ when applied in a practice setting? Draw on students’ experiences to illustrate the application of the standards in practice.

4. Role play a family–nurse situation. Practise the family interview questions listed in Table 18.3.

•

Refer to Table 18.3 below for the family interview questions.

Further Resources The Vanier Institute of the Family www.vifamily.ca Canadian Child Care Federation http://www.cccf-fcsge.ca Public Health Agency of Canada http://www.phac-aspc.gc.ca/ Statistics Canada www.statcan.gc.ca IFNA https://internationalfamilynursing.org/ Rowe Kaakinen, J., Gedaly-Duff, V., Padgett Coehlo, D., & Harmon Hanson, S.M. (Eds.) (2010). Family health care nursing: Theory, practice, and research (4th ed.). Philadelphia, PA: F.A. Davis.

Wright, L.M., & Leahey, M. (2013). Nurses and families: A guide to family assessment and intervention (6th ed.). Philadelphia, PA: FA Davis Company.

Hartrick Doane, G., & Varcoe, C. (2015). How to nurse: Relational inquiry with individuals and families in changing health and health care contexts. Philadelphia: Wolters Kluwer.

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Chapter 19 Gender and Community Health

Chapter 19: Gender and Community Health Suggestions for Guest Speakers 1. Ask a nurse who works in community health program planning to discuss how issues of sex and gender come in to planning interventions.

2. Skype or teleconference with someone from Health Canada who uses Gender Based Analysis in their work in community health.

3. Skype or teleconference with someone from Health Canada’s Gender and Health Unit 200 Eglantine Driveway Tunney's Pasture Ottawa, ON K1A 0K9 E-mail: Info@hc-sc.gc.ca Phone toll free: 866-225-0709 4. Ask a nurse researcher to discuss issues of gender and sex as they relate to their area of study.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students to read the following excerpt from Health Canada’s on-line document, “Exploring Concepts in Gender and Health”: Formal and Substantive Equality The term "equality" has usually been used to emphasize similarities between people. The legal concept of "formal equality" requires that people in the same or similar circumstances be treated the same. Historically, treating people equally was understood to mean giving women and men the same opportunities, services and programs. Sometimes, however, different treatment may be required to achieve fairness and justice when differences between people cause disadvantages and inequality. The legal concept of "substantive equality" reflects the importance of ensuring not only equality of opportunity but also equality of outcome. Gender based analysis is about substantive equality.

Think, pair, share: Ask the students to think about situations where different treatment may be required to achieve fairness and justice when differences between people cause disadvantages and inequality for five minutes. Next, have them write out the situation. Next, ask them to consider and list three reasons why CHNs would have to be cautious in how the different treatment was enacted and perceived by others. Ask them to share their thoughts with a partner.

Invite a number of students to share what they discussed with the bigger group.

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Chapter 19 Gender and Community Health Example of a situation where achieving fairness may require a CHN to treat people differently: Situation

Reasons for unequal treatment

Women who engage in • Evidence shows that most • sex work and who are new infections in this HIV positive are first to population are achieved receive free antiretroviral through paid sex. The drugs • drugs in a program that is reduce infectivity. Therefore, rolling out free drugs to it is in the best interest of the all affected people in the whole community to target community this group for intervention • • Women who engage in sex work are unlikely to be able to afford the drugs that are available in the community and are not free.

• Women who receive the free drugs are also more open to participating in education • sessions where the CHNs can introduce other ideas for preventing the spread of HIV such as raising the price of sex acts, insisting on condom use, treating STIs etc.

Reasons for caution HIV+ women who are not sex workers could enter sex work to obtain the free drugs.

Jealousy may lead to deeper disapproval by the community, with potentially life-threatening results Women who engage in sex work may not be the best candidates for adherence of the drug regimen due to demanding work schedules, low self-esteem, extreme poverty, external control by pimp etc.

Men could argue that they are biologically more likely to spread HIV and should therefore be considered for the free drug program before women.

Ideas for Self –Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application •

Read the following excerpt from Health Canada’s on-line document, “Exploring Concepts in Gender and Health”:

Formal and Substantive Equality The term "equality" has usually been used to emphasize similarities between people. The legal concept of "formal equality" requires that people in the same or similar circumstances be treated the same. Historically, treating people equally was understood to mean giving women and men the same opportunities, services and programs. Sometimes, however, different treatment may be required to achieve fairness and justice when differences between people cause disadvantages and inequality. The legal concept of "substantive equality" reflects the importance of ensuring .

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Chapter 19 Gender and Community Health not only equality of opportunity but also equality of outcome. Gender based analysis is about substantive equality.

Ask the students to think about situations where different treatment may be required to achieve fairness and justice when differences between people cause disadvantages and inequality. Next, have them write out the situation. Then, ask them to consider and list three reasons why CHNs would have to be cautious in how the different treatment was enacted and perceived by others.

Using the table below, ask them to write about the situation, the potential reasons for unequal treatment, and the reasons that CHNs ought to use caution.

Example of a situation where achieving fairness may require a CHN to treat people differently: Situation

Reasons for unequal treatment

Women who engage in • Evidence shows that most • sex work and who are new infections in this HIV positive are first to population are achieved receive free antiretroviral through paid sex. The drugs • drugs in a program that is reduce infectivity. Therefore, rolling out free drugs to it is in the best interest of the all affected people in the whole community to target community this group for intervention • • Women who engage in sex work are unlikely to be able to afford the drugs that are available in the community and are not free.

• Women who receive the free drugs are also more open to participating in education • sessions where the CHNs can introduce other ideas for preventing the spread of HIV such as raising the price of sex acts, insisting on condom use, treating STIs etc.

Reasons for caution HIV+ women who are not sex workers could enter sex work to obtain the free drugs.

Jealousy may lead to deeper disapproval by the community, with potentially life-threatening results Women who engage in sex work may not be the best candidates for adherence of the drug regimen due to demanding work schedules, low self-esteem, extreme poverty, external control by pimp etc.

Men could argue that they are biologically more likely to spread HIV and should therefore be considered for the free drug program before women.

• Read the following guiding questions for gender-based analysis from the document, “Gender and Sex-Based Analysis in Health Research: A Guide for CIHR Researchers and Reviewers”. This document is available at: http://www.cihr-irsc.gc.ca/e/32019.html#toc4 Ask students to consider how following this gender-based analysis might influence the quality and generalizability of future research. Ask the students to consider what potential bias might have existed prior to GBA guidelines questions being asked for research. What are the potential implications of using research that did not consider gender differences? .

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Chapter 19 Gender and Community Health Applying Gender- and Sex-Based Analysis Research Question • • • • • • •

Are sex and/or gender identified and defined? Are the definitions supported by recent academic literature?

Does the proposal demonstrate awareness of what is known about sex, gender and diversity (ethnicity, socioeconomic status, sexual orientation, migration status, etc.) in this area of research Are the concepts of sex, gender and diversity taken into account in the development of the research question(s)?

Are the concepts of sex, gender and diversity applied clearly and appropriately?

If used in the study, does the researcher identify and justify the choice of the sex of cells, cell lines, and/or animals?

If the applicant asserts that sex and/or gender and diversity are not relevant to the proposed research, what evidence is presented?

Does the research question reflect the diversity in and among females and males?

Data Collection • • • • •

Does the sex/gender/diversity composition of the sample reflect the research question?

Does the sample match the researchers' plans for generalizing from the data?

Have research instruments (i.e., surveys, measurements) been validated to reflect gender/sex and diversity?

If sex is used as a proxy for weight, height and body fat/muscle ratios, is there an explicit explanation and analytical strategy provided for employing this approach?

In the case of clinical trials: Does the sample reflect the distribution of the condition in the general population? For proposed clinical trials, are sufficient numbers of women and men included in the sample to enable safety as well as efficacy analysis? Where appropriate, how will the clinical trial track and account for female menstrual cycles?

Does the applicant plan to analyze results in the context of known sex-specific adverse effects, height-weight-sex relationships, and interactions with commonly used drugs?

Data Analysis and Interpretation • • •

.

Will the researchers disaggregate and analyze data by sex/gender?

Does the use of gender as a variable mask or intersect with other potential explanatory factors such as socioeconomic status, physical attributes and/or ethnicity?

What assumptions are being made about gender and/or sex-especially as they intersect with other diversity indicators such as ethnicity, sexual orientation, socioeconomic class, etc.-while formulating the research problem, sampling, data collection, analysis and interpretation?

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Chapter 19 Gender and Community Health Seminar Discussion Questions 1. Ask the students to consider how sex and gender influence the community health interventions at their clinical placement. Do staff offer people of different sexes and genders equal opportunity for service and outcome? Are there written policies that guide how people are treated? Are people treated differently? Why or why not? Do clients have an opportunity to be served by staff form different sexes and genders? Why or why not?

What would happen in this setting if a client were to ask for a nurse/staff member who was of another gender?

Case Study Questions 1. What prevents boys from reporting bullying?

•

Gender role prescriptions require that boys are stoic, unaffected and emotionally strong. Being seen as needy, weak, or hurt brings with it peer-based shaming.

2. How might girls’ experiences of societal body shaming impact how they relate?

•

One would hope that girls’ recognition of body shaming would bring young women closer together, yet there remains more incentive to participate in body shaming of others as opposed to speaking out against it.

•

Fat shaming remains one of the most prevalent forms of control of girls and women, and this phenomenon exists between girls as much as it does within society in general

3. Why has cyberbullying steadily increased, with girls primarily being the target?

•

Individual responses will vary

Canadian Research 19.1 1.

In your view, what beliefs do people living in Canadian society have about how men and women ought to behave in relationships?

•

2.

How can CHNs better understand men's depression and advocate for societal acceptance of sadness in men?

• • •

.

Individual responses will vary

It is essential that CHNs deeply reflect on their own assumptions regarding “normal” masculinity in order to advocate for gender transformation.

CHNs can become more gender transformative by unpacking gender-based assumptions regarding ‘normal’ masculinity.

CHNs need to role model a ‘calling-in-to-question’ stance when witnessing narrow gender role prescriptions being placed on boys/men’s ways of being, and advocate for the freedom to express a wide range of emotions.

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Chapter 19 Gender and Community Health •

3.

CHNs should advocate for all humans to be permitted and encouraged to express strong emotions, including fear, sadness, anxiety in order to prevent emotional suppression which can lead to depression

What is the responsibility of a CHN in promoting gender relations for all people regardless of how they negotiate gender relations in various family and social contexts?

• To promote social justice and health equity

Individual Critical Thinking Exercises 1. Imagine a world without gender – what would the world be like?

• While sex would still be at play, we would not define roles, identities, status or position based on norms associated with “sex.”

• Invite students to start with a list of “should” based on gender. Then invite them to switch them. Lastly invite them to reflect on how life would be different with NO expectation, especially for boys and girls.

• The response to this questions will have an individualized response. Therefore, the potential answers will vary from student to student. Instructors must ask students for rationale for the answers suggested.

2.

Are there countries that are trying to reduce gender disparities? Do a search online to see how gender disparities are being reduced around the world. Do you believe that any of the strategies that you have discovered could be applied in Canada?

• The response to this questions will have an individualized response. Therefore, the potential answers will vary from student to student. Instructors must ask students for rationale for the answers suggested.

3. How do you as a CHN improve the health of your clients from a gender-based perspective? In what ways are your expectations different for men and women in your practice?

• This would best be facilitated as a private exercise, perhaps in a think-pair-share structure so that students can quietly begin to understand their own lenses first.

• Gender is often co-constructed in health. For example, when a man explains that he has not been to a doctor in years – and never been sick a day in his life – he is aligning to masculine ideals about men’s autonomy, resilience and physical and mental strength. In essence it is a calling card that signifies identity and gives clues about the man’s gendered roles and relations. As a community health nurse you might highlight how prevention and/or .

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Chapter 19 Gender and Community Health effective self- management could maximize these qualities. In this way the man’s masculinity is not contested or undermined as incompetent but rather affirmed amid some guidance for maximizing the benefits of autonomy, resilience etc.

4. Why is an intersectional approach to gender-informed community health nursing practice necessary? What does it do?

•

It helps us identify all of the different ways in which people experience inequities. It draws our eyes towards the social and structural inequities in society and helps us to identify the actions we need to take as CHNs to promote social justice for all.

5. What barriers do CHNs face to create spaces where gender diversity is acknowledged and welcomed within the institutions where they work?

•

CHNs may face multiple barriers within the institutions they work in in creating spaces where gender role diversity can flourish. One barrier may include working with others who are not aware of their attitudes, values, beliefs, and biases. Another barrier might include being unable to begin conversations about gender because other colleagues may not be ready for such conversations.

Group Critical Thinking Exercises 1. Stand up and position yourself on a continuum from one side of the room to another. On one side of the room is feminine; on the other side of the room is the most masculine. After placing yourself on the continuum, look around and see where everyone else is. Discuss why you placed yourself where you did. How do your observations inform your understanding of gender?

•

It is anticipated that this exercise will help the students consider what is be meant by masculine and feminine. It also might help them think about how they are perceived as well as how they see themselves.

The group responses to these questions may differ from group to group, since the individuals in each group will respond and discuss based on their individual experiences.

Instructors must ask students for exemplars for the answers suggested.

•

2. In 2011, a news story was published about a couple in Canada who opted to raise their baby gender-free. What are our thoughts about this? In groups, have a debate in favour or opposition to this. (See https://www.ctvnews.ca/baby-raised-without-gender-sets-off-debate1.649286) •

.

Debates will vary based on individual student positions

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Chapter 19 Gender and Community Health •

The group responses to these questions may differ from group to group, since the individuals in each group will respond and discuss based on their individual experiences. Instructors must ask students for exemplars for the answers suggested.

3. Now that you understand the health inequities experienced by transgender individuals, what are some specific ways in which CHNs can serve as activists to improve the quality of life of this marginalized population?

•

Student responses will need to provide the specific examples and community health nursing interventions

Further Resources WHO Gender, Women, Health http://www.who.int/gender/en/ Gender & Health Collaborative Curriculum http://genderandhealth.ca/ Health Canada Gender based Analysis Policy http://www.hc-sc.gc.ca/hl-vs/gendergenre/analys/index-eng.php European Men’s Health Forum http://www.emhf.org/ CIHR’s Gender and Sex-Based Analysis in Health Research: A Guide for CIHR Researchers and Reviewers http://www.cihr-irsc.gc.ca/e/32019.html#toc4 Health Canada’s Gender Based Analysis Policy http://www.seniorspolicylens.ca/Root/Materials/Adobe%20Acrobat%20Materials/Gender_analy sis.pdf Armstrong, P. & Deadman, J. (Eds.) (2008). Women’s health: Intersections of policy, research and practice. Toronto: Women’s Press.

Johnson, J. L., Greaves, L., & Repta, R. (2008). Better science with sex and gender. Vancouver: Women’s Health Research Network.

Institute of Medicine (2001). Exploring the biological contributions to human health: Does sex matter? Washington: National Academy Press.

Robertson, S. (2007). Understanding men and health: Masculinities, identity and well-being.

Maidenhead, UK: Open University Press.

100% Woman – A documentary film by Karen Duthie http://www.100percentwoman.com/ XXY http://www.imdb.com/title/tt0995829/

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Chapter 20 Lesbian, Gay, Bisexual, Transgender, Queer, and Two Spirit Clients

Chapter 20: Lesbian, Gay, Bisexual, Transgender, Queer, and Two Spirit Clients Suggestions for Guest Speakers 1. Ask a nurse who works specifically with LGBTQ2S clients to speak about issues specific to this population.

2. Ask a nurse researcher who studies health issues related to LGBTQ2S client to discuss their work with the class.

3. Skype or teleconference with a nurse advocate who works with issues of interest to LGBTQ2S communities.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Gather some of the forms used at major medical institutions and community agencies in your region. Ask the students to decide if the language is inclusive. If not, how might it become more inclusive?

2. Review the Six Steps in Planning for Equity-based Interventions including: literature and local research & evaluation results; examine broader and local health data; relationship: health indicators; identify information gaps; engage key stakeholders; and determine priority populations and suitable practices. Consider how the following the Six Steps in Planning for Equity-based Intervention might be used for a CHN who wants to connect with LGBTQ2S2S clients?

Break the students up into smaller groups and ask them to report on the following Six Steps in Planning for Equity-based Intervention, as they relate to LGBTQ2S populations. Choose different public health intervention that you would like to engage the LGBTQ2S in (i.e. smoking cessation, safer sexual practices, suicide prevention, addictions prevention, etc.). On poster paper, have the students outline their plan for creating equity-based interventions for the LGBTQ2S communities.

Step one - Literature and local research & evaluation results (Describes relationship between socio-demographics and health indicators, health risks, and service utilization) • • • .

Does the published literature include data on LGBTQ2S? Is there literature on some sub-populations but not others (for example, are transgender people included and data specifically on their risks described?)

Is there pre-existing local research on the health issue?

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Chapter 20 Lesbian, Gay, Bisexual, Transgender, Queer, and Two Spirit Clients • •

How will you know what the current situation is?

How will you measure impact?

Step two - Examine broader and local health data a. b. c. d.

What data could you collect on the issue?

Where will you collect the data?

How will you collect the data?

Who would you include as data collectors?

Step three - Relationship: health indicators and social determinants of health (SDOH) a. What information is available on the SDOH as they pertain to LGBTQ2S communities? b. What is known about the SDOH as they relate to the health intervention that you are assessing?

Step four - Identify information gaps a. What is not known that must be known in order to plan an equitable intervention? b. Can the information be gathered in a smaller pilot or demonstration project? c. How will you identify the population that you would like to collect the data on?

Step five - Engage key stakeholders (Define process to engage key stakeholders in discussing results and examining local context) a. What current partnerships exist and should be maintained? What can be learned from examples? b. What are current trends that may provide opportunities or reflect best practices? c. How ready is the community for the considered approach? Is there a need to further engage partners? d. Are there approaches that have proven to work better than others for some priority populations?

Step six - Determine priority populations and suitable practices a. Review and discuss: - Community health needs - Mandate - Potential impact - Resources required - Capacity - Collaboration – outreach and participation b. Decide on priority populations and most suitable practice

.

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Chapter 20 Lesbian, Gay, Bisexual, Transgender, Queer, and Two Spirit Clients

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

2. Clarify any questions about the information from the text.

Practice Application 1. Gather some of the forms used at major medical institutions and community agencies in your region. Ask the students to decide if the language is inclusive. If not, how might it become more inclusive?

2. Review the Six Steps in Planning for Equity-based Interventions including: literature and local research & evaluation results; examine broader and local health data; relationship: health indicators; identify information gaps; engage key stakeholders; and determine priority populations and suitable practices. Consider how the following the Six Steps in Planning for Equity-based Intervention might be used for a CHN who wants to connect with LGBTQ2S2S clients?

Break the students up into smaller groups and ask them to report on the following Six Steps in Planning for Equity-based Intervention, as they relate to LGBTQ2S populations. Choose different public health intervention that you would like to engage the LGBTQ2S in (i.e. smoking cessation, safer sexual practices, suicide prevention, addictions prevention, etc.). On poster paper, have the students outline their plan for creating equity-based interventions for the LGBTQ2S communities.

Step one - Literature and local research & evaluation results (Describes relationship between socio-demographics and health indicators, health risks, and service utilization) • • • • •

Does the published literature include data on LGBTQ2S? Is there literature on some sub-populations but not others (for example, are transgender people included and data specifically on their risks described?)

Is there pre-existing local research on the health issue?

How will you know what the current situation is?

How will you measure impact?

Step two - Examine broader and local health data e. f. g. h.

.

What data could you collect on the issue?

Where will you collect the data?

How will you collect the data?

Who would you include as data collectors?

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Chapter 20 Lesbian, Gay, Bisexual, Transgender, Queer, and Two Spirit Clients Step three - Relationship: health indicators and social determinants of health (SDOH) c. What information is available on the SDOH as they pertain to LGBTQ2S communities? d. What is known about the SDOH as they relate to the health intervention that you are assessing?

Step four - Identify information gaps d. What is not known that must be known in order to plan an equitable intervention? e. Can the information be gathered in a smaller pilot or demonstration project? f. How will you identify the population that you would like to collect the data on?

Step five - Engage key stakeholders (Define process to engage key stakeholders in discussing results and examining local context) a. What current partnerships exist and should be maintained? What can be learned from examples? b. What are current trends that may provide opportunities or reflect best practices? c. How ready is the community for the considered approach? Is there a need to further engage partners? d. Are there approaches that have proven to work better than others for some priority populations?

Step six - Determine priority populations and suitable practices a. Review and discuss: - Community health needs - Mandate - Potential impact - Resources required - Capacity - Collaboration – outreach and participation b. Decide on priority populations and most suitable practice Seminar Discussion Questions 1. Ask the students to consider how the sexual orientation of clients influences the community health interventions at their clinical placement. Do staff offer people of all orientations equal opportunity for service and outcome? Are there written policies that guide how people are treated? Are people treated differently? Why or why not? Is sexual orientation a factor in the health challenge that your community placement is working with?

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Chapter 20 Lesbian, Gay, Bisexual, Transgender, Queer, and Two Spirit Clients Case Study Questions 1. What support or assistance might you want to request from the school health committee, or the vice-principal and principal, in taking on this role?

•

The school nurse might want to ask the School Health Committee, or the Principal and Vice Principal for explicit, written support for the nurse’s role as staff sponsor for the GSA, and public support in the school newsletter or at a school board meeting; likewise, the school nurse might request that the Principal directly handle communication with concerned parents, as the head of school.

2. What health information and skills-building support do you think the students who start the GSA will want or need?

•

Students might need some education around group dynamics or group organizing; health education on sexual health and healthy relationships, stress management, communicating with parents, coping with depression, or substance use/abuse; some education on how to respond in crisis situations (i.e., when a friend is being bullied or expresses suicidal ideation, how to get help from an adult); they might some coaching on how to decide the group’s main purposes (social justice and activism, social support, health education, or recreation?)

3. How would you suggest engaging with parents before a GSA becomes a controversy? Or after there is opposition?

•

Students might suggest the nurse should hold a school meeting for parents to inform them about the GSA, and the research evidence for its need and its benefits; or they might suggest the principal mention it in the school newsletter. If there is opposition, it would be important for the school nurse to share the research evidence about levels of homophobic bullying, of the link between bullying and suicide or other health risks, and the known benefits of having a GSA. The nurse might also want to engage supportive local champions, such as supportive local religious leaders, or newspaper reporters, or the Parent Advisory Council in the school, if these are supportive, to help champion the importance of a GSA for the school.

Canadian Research 20.1 Note: these are really open-ended discussion questions to get students thinking and talking about the research article, there are no specific answers 1. Why do you think Two Spirit homeless youth might experience more health inequities than other Indigenous homeless youth? How might the intersection of racism and stigma contribute to their health issues? .

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Chapter 20 Lesbian, Gay, Bisexual, Transgender, Queer, and Two Spirit Clients •

Individual responses will vary

2. This research identifies key resilience factors among Two Spirit youth linked to culture and family connectedness. If you are not Indigenous, how might you, as a CHN working with homeless Two Spirit youth, support their cultural safety in your practice?

•

Individual responses will vary

3. If you were providing community health nursing care with homeless Indigenous youth, and one of the young people disclosed they were Two Spirit, what are some of the health risks you might assess and need to address?

•

Individual responses will vary

Individual Critical Thinking Exercises 1. What is your belief about sexual orientation? Do you think it is genetic or a learned phenomenon (i.e., nature or nurture)? What factors in your life may have influenced your thinking?

This is a reflective question, there is no right or wrong answer.

2. A client discloses to you she is a lesbian. Do you enter this into her chart or tell other members of the health team about this? Why or why not?

This question is one to lead reflective thinking; the answers will depend on the context. For example, what are the policies of the health care setting? How confidential is the chart or electronic charting system, and how well trained are the providers and support staff in principles of confidentiality and privacy? Has the client indicated whether she is out to her family, at work, among friends? You might consider asking the patient what she would prefer in terms of documentation in charting. The reason is that disclosure in some circumstances could leave the patient vulnerable to poor treatment or homophobia within the health care system, or place her at risk for rejection and violence from family, or being fired from work, although in Canada it is no longer legal to fire someone on the basis of their sexual orientation.

3. How would you address a transgender client who has male genitalia but dresses as a woman?

It would be best to directly ask the client, “How would you prefer to be addressed?” or “What pronouns do you prefer I use?” This recognizes the client’s status in a respectful way, and enhances autonomy for the client.

4. What are your feelings regarding caring for a patient with HIV/AIDS? What are your ethical responsibilities regarding caring for such a patient? You may find it helpful to draw upon the CNA Code of Ethics when thinking about these questions. .

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Chapter 20 Lesbian, Gay, Bisexual, Transgender, Queer, and Two Spirit Clients This is another reflective set of questions to raise self-awareness about one’s feelings, values, and professional responsibilities.

5. What, if any, ethical issues can arise from refusing to care for a patient with HIV/AIDS? Patient abandonment, as well as perceived discrimination due to refusal of care, are both ethical issues and may also be legal issues in your jurisdiction.

6. Do you think that LGBTQ2S people should have access to specialized clinics for their healthcare? Why or why not?

This is a question to help with critical reflection, there are no right or wrong answers.

Group Critical Thinking Exercises These questions are designed to raise self-awareness and generate discussion—there are no right or wrong answers.

1. Identify homophobic, biphobic, transphobic, or heterosexist attitudes that you have witnessed as a student at the university, and during your clinical experiences. How did you deal with these?

•

This question is designed to raise self-awareness and generate discussion—there are no right or wrong answers.

2. Do you think that a LGBTQ2S nurse should be “out” in the workplace? Why or why not?

•

This question is designed to raise self-awareness and generate discussion—there are no right or wrong answers.

3. A client expresses discomfort with being cared for by one of your colleagues who is LGBTQ2S. How do you think you and the clinical setting should respond? Would your response be different if the patient had expressed discomfort with being cared for by a nurse of colour? Or a nurse who is Jewish, Muslim, or Sikh?

•

This question is designed to raise self-awareness and generate discussion—there are no right or wrong answers.

Further Resources Egale Canada, a national organization that advances equality and justice for lesbian, gay, bisexual, and trans-identified people and their families across Canada www.egale.ca PFLAG Canada, a registered charitable organization that provides support, education, and resources to parents, families, and individuals who have questions or concerns about sexual orientation or gender identity www.pflagcanada.ca

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Chapter 21 Older Adult Health

Chapter 21: Older Adult Health Suggestions for Guest Speakers 1. Invite a nurse to speak to the class who works in a nursing home, chronic care facility etc. to discuss issues of care with the older adult.

2. Ask a nurse who works in an elderly outreach, assessment or liaison capacity to discuss issues of senior’s care with the class.

3. Invite a nurse who works at a senior’s day program to discuss health promotion.

4. Skype or teleconference with a representative of a seniors’ advocacy group, such as the Advocacy Group for the Elderly in Toronto http://www.advocacycentreelderly.org/who_we_are.php Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Provide the students with a falls assessment check list from your local public health unit.

Ask the students to consider where a falls assessment program could take place (doctor’s offices, flu clinics, malls etc.). Who should carry them out (doctors, public health nurses, student nurses)? Should the assessment be given selectively (based on age, infirmary, by recommendation) or universally? What should happen as follow up for those people who are shown to be at risk of falls? Brainstorm some ideas. Compare the students take on the “ideal” situation with what is actually happening in falls prevention in your community.

2. Ask students to compare the life expectancy in Canada over the past 10 decades. This information can be found on the Statistics Canada website. Ask the students to consider some of the reasons for the increase in life expectancy? What are some of the issues that seniors faced with their aging parents/grandparents that they will not need to face? What issues will they need to face that were not around in generations past? What misconceptions might seniors have about health and options for care? What can nurses do to impact the senior’s quality of life in their latter years?

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Provide the students with a falls assessment check list from your local public health unit.

Ask the students to consider where a falls assessment program could take place (doctor’s .

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Chapter 21 Older Adult Health offices, flu clinics, malls etc.). Who should carry them out (doctors, public health nurses, student nurses)? Should the assessment be given selectively (based on age, infirmary, by recommendation) or universally? What should happen as follow up for those people who are shown to be at risk of falls? Brainstorm some ideas. Compare the students take on the “ideal” situation with what is actually happening in falls prevention in your community.

2. Ask students to compare the life expectancy in Canada over the past 10 decades. This information can be found on the Statistics Canada website. Ask the students to consider some of the reasons for the increase in life expectancy? What are some of the issues that seniors faced with their aging parents/grandparents that they will not need to face? What issues will they need to face that were not around in generations past? What misconceptions might seniors have about health and options for care? What can nurses do to impact the senior’s quality of life in their latter years?

Seminar Discussion Questions 1. Ask the students to consider how the age of the client changes how community health nurses interact with people at their clinical placement. Is the clinical placement setting accessible to people with physical and sensory challenges? Might the age of the staff working at the clinical placement influence the older person’s opportunity for quality service? Are people of different ages treated differently? Why or why not? How is age seen at the clinical placement (a normal healthy part of life, a disorder, etc.).

Case Study Questions 1. What is the first issue the CHN would discuss with Mrs. McNeil? ● Developing therapeutic relationship and describing how the CHN can work with her to help her continue to be independent with her medications. ● Assess clients understanding of her health condition, how to manage symptoms and when to communicate with primary care when symptoms are progressing. Discuss how medications can help her to manage her chronic condition and help prevent a situation that may require hospitalization.

2. Why is medication self-management important to promote? ● CHN role is to partner with clients and families not to create client dependence on having a nurse in the home or as a resource in the community. CHNs visits are maybe once a day or a few times a week. CHNs coming into the home need to support clients and families to do what they can for themselves as. ● Medication self-management helps support clients outcomes and feelings of well-being and control of health. ● The client may need some support and teaching post hospitalization to get back on track.

CHNs should engage and encourage clients and families to be involved in self-care.

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Chapter 21 Older Adult Health 3. What resources in the community could the CHN collaborate with to support Mrs. McNeil in managing her medications? ● Clients, local community pharmacist, and primary care providers ● Medication checks and the availability any medication safety programs offered by community pharmacists and local pharmacy chains. ● Whether there is a medication reminder service or blister packaging option available.

Canadian Research 21.1 1. Identify barriers to physical activity at the personal (individual) level: There are many factors that present an obstacle to physical activity. Amongst these are: ● Chronic conditions (e.g. depression, arthritis) ● Symptoms (e.g. pain and fatigue) ● Functional limitations including strength and flexibility ● Motivation ● Self-efficacy and self-esteem ● Time ● Awareness (e.g. benefits, recommendations, knowledge and experience)

2. Identify barriers older adults may face in their access to physical activity.

There are many barriers to access. Students should consider the social determinants of health as part of their response. Some barriers are: ● Limited resources and opportunities ● Limited/no options within physical activity programs to support older persons with functional limitations and chronic health conditions ● Costs ● Geographical distance ● Environmental factors (e.g. weather, transport, and safety) ● Limited/no accommodation for cultural and language minorities ● Lack of knowledge and awareness 3. What are the benefits of the approach used by CHNs in the BSBB Program? ● The BSBB goals were congruent with the city’s emphasis on creating age-friendly communities, which was critical for funding and support. ● The CHNs built a strong partnership with stakeholders in the development, implementation, and evaluation of the BSBB. This ensured the BSBB was relevant and sustainable. ● The BSBB comprised of multiple interventions, which are likely to be more effective than the individual components alone. ● The BSBB was based on evidence-based (e.g. physical exercise recommendations, barriers to access to physical activity, and risk factors for falls). ● The CHNs sought the views of older persons who took part in the BSBB .

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Individual Critical Thinking Exercises 1. Arrange a visit with an older adult and discuss the health care system of the past and how the system has changed. Does the individual have any advice for you as a future nurse?

• This exchange with an older adult should allow the student to compare the health care system of the past and of the present, especially in regards to home visits by the doctor, the need to pay to receive health care services and the role of the nurse.

2. Observe how older people are portrayed in the media. Is ageism evident? How? Why? Reflect on your own feelings about older persons and aging.

• This exercise should describe how older adults are described in the media (print, audio and visual) as well as people’s discourse in regards to older adults. A description of why the student believes this was happening and the reasons or context would frame the presentation.

3. Examine your surroundings. What barriers do you see to older persons with limited mobility? What might facilitate access?

•

Individual responses will vary

4. Investigate the community support programs in your community. Are they easily located?

Are the referral process and cost easily identified? What barriers are there to accessing the programs?

•

Individual responses will vary

5. Visit the Alzheimer’s Society of Canada website, and identify what information would be useful to a CHN preparing to meet with a group of family caregivers.

• The goal of this exercise is the raise consciousness about information found on a particular web site and its usefulness to family caregivers.

Group Critical Thinking Exercises 1. Discuss your findings from the Individual Critical Thinking Exercises with other students.

•

In a group setting, students should discuss their findings and/or experience with the five exercises in the Individual Critical Thinking Exercises. This provides an opportunity for exchange of information between students.

2. Find out about your province’s policy regarding older drivers. Discuss if the policy is appropriate and how it is enforced. What are the implications of an older adult losing her or his driver’s license? .

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Driving is a major factor in an older adult’s independence. Therefore, this exercise will create awareness of provincial legislation in regards to driving and older adults and create opportunity to appreciate the impact of losing a driver’s licence (isolation, frustration, depression).

3. Arrange to speak with a CHN who works with older adults to discuss her or his role.

After the meeting, as a group, discuss the CHN’s perspective on the role. Is it what you expected? Why or why not?

•

Arrange to speak with a CHN who works with older adults to discuss her or his role.

After the meeting, as a group, discuss the CHN’s perspective on the role. Is it what you expected? Why or why not?

Further Resources The Canadian Network for the Prevention of Elder Abuse (CNPEA) http://www.cnpea.ca The Canadian Gerontological Nursing Association (CGNA) http://www.cgna.net National Initiative for the Care of the Elderly (NICE) www.nicenet.ca Advocacy Centre for the Elderly http://www.advocacycentreelderly.org/who_we_are.php National Initiative for the Care of the Elderly. (2009). When Someone Close to you is Dying.

Toronto: Author. Retrieved from http://www.nicenet.ca/files/EOL-_Booklet_%28v.11%29.pdf The Ontario Network for the Prevention of Elder Abuse. (2009). Safety Planning for Older Persons. Retrieved from http://www.onpea.org/english/pdfs/InfoSheetSafetyPlanning.pdf National Film Board of Canada, & Scott, C. (1990). The company of strangers (a/k/a Strangers in Good Company). Canada: NFB. 100 minutes. See www.onfnfb.gc.ca/eng/collection/film/?id=18345 Polley, S. (2006). Away from her. Canada: Mongrel Media. 100 minutes.

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Chapter 22 Indigenous Health

Chapter 22: Indigenous Health Suggestions for Guest Speakers 1. Invite a nurse who works with First Nation communities to speak to the class.

2. Invite an elder from a local First Nation community to speak to the class about their culture as it related to health and wellness.

3. Skype or teleconference with a nurse who works for the First Nations and Inuit Health Branch.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Watch the Assembly of First Nations - HPV Video, http://www.youtube.com/watch?v=8ysLE-UAyXo&feature=player_embedded Discuss with the students the merits of having young, FN people speaking in the health promotion video to promote the HPV vaccine among their peers. Consider the impact of CHNs sharing the power to make decisions. What might that do to influence the participation of the youth if they believe that the adults respect young people’s input.

What might it do for the relationship between the CHN and his/her community if they are willing to provide support and opportunity for youth to reach out to their peers.

Ask the students to answer the following questions: -

If you were a CHN wanting to get this message out to young FN people, how would you go about planning what approach to take?

Who would you involve in the planning process (teachers, parents, youth groups, etc.)?

To what extent would youth be involved in planning the campaign (tokenism verses having the youth actively involved in decision-making)?

2. Ask the students to read the article: “Ain’t no smokin’ at the house of blue lights: ITK launches blue light campaign to combat tobacco.” NUNATSIAQ NEWS May, 2010 www.nunatsiaqonline.ca/stories/article/6789_aint_no_smokin_at_the_house_of_blue_lig hts/ Non-smoking Inuit homes in Canada will glow blue over the coming year to signal their household’s commitment to go smoke-free, said Mary Simon, president of Inuit Tapiriit Kanatami, in Ottawa at the May 31 launch of two new programs aimed at reducing smoking rates and improving the health of families, infants and new mothers. .

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Chapter 22 Indigenous Health “These programs are about reducing the extraordinarily high prevalence of smoking among Inuit, which contributes to a rate of lung cancer among Inuit that is the highest in the world — and rising,” said Simon in an ITK news release.

“They are about providing support and encouragement to Inuit, and helping families realize that they can take control of their health and their lives.”

The projects include the “Blue Light Campaign,” in which families will get a blue light bulb to install on their porch to signal that their home is smoke free.

The light means either that there are no smokers in the household, that the household’s smokers have always smoked outdoors, or that they have begun smoking outdoors to reduce the impact of second-hand smoke on others in the family, ITK says.

A second project, called “Born Smoke-Free,” is aimed at women who are pregnant or might become pregnant.

Some studies have found smoking rates of 80 per cent or more among pregnant women.

In Iqaluit, researchers determined that 85 per cent of infants had been exposed to tobacco in the womb, ITK notes.

“Recognizing these alarming statistics does not mean casting judgment,” said Simon.

“Our goal is to promote Inuit-specific, culturally affirming and community-empowering initiatives to reduce the use of tobacco among Inuit.”

IYK says the programs, already started in several Nunatsiavut and Nunavik communities, will now be extended to select communities in Nunavut, the Northwest Territories and one more Nunavik community.

Inuit households in Ottawa will also be included through the Ottawa-based Tungasuvvingat Inuit organization.

The May 31 launch of the two programs coincides with the annual World No Tobacco Day. Discuss the implications of the Blue Lights program. Ask the students to describe how the program might be received in the communities where they live.

Ideas for Self-Study or Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Watch the Assembly of First Nations - HPV Video, http://www.youtube.com/watch?v=8ysLE-UAyXo&feature=player_embedded Discuss with the students the merits of having young, FN people speaking in the health promotion video to promote the HPV vaccine among their peers. Consider the impact of CHNs sharing the power to make decisions. What might that do to influence the participation of the youth if they believe that the adults respect young people’s input.

What might it do for the relationship between the CHN and his/her community if they are willing to provide support and opportunity for youth to reach out to their peers.

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Chapter 22 Indigenous Health Ask the students to answer the following questions: -

If you were a CHN wanting to get this message out to young FN people, how would you go about planning what approach to take?

Who would you involve in the planning process (teachers, parents, youth groups, etc.)?

To what extent would youth be involved in planning the campaign (tokenism verses having the youth actively involved in decision-making)?

2. Ask the students to read the article: “Ain’t no smokin’ at the house of blue lights: ITK launches blue light campaign to combat tobacco.” NUNATSIAQ NEWS May, 2010 www.nunatsiaqonline.ca/stories/article/6789_aint_no_smokin_at_the_house_of_blue_lig hts/ Non-smoking Inuit homes in Canada will glow blue over the coming year to signal their household’s commitment to go smoke-free, said Mary Simon, president of Inuit Tapiriit Kanatami, in Ottawa at the May 31 launch of two new programs aimed at reducing smoking rates and improving the health of families, infants and new mothers.

“These programs are about reducing the extraordinarily high prevalence of smoking among Inuit, which contributes to a rate of lung cancer among Inuit that is the highest in the world — and rising,” said Simon in an ITK news release.

“They are about providing support and encouragement to Inuit, and helping families realize that they can take control of their health and their lives.”

The projects include the “Blue Light Campaign,” in which families will get a blue light bulb to install on their porch to signal that their home is smoke free.

The light means either that there are no smokers in the household, that the household’s smokers have always smoked outdoors, or that they have begun smoking outdoors to reduce the impact of second-hand smoke on others in the family, ITK says.

A second project, called “Born Smoke-Free,” is aimed at women who are pregnant or might become pregnant.

Some studies have found smoking rates of 80 per cent or more among pregnant women.

In Iqaluit, researchers determined that 85 per cent of infants had been exposed to tobacco in the womb, ITK notes.

“Recognizing these alarming statistics does not mean casting judgment,” said Simon.

“Our goal is to promote Inuit-specific, culturally affirming and community-empowering initiatives to reduce the use of tobacco among Inuit.”

IYK says the programs, already started in several Nunatsiavut and Nunavik communities, will now be extended to select communities in Nunavut, the Northwest Territories and one more Nunavik community.

Inuit households in Ottawa will also be included through the Ottawa-based Tungasuvvingat Inuit organization.

The May 31 launch of the two programs coincides with the annual World No Tobacco Day. Discuss the implications of the Blue Lights program. Ask the students to describe how the program might be received in the communities where they live. .

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Seminar Discussion Question Ask the students to consider the history of colonialism on FN people in their community. What impact might that experience have had on the social determinants of health (income, social support, child development, etc.)? How might the experience influence how people access the health care system today? What resources are available at their community health placement that are specifically aimed at assisting FN people? What resources would be helpful?

Case Study 1. What are the pearls of wisdom that stand out for you in this story?

•

Individual responses will vary

2. How would you apply these teachings to your community health nursing practice with Indigenous communities?

•

Indigenous ways of knowing supports the learner to hear the lessons needed that are most relevant to them at that time. Using Carper’s fundamental ways of knowing in nursing can prompt the learner to reflect on these teachings from a nursing lens.

Cue questions: Aesthetic Way of Knowing: • What were the teachings in the story?

• What were my reactions to the story? Why did I respond this way?

• What were the feelings that surface for the people in the story?

• How did I know this?

Personal Way of Knowing: • What were the feelings that surfaced for me in the story?

• What internal factors were influencing me?

Ethical Way of Knowing: • How did the teachings of this story match my beliefs?

• What parts of the story were incongruent with values of the teachings?

Empirical Way of Knowing: • What knowledge from this story informs my practices?

Reflexivity: • How does this connect with my previous experiences?

• Does this change how I could have handled things better in a similar situation?

• What would be the consequences or alternative actions for the patients/community? Others? Myself?

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Chapter 22 Indigenous Health • • •

How do I now feel about this experience?

Can I support myself and others better as a consequence?

Has this changed my ways of knowing?

Reference for Case Study and Questions: • Johns, C. (1995), Framing learning through reflection within Carper's fundamental ways of knowing in nursing. Journal of Advanced Nursing, 22: 226-234. doi:10.1046/j.1365-2648.1995.22020226.x • Secwepemc Elder*, Hulko, W., Wilson, D., Mahara, S., Campbell-McArthur, G., William, J., De Rose, C., & Patrick Moller, E. (2014), We Call it Healing’, In press 3. How would you honour the Indigenous Knowledge from this story’s teachings?

•

Individual responses will vary

Canadian Research 22.1 1. As a CHN, how might these findings influence your practice and approach when providing care to Indigenous clients?

•

Relational, culturally safe practice guided by relational inquiry. Holistic client centered care.

2. How would you address the complex reasons of participants resistant to accessing care including stigma related to their Indigeneity, discourses of blame, poverty, and lack of system capacity? What attention is required to address these structural injustices acting as barriers to health care services?

•

Disrupt the colonial narratives that contribute to the harm and violence Indigenous people face in access to care. Take a social justice lens to nursing advocacy for patients, families, communities and systems.

3. What would you do if you witnessed stigma or discrimination against an Indigenous client?

•

Address the issue with the patient, health care provider, manager and/or regulatory college.

Individual Critical Thinking Exercises 1. What is the difference between cultural safety and cultural humility, and how do these concepts improve health outcomes?

Cultural humility supports the continual self-reflection of one’s beliefs by acknowledging personal and systemic biases and adopting a philosophy of oneself as a learner in relation to another’s experience. Cultural humility allows CHNs to come to .

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Chapter 22 Indigenous Health know a community as the expert with recognition and regard for health and healing practices meaningful to the community and its peoples supporting mutual trust.

Cultural safety in nursing practice is a reflective practice on one’s own beliefs, practices and histories and how they impact the people we serve.

Cultural safety and cultural humility support a nursing practice that is client centered and reflexive of one’s personal biases and challenges systemic racism improving health outcomes and service delivery.

2. What TRC Calls to Action specifically apply to nursing? How will you incorporate the TRC’s Calls to Action into your nursing practice?

•

Nurses hold an irrefutable responsibility and a key role in supporting the calls to action in reconciliation in order to facilitate healing. The TRC has 94 calls to action that holistically supports healing for survivors, communities and Canada’s overall relationship with Indigenous peoples including calls to action in education, justice, child welfare, culture, language and health. The TRC’s recommendation number 24 specifically addresses health and nursing.

3. What does reconciliation mean to you? How will your understanding of reconciliation apply to your nursing practice?

•

It is important for each nurse to define what reconciliation means to them and what acts of reconciliation will support their nursing practice. Reconciliation is both individual and collective. It is an evolving and ongoing process of reflexivity and awareness.

4. Reflect on your own culture and what practices you cherish most. Food, family, language, customs, and spirituality are all elements that make up your own unique culture. Imagine you were no longer able to connect with your culture. How would you feel? What would be some of the impacts on your life and well-being?

•

Individual responses will vary

Group Critical Thinking Exercises As a class, watch the film Colonization Road (http://www.cbc.ca/firsthand/episodes/colonization-road) 1. What are the causes of the disproportionately high adverse health outcomes for Indigenous populations in Canada when compared to non-Indigenous populations?

•

Colonization, systemic racism, colonial and assimilative policies.

2. How has enforced geographical isolation contributed to issues related to the quality of life of Indigenous peoples?

•

Colonization, the Indian Act, racist legislation, implementation of reserves, etc.…

3. What are three ways that CHNs can decolonize health promotion practice? .

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The decolonization of nursing practice is an interactive process to expose, resist and transform colonial processes within nursing and health care that oppress Indigenous peoples and instead affirm and support the strength and knowledge within Indigenous cultures. Seek guidance from community members, honour Indigenous ways of knowing, challenge colonial narratives that oppress and harm Indigenous peoples, support self-determination and self-governance.

Further Resources

Aboriginal Nurses Association of Canada (ANAC) www.anac.on.ca National Aboriginal Health Organization (NAHO) www.naho.ca Health Canada, First Nations and Inuit Health http://www.hc-sc.gc.ca/fniah-spnia/index-eng.php Health Council of Canada, Aboriginal Health http://www.healthcouncilcanada.ca/accord.php?mnu=1&mnu1=7 National Collaborating Centre for Aboriginal Health http://www.nccahccnsa.ca/Publications/Lists/Publications/Attachments/101/abororiginal_health_web.pdf

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Chapter 23 Community Mental Health

Chapter 23: Community Mental Health Suggestions for Guest Speakers 1. Ask a nurse that works in the community as a case manager or on an emergency response team to discuss issues related to mental health.

2. Ask a community health nurse researcher who studies mental health issues to Skype, teleconference, or visit the class.

3. Ask a representative of a mental health advocacy or support group to visit the class.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Learn about a different type of mental health therapy, a clip from the comedy troupe, “Stand up for Mental Health” found at: http://www.youtube.com/watch?v=ULilbh9x_bw Discuss what kind of impact talking about mental health issues in this way might have on how we think about people with diagnosed mental illnesses? How does watching the video make you feel?

2. Ask the students to break up into 5 groups. Ask the students to consider one of the following mental illnesses. Assign a reporter to take notes. Answer the question: How might this illness effect the other social determinants of health (income and social status, social support, education, literacy employment, life skills, personal health practices, coping skills, access to health services)? Ask the groups to share their discussion findings with the larger group.

Mood disorders encompass depression, bipolar disorders, dysthymia and cyclothymias, depression being the most prevalent with rates of 4.2% for men and 6.3% for women in Canada in the past 12 months (Government of Canada, 2006). Physical illnesses, such as heart disease, thyroid conditions, and diabetes, often potentate depression. The utmost concern for people with depression is risk of suicide. Ongoing assessment of suicide risk is necessary and must be followed by appropriate intervention. Family members are affected by the depressive episodes and require peer support, education, and resource information.

Bipolar illness has a population prevalence of 2.4% and is increasingly recognized in children and adolescents (Government of Canada, 2006). Children may suffer from comorbidity, most commonly attention deficit disorder and conduct disorder (Kowatch & .

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Chapter 23 Community Mental Health DelBello, 2005). Adults with bipolar disorder often place themselves and their families at risk. Grandiosity, poor judgment, impulsivity, and expansive mood may lead to social and financial indiscretions, increasing the visibility of the MI and shame related to the stigma associated with MI. Anxiety disorders are the most common of all psychiatric disorders and consist of generalized anxiety disorder, specific phobia, post-traumatic stress disorder, social phobias, obsessive-compulsive disorder, panic disorder, and agoraphobia. Lifetime prevalence rates are estimated at 10%, with anxiety disorders being the most commonly treated MI in children with a rate comparable to asthma (Castellanos & Hunter, 2000). Substance abuse and depression may develop secondary to anxiety.

Schizophrenia, affecting 1% of the population, is a serious MI characterized by delusions, hallucinations, social withdrawal, and lack of insight. The associated costs of treatment, management, lost potential, and suffering of people with schizophrenia and their families are high. Hospitalization is required in acute illness, with schizophrenia being the most common diagnosis of involuntary patients (Government of Canada, 2006). To ensure their family members’ well-being, families absorb much of the burden of care in the community.

Disproportionate numbers of people with schizophrenia are found in homeless and prison populations. People with schizophrenia require adequate health services to promote their physical health and to monitor medications and complications such as diabetes and cardiovascular problems. Comprehensive services for housing, vocational and recreational opportunities, and treatment of co-occurring substance abuse problems are needed to promote mental health and recovery. Integration of these services and supportive government policies is needed to promote recovery and basic well-being (Kirby & Keon, 2006).

Post-traumatic stress disorder (PTSD) is characterized by distressing symptoms of repeated and intrusive memories, dreams and thoughts related to witnessing, experiencing or being confronted with a traumatic event that is perceived as threatening to self or others.

Criteria of the disorder include avoidance of situations that are reminiscent of the trauma, hyper arousal and exaggerated startle response. Global incidence of PTSD is estimated at 7–12% of the population (Sareen, Cox, Stein, Afifi, Fleet, & Anderson, 2007). There is increased awareness of this disorder related to military personal.

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Chapter 23 Community Mental Health Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Learn about a different type of mental health therapy, a clip from the comedy troupe, “Stand up for Mental Health” found at: http://www.youtube.com/watch?v=ULilbh9x_bw Engage in an on-line chat about what kind of impact talking about mental health issues in this way might have on how we think about people with diagnosed mental illnesses? How does watching the video make you feel?

2. Ask the students to break up into 5 groups. Ask the students to consider one of the following mental illnesses. Assign a reporter to take notes. Answer the question: How might this illness effect the other social determinants of health (income and social status, social support, education, literacy employment, life skills, personal health practices, coping skills, access to health services)? Ask the groups to share their discussion findings with the larger group.

Mood disorders encompass depression, bipolar disorders, dysthymia and cyclothymias, depression being the most prevalent with rates of 4.2% for men and 6.3% for women in Canada in the past 12 months (Government of Canada, 2006). Physical illnesses, such as heart disease, thyroid conditions, and diabetes, often potentate depression. The utmost concern for people with depression is risk of suicide. Ongoing assessment of suicide risk is necessary and must be followed by appropriate intervention. Family members are affected by the depressive episodes and require peer support, education, and resource information.

Bipolar illness has a population prevalence of 2.4% and is increasingly recognized in children and adolescents (Government of Canada, 2006). Children may suffer from comorbidity, most commonly attention deficit disorder and conduct disorder (Kowatch & DelBello, 2005). Adults with bipolar disorder often place themselves and their families at risk. Grandiosity, poor judgment, impulsivity, and expansive mood may lead to social and financial indiscretions, increasing the visibility of the MI and shame related to the stigma associated with MI. Anxiety disorders are the most common of all psychiatric disorders and consist of generalized anxiety disorder, specific phobia, post-traumatic stress disorder, social phobias, obsessive-compulsive disorder, panic disorder, and agoraphobia. Lifetime prevalence rates are estimated at 10%, with anxiety disorders being the most commonly treated MI in children with a rate comparable to asthma (Castellanos & Hunter, 2000). Substance abuse and depression may develop secondary to anxiety.

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Chapter 23 Community Mental Health Schizophrenia, affecting 1% of the population, is a serious MI characterized by delusions, hallucinations, social withdrawal, and lack of insight. The associated costs of treatment, management, lost potential, and suffering of people with schizophrenia and their families are high. Hospitalization is required in acute illness, with schizophrenia being the most common diagnosis of involuntary patients (Government of Canada, 2006). To ensure their family members’ well-being, families absorb much of the burden of care in the community.

Disproportionate numbers of people with schizophrenia are found in homeless and prison populations. People with schizophrenia require adequate health services to promote their physical health and to monitor medications and complications such as diabetes and cardiovascular problems. Comprehensive services for housing, vocational and recreational opportunities, and treatment of co-occurring substance abuse problems are needed to promote mental health and recovery. Integration of these services and supportive government policies is needed to promote recovery and basic well-being (Kirby & Keon, 2006).

Post-traumatic stress disorder (PTSD) is characterized by distressing symptoms of repeated and intrusive memories, dreams and thoughts related to witnessing, experiencing or being confronted with a traumatic event that is perceived as threatening to self or others.

Criteria of the disorder include avoidance of situations that are reminiscent of the trauma, hyper arousal and exaggerated startle response. Global incidence of PTSD is estimated at 7–12% of the population (Sareen, Cox, Stein, Afifi, Fleet, & Anderson, 2007). There is increased awareness of this disorder related to military personal.

Seminar Discussion Questions Ask students to reflect on the importance of mental health promotion to their community placement and to society. Is mental health a major goal of the population served in their population? Are there opportunities for improvement? How have they observed/experienced stereotyping of people living with mental illness in the past? What can nurses and student nurses be doing to influence change in an insensitive environment? What can nursing students/instructors be doing? How might someone advocate for awareness of stigma against people with mental illness?

Case Study Questions 1. What resources can help you to process your feelings in order to practise self-care and continue to work with the youth?

•

.

The experience of losing a youth and co-worker to suicide is devastating and the nurse needs to be aware that he/she will be affected by this sad occurrence. The nurse may experience some of the emotions that many people who experience a suicide go 185

Chapter 23 Community Mental Health thorough: anger, grief, guilt and hopelessness. It could be helpful to have a debriefing of this event for the health care team. This should be a safe place for team members to discuss how they are feeling and review lessons learned to help them in the future. Every nurse has a different reaction to situations, personal counselling may help some, talking to an experienced nurse who has developed ways of managing these experiences may benefit another. The most important thing is to practice self-care and know that it is normal to have emotional reactions to suicide. Seek out support that you may need.

2. How will you assist the youth to understand Gary’s suicide and process their emotions?

•

Youth who knew Gary will have different reactions. They may be shocked, overwhelmed and may feel that if he could not be successful, how could they possibly be so? The most important thing would be to find some way to honour Gary’s life and to develop an understanding that many people have suicidal thoughts but there is always someone to help if the person can reach out. The nurse will encourage expressions of feelings and use the moment to teach about suicide prevention, what to do when you believe that someone is suicidal. This will empower the youth. The nurse would also ensure that youth have follow up care in the event that they need to discuss their feelings further, a program like Mental Health First Aid could be effective after the suicide of Gary. Visit this website to learn about the program. (http://www.mentalhealthfirstaid.ca/EN/Pages/default.aspx)

3. How can CMHNs support peer support youth peer workers who may be struggling with their personal circumstances?

•

•

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CHNs can support workers who have lived experiences and are stepping up to jobs within the service field by being aware that people with lived experience may feel pressured to do well. They may be held up to others as an example and if something happens that they are not able to live up to the expectations, that they or others may place on them, it may be discouraging. They may view themselves as failures.

CHNs can support people with lived experiences in their roles by ensuring that they are not overwhelmed with tasks, that the person is challenged in a healthy manner and that the workplace is safe and compassionate.

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Chapter 23 Community Mental Health Canadian Research 23.1 1. What measures can CMHNs employ to ensure that family caregivers’ needs for rehabilitation services are met?

•

Community mental health nurses need to consider the needs of the family and the care that the family contributes to the well-being of the mental health patient. Often family members have not had satisfactory relationships with professionals. While this situation has improved, each community nurse can have an impact with family members. Nurses can validate family effort; treat family members as an equal part of the care team, ensure that services for respite are available and promote mental health of family members by encouraging them to use self-care.

2. What is the role of CMHNs in advocating for and supporting the caregiver?

•

The results of this study demonstrate that there is a need for more rehabilitative services, improved access to services and continued and improved collaboration between health care professionals and family caregivers. The community nurse can practice from a philosophy that validates and appreciates family efforts, convey this to other team members and advocate for collaborative efforts to include family’s perspective on points of care. Ongoing consultation with family regarding services and inclusiveness are important and can be organized by the community nurse. Nurses can participate in research examining families and health care professionals’ working relationships.

Individual Critical Thinking Exercises 1. What strategies might a CMHN use to promote the mental health of elementary schoolage children?

• Identify partners who will assist the CMHN to provide mental health promotion activities. Some possible partners are guidance teachers, physical education teachers, school administration, parents, community organizations working with children and psychological support services. Children themselves may have wonderful ideas on what is helpful to them.

• Emphasize training for teachers to recognize signs of mental illness in children and to advocate for early intervention. Early intervention mitigates future problems. Educate teachers to work with parents to reduce the stigma of accepting mental health help for their children. Assist parents to develop healthy parenting skills to decrease incidences of child abuse.

• Analyze what inequities exist in the school system that impact on mental health issues.

For example, how are children with disabilities accepted, how are diverse cultural backgrounds integrated, what are policies on bullying, do both the bully and the victim .

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•

receive assistance? What is the balance between competitiveness and cooperation in school activities? Brainstorm with partners what policy changes need to be made to support equitable inclusion of all children.

Organize fun activities that will involve the school and larger community and simultaneously educate children and families on mental illness and mental health. For example, games, quizzes and projects that emphasize facts on mental illness and life skills for mental health. Ensure that school days are organized to promote mental health and manage stress in a productive manner. Assist parents to understand the stress that children face in Canadian society; encourage discussion of this topic, highlight resources and empowerment strategies that schools, families, and children can use to control their daily environments to promote mental well-being of children. Ensure that children wear helmets in all activities that may cause brain injuries. Educate children and families about preventable brain injuries.

2. How would a CMHN implement the recovery model with a person who suffers from depression and that person’s family?

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In order to use the principles of The Recovery Model to help the client and the family, nurses must examine and challenge their own beliefs about recovery in mental illness.

The nurse needs to be aware of the current deficiencies in the mental health system that may sabotage recovery and be prepared to advocate for holistic rehabilitative resources.

Obstacles, such as some health care professionals not believing that recovery is possible, will be encountered. The family will need to understand that the recovery model values self-help, empowerment of the individual and works towards assisting the client to develop a healthy lifestyle. In order for the recovery model to be successful, it is important that basic resources are in place. The nurse who is using the recovery model principles will attempt to ensure that basic supports such as housing, meals and health care are available to allow the client to obtain wellness. The process of recovery includes crisis intervention, case management, and rehabilitation that provides people in recovery with enrichment strategies to help them have a satisfying life. When the client is acutely depressed, the nurse may need to initiate crisis intervention for suicidal ideation and safety. As the client recovers from depression, the nurse will encourage client involvement in decisions making with the goal of empowering the client. The nurse will work to engage the client and the family in the recovery process ensuring that client’s choices are respected, that the client is involved in care decisions, and that the relationship between the nurse and the client is nurtured and respectful. The nurse will recognize that other people beside professionals are vital in the recovery process and encourage use of community resources.

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Chapter 23 Community Mental Health 3. What issues are important to consider in designing mental health services for diverse cultural groups?

•

Due to increasing migration to Canada, CMHNs are challenged to meet the mental health needs of diverse cultural groups. Services remain largely organized around the dominant culture and are not always appropriate for immigrants and refugees. Nurses cannot meet all the demands of each diverse group but CMHNs can be open to diverse interpretations of mental illness and mental health and incorporate immigrant perspectives into the planning of service delivery. CMHNs may facilitate discussion of mental health and illness among community members, educate themselves on cultural beliefs on illness and treatment, and work collaboratively with community members to address mental illness and mental health problems in diverse ethno communities.

4. What are the unique challenges that face Indigenous people in restoring mental health and healing to their communities?

•

First Nations people do not have adequate mental health services. In addition, they do not always feel comfortable with the services that are provided resulting in underutilization of services. CMHNs need to be aware of this discomfort and attempt to provide more culturally appropriate services. CMHNs can educate themselves on the diverse groups within First Nations peoples and attempt to understand their beliefs about mental illness and health, the inter-generational trauma issues, socio-economic factors that affect their situations and look for ways to work positively with First Nations peoples. CMHNs must also be aware of the resilience of the First Nations people in overcoming historical oppression. CMHNs continuously monitor their own attitudes and reactions to diverse perspectives and reflect on their own judgments.

5. Why do you think “people first” language is important?

• •

It places value on the person within the illness and serves to remind health care providers that the illness is not the ultimate definition of the person.

With mental illness, because of the stigma and discrimination associated with psychiatric/mental illness labels, people first language demonstrates respect towards the individual.

6. Reflect on each of the following sets of statements.

Madison is mentally ill.

Madison has a mental health issue.

Madison is experiencing psychological distress.

Brian is a drug addict.

Brian uses drugs.

Brian struggles with substance misuse. .

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Anthony is schizophrenic.

Anthony has schizophrenia.

Anthony lives with schizophrenia. a) What are the differences between each statement? Does the phrasing of each statement impact how you perceive these individuals?

•

While each set of statements appears to say the same thing, there are important differences. The main difference lies in the labeling of each individual in relation to a mental health issue. Some statements, such as the first of each set (Madison is mentally ill; Brian is a drug addict; Anthony is schizophrenic), give the impression that the person’s condition is definitive and takes over their identity. These statements are highly stigmatizing, in that they reduce the person to their condition. The last statement of each set uses “person first” language, which puts more emphasis on the persons and their lived psychological experiences, rather than their diagnosis, symptoms or behaviours. Using a “person first” approach when speaking improves how people with mental health issues are perceived, which reduces stigma.

b) How would you prefer to be described if you were Madison, Brian, or Anthony?

•

Putting oneself in another person’s shoes can help reflect on their experiences as though they were one’s own and develop empathy. Identifying how one would prefer to be described or spoken to is an important aspect of reflective practice, and may make one more aware of the power of language when providing nursing care.

Group Critical Thinking Exercises 1. How might CMHNs ensure that the physical and mental health needs of PMHIs are met within the mental health care system?

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CMHNs can attempt to ensure that the physical and mental health needs of people with mental illness are met within the mental health care system by: i.

Advocating for mental health professionals to be part of primary health care; either on call or on site; ii.

Advocating for increased education for all primary health care providers to be able to adequately assess for mental illness, intervene with appropriate intervention, and refer to comprehensive resources; iii. Designing policies and practices that facilitate the use of services and welcome people with mental illness to primary health care sites; iv.

Acting as resources to implement programs on mental health promotion; and assisting primary health care providers with information on community resources for people with mental illness.

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2. How might CMHNs influence and develop a national suicide prevention strategy?

•

CMHNS can influence and develop a national Suicide Prevention strategy by: i. Increasing public awareness of the incidence of suicide in Canada ii. Promoting educational programs on the warning signs of suicide iii. Advocating for policies that control toxic substances used in suicide • detoxifying domestic gas and car exhaust • decreasing access to firearms • monitoring media reporting of suicide iv.

Treating mental illness (especially depression/schizophrenia/alcoholism) v.

Training primary health care providers to assess for suicide (WHO, 2003).

3. How can the principles of recovery be implemented and researched within the mental health system?

Principles of recovery may be implemented in the mental health system by: • Increasing education and discussion on the philosophy underpinning recovery • Challenging beliefs within the mental health system that recovery is not possible • Examining and reporting on services that are using recovery principles and how they are implemented • Speaking with people with mental illness and families on their experiences with recovery • Facilitating grass roots efforts to advocate for recovery oriented services • Influencing policy makers to implement comprehensive policy to provide services that will address social inequities and allow recovery Principles of recovery may be researched by: • Qualitative analysis of focus groups interviews composed of people with mental illness, employers, health care providers and/or families • Evidence based inquiry that is appropriate to the level of development of recovery policy and services.

Note: In Canada, recovery principles in mental health services may not be fully developed or adequately supported at the present time to determine their value in the treatment of mental illness and the promotion of mental health. Evidence based practice research, which values randomized control trials as the highest form of evidence, must also advance research that will measure outcomes related to recovery, inclusive of qualitative and non-traditional measures of studying outcomes (Anthony, Rogers, & Farkas, 2003).

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Chapter 23 Community Mental Health Further Resources Anxiety Disorders Association of Canada www.anxietycanada.ca Canadian Federation of Mental Health Nurses http://www.cfmhn.ca/ Canadian Mental Health Association http://www.cmha.ca Canadian Psychiatric Research Foundation http://www.cprf.ca National Network for Mental Health http://www.nnmh.ca Schizophrenia Society of Canada http://www.schizophrenia.ca Mental Health Commission of Canada http://www.mentalhealthcommission.ca/ Canadian Mental Health Association http://www.cmha.ca/ Kirby, M. J., & Keon, W. J. (2006). Out of the shadows at last: Highlights and recommendations.

The Standing Senate Committee, Final Report of the Standing Senate Committee on Social Affairs, Science and Technology Mordoch, E., & Hall, W. (2008). Children’s Perceptions of Living with a Parent with a Mental Illness: Finding the Rhythm and Maintaining the Frame. Qualitative Health Research, 18 (8), 1127- 1144.

Stewart, S. (2008). Promoting Indigenous mental health: Cultural perspectives on healing from Native counselors in Canada. International Journal of Health Promotion and Education, 46(7), 49-56.

The Interventionist: Chronicles of a mental health crisis team. National Film Board of Canada, 2006.

Third World Canada, Productions Cazabon, 2010

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Chapter 24 Rural Health

Chapter 24: Rural and Remote Health Suggestions for Guest Speakers 1. Invite a nurse who works or has worked as a contract nurse to rural and remote communities to visit the class.

2. Skype or teleconference with a nurse in a rural or remote setting.

3. Interview a nurse who works for FNIHB who recruits nurses to work in Indigenous rural and remote communities.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students to find a newspaper article about the nursing shortage. Ask them to consider if the similar is true for nursing in rural and remote areas. Direct them to answer the following questions: What factors are contributing to the shortage? What can be done to mitigate further nursing shortage? Ask the students to create a mind map to outline some of their thoughts.

2. Review the Government of the Northwest Territories website, which describes the opportunities for CHNs in the remote parts of their territory. The website is found at: www.practicenorth.ca/index.php?page=working-in-the-nwt What incentives are offered or could be offered? What are some of the benefits of working in rural and remote areas? What are some of the drawbacks? Ask the students to come up with an ideal recruitment advertisement that would entice them or others to consider moving to a rural or remote community.

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Ask the students to find a newspaper article about the nursing shortage. Ask them to consider if the similar is true for nursing in rural and remote areas. Direct them to answer .

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Chapter 24 Rural Health the following questions: What factors are contributing to the shortage? What can be done to mitigate further nursing shortage? Ask the students to create a mind map to outline some of their thoughts.

2. Review the Government of the Northwest Territories website, which describes the opportunities for CHNs in the remote parts of their territory. The website is found at: www.practicenorth.ca/index.php?page=working-in-the-nwt What incentives are offered or could be offered? What are some of the benefits of working in rural and remote areas? What are some of the drawbacks? Ask the students to come up with an ideal recruitment advertisement that would entice them or others to consider moving to a rural or remote community.

Seminar Discussion Questions Does the clinical placement organization work in rural and remote areas? If so, how does the service differ from those in urban areas? If not how would clients with similar needs access care in rural and remote communities? Who might meet the needs of those requiring assistance like your clinical placement provides, in a rural or remote area?

Case Study Questions 1. What are the challenges that arise for CHNs in addressing the mental health needs and supports for this family?

For the home care nurse: • Holistic assessment, including a thorough physical and mental assessment of Mrs. Gibbons.

• Provision of care in the home to Mrs. Gibbons depending upon her acceptance, for example, with bathing, assisting with eating, and ambulating.

• Provide emotional support to Mrs. Gibbons and her family members.

• Assess family members for caregiver burden and provide advice and information about the same.

• Make appropriate referrals to mental health professionals and other specialty agencies as necessary (i.e., palliative care nurse and team, physiotherapy, respiratory therapy, Amyotrophic Lateral Sclerosis (ALS) Society).

For the palliative care nurse: • Explore options with Mrs. Gibbons and her family regarding end-of-life choices (where to die, medication use, inclusion of family and friends).

• Explore Mrs. Gibbons meaning of spirituality and religion in her life. .

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Help Mrs. Gibbons and her family prepare for her death and management of their grief and bereavement.

Provide emotional support to the Mrs. Gibbons and her family members.

Teach self-care strategies to the Gibbons family.

Advocate with Mrs. Gibbons’ family physician and other health personnel regarding end-oflife care requests.

2. Identify three factors related to living in a rural setting that provide challenges in the delivery of nursing care for Nancy Gibbons. Identify how a home care nurse could address these factors.

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Challenge 1: Lack of access to resources such as special equipment. This could be addressed by working with the ALS Society or Red Cross to locate necessary equipment in the community while also seeking out donations from other groups such as home care supply companies.

Challenge 2: Lack of access to care providers such as personal aides could be addressed by enquiring about family members or church volunteers who would be able to help with activities such as feeding during meal times.

Challenge 3: Privacy and confidentiality are often limited because of the close relationships held between community members. The home care nurse may need to assist the family in designating certain times (for example, when Mrs. Gibbons is near death) for non-family visits to be limited or stopped.

3. Identify three rural community resources that could provide assistance to the Gibbons Family. Identify how a palliative care nurse could incorporate these factors into a care plan for Nancy.

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Factor 1: Close knit, trusting communities with a high level of acceptance and concern when others need help. With consent of the family, the palliative care nurse could work with a few specific individuals to brainstorm how the Gibbons’ family could best be assisted and what support would be forthcoming from the community.

Factor 2: Rural communities are based upon interwoven caring relationships; community members and organized groups such as the local churches work together to assist others when the need is there. Examples of this assistance range from providing food for the Gibbons’ family to doing errands such as picking up their mail in town or feeding animals on the farm.

Factor 3: Limited palliative care infrastructure in rural communities that works as a positive note because it is usually less cumbersome with less “red tape” to address issues that arise.

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Chapter 24 Rural Health Canadian Research 24.1 1. What initiatives can nursing organizations take to support nurses who work in rural and remote settings?

• • • •

Continuing education initiatives available by distance Readily available evidence online through sometimes poor or dial-up or satellite telecommunications Support for rural nurses to develop communities of practice or get timely evidence.

Support the development of virtual work groups to address issues or topics of interest 2. What is the responsibility of health regions in preparing rural and remote area nurses to address disasters?

• • •

Investigation of past disaster events and the challenges and opportunities for improvement in the communication of disaster management and the role of CHNs. Support rural and remote health authorities and communities to develop sustainable strategies that address disaster event management.

Support rural and remote health authorities and regions to build capacity in communities and health services in ways that address rural and remote population health care needs. That is, not impose urban-centric solutions on rural and northern areas.

3.

• • •

• •

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Given the geographic isolation of many rural and remote-area nurses, what is the best way to ensure ongoing training in disaster preparation and recovery?

Creation and implementation of disaster planning committees within the town/district office that would officially orientate the new rural CHN to community disaster management plans.

Inter-sectoral committee of the health region and the local community governance designates to develop strategies to educate and provide mock training events for rural and remote CHNs. Communities, governments and industries can address issues of emergency housing, schooling, employment, health services delivery and other amenities that will help families in rural communities during a disaster event.

Foster community support of CHNs to be released from work duties to periodically receive relevant continuing education.

Ensure community linkages with provincial services are strong so that issues of internet connectivity or back-up power generation are not barriers for nurses providing care in disaster events.

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Chapter 24 Rural Health Individual Critical Thinking Exercises 1. Examine the provincial or territorial nursing standards related to professional boundaries, and identify three challenges in the provision of care in rural and remote communities. As a professional RN, how would you address the challenges without jeopardizing ethical standards and professional boundaries?

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Challenge One: One issue noted within professional boundaries documents focuses on friendships and the difficulties individuals may have in being both a friend and a professional registered nurse. The real challenge is that given the nature of rural and remote communities where friendships are common with a variety of people, it would be unlikely that another nurse could care for the client without a similar conflict. Hence, it is extremely important for the registered nurse to develop a manner of practice that does not jeopardize the friendship but still maintains professional standards and accountability.

Challenge Two: A second issue is the potential for other community members to enquire about clients when the nurse is off duty. Often times such enquiries are motivated from concern about the client’s welfare but the nurse needs to ensure she/he maintains confidentiality and does not divulge information about the client’s health.

Challenge Three: A third challenge would be that the registered nurse may be aware of additional information related to the client’s health history that has been withheld. The registered nurse cannot provide the information without the permission of the client and may need to weigh the options and discuss the situation with the client and encourage them to share the additional information in light of their health status.

2. You work in a public health office in a large agricultural area that includes established farm families and feedlot operators. Over the past few years, there has been an increase in migrant farm workers from Mexico that has added to the diverse mix of the area, which includes conservative religious groups who also work in the agricultural industry. Locating and communicating with these groups has become increasingly challenging, and ensuring routine public health programs such as immunizations has become even more difficult due to varied beliefs and practices. What are three barriers that need to be addressed? Who can you turn to for guidance and support? What actions on your part might facilitate collaboration? What are short- and long-term goals in this situation?

• • • •

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Barrier One: Communication issues including language barriers between the migrant workers and the nurses.

Barrier Two: Locating migrant workers: Barrier Three: Lack of health information about the migrant workers: Actions: Determine if there is a not-for-profit organization, church(es) or other programs that are working with the migrant workers.

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Locate translators in the appropriate languages to work with you and assist with translation with the migrant workers Work with the farm families and feedlot operators to attempt to determine the numbers of migrant workers, their basic health needs and ideas how to address such needs (for example, are the farmers willing to have mobile clinics on their properties?)

Find out if there are key members within the migrant worker groups that you need to work with in order to meet any health needs that arise.

Work with your health organization to determine if flexible scheduling to address the migrant worker health needs can be applied (e.g., Saturday or evening clinics).

3. You work in collaboration with a long-term care facility that has just developed a support group for rural families caring for a relative with dementia, which is most commonly caused

by Alzheimer’s disease. After the first six months of the service, only three family members have attended the group, even though you are sure that many others could benefit from the support. What issues could make families reluctant to participate in this service? In what ways can technology (e.g., Skype, telehealth) be used to facilitate participation?

The following issues may explain why families are reluctant to participate in the caregiver support group: •

The caregivers may not have respite care available to them and may feel too exhausted to attend the support group; • The in-person caregiver support group would mean that the caregivers must travel to a specific location. This can hinder involvement due to the time commitment and travel over potentially bad roads; • There may be discomfort in attending the caregiver group because of a lack of acceptance of the diagnosis of dementia; • The caregiver group might focus on the needs of women as caregivers and not consider men as caregivers.

Technology is a feasible alternative in assisting the caregivers deal with their situation. The benefits of using Skype or other versions of technology include: • • •

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The caregivers can receive support from the comfort of their home reducing their need to travel while also meeting the needs of caregivers across a large geographic distance; The time for the support group to meet can be flexible and better suit the demands on the caregivers’ schedules; A support group that meets in this manner increases the potential to make new acquaintances in other geographic settings who are facing similar issues; and,

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There is the potential to include other members of the inter-professional team (i.e. neurology specialists) from a range of geographic areas including urban settings thereby enhancing the information and support that is provided to the caregivers in the rural areas.

Group Critical Thinking Exercises 1.

You work part time as a CHN in a two-nurse office in a remote community. The other nurse works full time. You are both responsible for implementing the full range of public health programs. Because of the difficulty in finding casual replacements over the last two months, you deferred your vacation and have worked more than full time. You have just received a call that the full-time nurse has gone on sick leave. As your manager, who works 500 kilometres away, tells you this, she adds that the medical health officer has identified two tuberculosis cases in your community. Your manager asks you to work overtime again, and you are debating what your answer should be. As a group, identify the following: Personal and professional concerns you would face in this situation.

• Personal concerns could include: developing personal health problems or exacerbating tensions within your own family because of your lengthy absence; burn-out; resigning from the position due to the high stress of the job demands; experiencing moral distress about the competing needs.

• Professional concerns include: being unable to provide nursing care that meets the professional nursing standards and competencies; contributing to the turn-over rate of health professionals in rural communities. If solutions are not found, there is the potential of TB infection spreading within your own small community.

Dilemmas being faced by the public health administration.

• Unable to appropriately staff the public health office however there is an urgency to investigate the identified TB cases.

• Lack of staffing would reduce the provision of care and the quality of the care that is provided.

• Unable to offer all public health programs.

• Unable to meet public health goals and targets which could negatively impact the public’s health.

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Chapter 24 Rural Health Potential impacts on client and community safety.

• There is a high potential for a TB outbreak in this community if surveillance and treatment is not promptly initiated. This puts the overall community at risk and jeopardizes their health and wellbeing.

• There is a lack of quality health care due to staffing shortages available to individuals and the community. This could lead to a reduction of immunizations, decreased herd immunity, an increase of preventable communicable diseases and a reduction of public education on health promotion and education topics.

Strategies, including ones that reflect interprofessional practice, to address the previous concerns • As the public health nurse, you could request a meeting with the health administration to discuss the concerns about the lack of staff and request information about their recruitment and retention strategies.

• The health administration needs to consider other ways to provide care (i.e., an interprofessional team approach) that would help ensure health promotion and education is still ongoing although it may be delivered by a paraprofessional or community member with specific training. If this were to occur, the community health nurse would concentrate on immunizations and communicable diseases to ensure that the provincial public health act is met.

• Recruit community members and educate them as peer educators in TB. These members can share information specific to TB and the prevention of it with community members.

2.

You are the new CHN in an outpost setting on a community-based Indigenous reserve.

Two other nurses are stationed at the centre, but they are from the community and live with their spouses away from the station. You are the only nurse who works at the outpost accommodation. This particular community, with a population of 545, is fly-in only with interruptions of flight service due to inclement weather. As a group with your classmates, identify the following:

Priorities you would engage in as the new nurse Become familiar with the community and its unique patterns by engaging in a variety of activities such as: • Introducing yourself to the different departments and people who provide health and social services in the community (i.e., day cares, schools, substance abuse treatment centre, RCMP).

• Having coffee with elders.

• Meeting the local band administration.

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Meeting those who contribute to the promotion of health in the community, e.g. grocery store, recreation leaders, housing coordinator, etc.

Finding out specific information such as: o cultural traditions and practices within the community. o the historical development of the community and its members (including residential schools, proximity to traditional hunting lands, etc.). o identify how the culture is integrated in everyday life and within institutions such as the band administration, schools and churches. o identify the current state of community self-government status and related community strengths and issues. o Identify how health, social and transportation services are organized and financed in the community.

The process you would use to assess the community.

• Asset mapping which would allow you to focus on the strengths of the community.

• Conducting a windshield survey which would allow you to physically walk around the community and see what is available within it.

How you would develop a relationship with the other nurses and community residents.

• Participate in local activities (rodeos, fairs, recreational programs, school concerts etc.).

• Be open and interested in their culture and community.

• Ask questions to find out more about community members lives, traditions and beliefs.

• Socialize with the other nurses during coffee and lunch breaks.

3.

You have been a home care nurse working in several eastern coastal communities for five years. It is a job you love mostly because of the people you care for and the diversity within your everyday work. You are currently mentoring an undergraduate nursing student from an urban-based nursing program. The student has made it clear that it was not her choice to come to a rural area or to do home care. As a group:

Identify how you will address the student’s issues in a productive manner.

• • •

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Develop a trusting relationship with the student; be respectful of her ideas but also explain to her that you expect her to respect the home care clients and situations she will be working in Find out what the student’s area of interests is and where she hopes to work when she has completed her program Find out in particular what she does not like about home care and about rural areas; based upon this discussion attempt to plan visits and activities in a way that refutes her beliefs about home care and rural areas

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Chapter 24 Rural Health Identify ways in which you can encourage the student to see the benefits of her practicum experience in rural communities.

• Invite the student to relevant continuing education sessions hosted by your health region • Invite the student to social events within your home care official and within the health region • Have the student complete some family and community history interviews with some of the older clients who have lived in the area all of their lives • Find out more about how student choices are handled at the university; acknowledge that her choice was not granted but that there are lessons to be learned no matter where she is placed

Further Resources Canadian Association for Rural & Remote Nursing www.carrn.com Canadian Rural Health Research Society http://crhrs-scrsr.usask.ca Centre for Rural and Northern Health Research www.cranhr.ca Rural Policy Research Institute http://rupri.org Hegney, D., Pearson, A., & McCarthy, A. (1997). The role and function of the rural nurse in Australia. Canberra: Royal College of Australia.

Stewart, N., Kulig, J., Penz, K., Andrews, M. E., Houshmand, S., Morgan, D., MacLeod, M., Pitblado, J. R., & D’Arcy, C. (2006). Aboriginal registered nurses in rural & remote Canada: Results from a national survey. Saskatoon: University of Saskatchewan. R06-2006.

Stewart, N., & MacLeod, M. (2005, August). RNs in nurse practitioner positions in rural and remote Canada. The Nature of Rural & Remote Nursing, 3. Retrieved October 8, 2007, from http://www.ruralnursing.unbc.ca/factsheets/factsheet3.pdf.310 Part 3 COMMUNITY CLIENTS WITH SPECIAL NEEDS

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Chapter 25 Chronic Care, Long-Term Care, and Palliative Care

Chapter 25: Chronic Care, Long-Term Care, and Palliative Care Suggestions for Guest Speakers 1. Invite a nurse who works or has worked in palliative care to visit the class 2. Invite a nurse who works or has worked in long-term care to visit the class Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students to find a newspaper article about various issue relating to nursing care in the long-term setting. Ask them to consider if the similar is true for nursing in other areas.

Direct them to answer the following questions: What factors are contributing to these issues? What can be done about these issues? Ask the students to create a mind map to outline some of their thoughts.

2. Ask the students to find a few articles about various ethical issues that are relevant to hospice care. Ask them to summarize the key points. Direct them to answer the following questions: What factors are contributing to these ethical issues? What can be done about these issues? Ask the students to create a mind map to outline some of their thoughts.

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Ask the students to find a newspaper article about various issue relating to nursing care in the long-term setting. Ask them to consider if the similar is true for nursing in other areas.

Direct them to answer the following questions: What factors are contributing to these issues? What can be done about these issues? Ask the students to create a mind map to outline some of their thoughts.

2. Ask the students to find a few articles about various ethical issues that are relevant to hospice care. Ask them to summarize the key points. Direct them to answer the following questions: What factors are contributing to these ethical issues? What can be done about these issues? Ask the students to create a mind map to outline some of their thoughts.

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Chapter 25 Chronic Care, Long-Term Care, and Palliative Care Seminar Discussion Questions 1. What is the state of long-term care in the province that you live in? How easy or difficult do you think it is for patients to be placed in a long-term care setting? What policies do you think need to be put into place in order to maximize placement into long-term care for those who need it?

2. What do you think is the best way to care for the older adults in our population?

Case Study Questions 1. As the home care nurse, how would you share information about Helen with her daughter and primary care physician?

•

• •

Determine how Helen’s daughter would like to communicate – e.g., by email or a quick phone call if/when issues arise; problem-solve with her to determine what might be Helen’s preferences for care; ensure to include positive comments and things that are going well for Helen rather than focusing on problems/issues alone Encourage feedback from Helen’s daughter and establish a therapeutic relationship; include Helen, as appropriate, in any communication A communication book where issues/concerns can be recorded (sign/date all entries) may be useful in addition to telephone messages with the physician; this may be a source of information for the daughter as well 2. What kinds of recommendations would you make to the staff to be able to support Helen and her daughter in the new home?

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•

The staff may require education about dementia, e.g., Helen will likely require 4-6 weeks to become accustomed to the home’s routine and she will require calm and patient reminders until she can settle Encourage Helen’s daughter to provide familiar items to display in Helen’s private room, e.g., pictures; inquire what some of Helen’s favourite foods are and offer them to her Encourage a regular, predictable routine be adhered to so Helen can begin to understand what to expect over a regular day, e.g., regular meal times Encourage regular physical activity to help Helen sleep, make sure to include regular healthy snacks to ensure Helen gets enough calories Include Helen in the functioning of the home, e.g., preparing meals; these kinds of activities may give her purpose Provide safe distractions to Helen, e.g., folding laundry, playing the piano

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Chapter 25 Chronic Care, Long-Term Care, and Palliative Care

3. What other kinds of community-based services may benefit Helen?

• •

Respite or adult day care programs specific to persons with dementia Contact the local Alzheimer Society and determine what programs would benefit Helen and/or her daughter

Canadian Research 25.1 1. Which variables identified in the study are most important for the CHN to consider to improve health outcomes of family caregivers of individuals living with MCCs? •

Consider older female women and how they view their role as a family caregiver, i.e., do they have confidence in their abilities and are they assertive in voicing their own needs? Important to consider the level of burden family caregivers are experiencing and what services should be offered to alleviate that burden, if possible.

2. What strategies could policy makers address to better support family caregivers?

•

In broad terms, policy makers should consider ensuring family caregiving is a priority to be addressed given the important role family caregivers play in supporting persons living with MCC. Increase services and access to mental health programs; recognize family caregivers as being in need of services and interventions in the same way as the relative for which they provide care.

3. How might you design a community-based social support group for family caregivers of persons living with MCCs? What content would be important to address?

•

Consider grouping participants by the dominant chronic condition that the family caregiver is dealing with, e.g., CVA, dementia, or diabetes; this may enable you to focus content to the challenges with a specific disease. Perhaps consider having a female only group and look at ways to specifically support and improve mental health. It will be important to address what services are available in the community to family caregivers and how to navigate the access to those services.

Individual Critical Thinking Exercises 1. Given the notion of an informed or activated patient being essential to chronic care, how can the CHN support and engage patients in managing their chronic conditions? .

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• • • •

Act as an advocate Keep up to date on specific issues related to the chronic condition of the patient, and use that knowledge to educate the patient about potential issues in their particular situation Encourage feedback and insights from the patient and their family as a means to determine preferences for interventions or services An informed patient essential to chronic care, the role of the CHN is to provide education, family support, conduct family meetings

2. How do your own cultural beliefs affect your work with others?

• • •

Consider and reflect on your beliefs about health and wellness and how they may bias your interactions with patients who may not share your same cultural views Reflect on your own culture, values and beliefs, what rules are important in your own family, what gets talked about and what doesn’t?

Consider how these beliefs may affect your work with people of different beliefs

3. What experiences of caregiving have you had? How do these experiences shape your work as a nurse?

•

Often previous caregiving experience is an opportunity to become empathetic to what is going on for patients and their families • Consider what worked well in your past experience and reflect how that can become part of your formal nursing care • Our own caregiving experiences for parents, children, grandparents, partners may affect a decision to pursue nursing as a career, were these positive or negative? What will sustain you when the going gets tough?

4. Have you had family who received palliative care services? What was your experience?

•

Successful treating of pain and suffering can be a very profound experience, as can less than optimal treatment. In the case of palliative care at the end of life, consider the impact of observing that care and how impacted your experience of having a family member/friend die

Group Critical Thinking Exercises 1. In what ways do social, cultural, and environmental factors affect health and how can they be addressed and acknowledged in the context of chronic care?

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Chapter 25 Chronic Care, Long-Term Care, and Palliative Care • •

•

Nursing is a profession that acknowledges where our patients come from as far as sociocultural contexts; patients shape and are shaped by their environment.

In terms of a chronic condition it is important to determine what treatments may be affected by the context of the individual patient, e.g., patients with diabetes who have a low socio-economic status may have limited funds to access fresh, nutritious foods; this must to be taken into consideration when providing education about diet.

Social, cultural, environment have a huge impact on health. Will these shape health care decisions? What services are needed to address these needs?

2. Considering the scarcity of health care resources, how should funding be allocated among acute, long-term, and palliative care?

• •

Who is the most in needy, community caregivers? EOL caregivers? Who gets more of the resources? What is the risk/benefit of caregiving in the community?

Palliative care needs in the community can arise in many settings, such as home care, LTC, personal care homes, would acute care specialists also provide home visits?

Dedicated hospice personnel? How can more hospice palliative care services be made available?

3. Who should manage palliative care needs in the community setting?

•

Should hospital-based nurses provide care across the sectors, providing continuity in the community? Dedicated expert palliative care staff? Certified palliative care nurses?

4. What are the challenges and opportunities in implementing a consistent palliative approach to care across Canada?

•

There are many challenges in implementing a consistent palliative approach, including a general discomfort with talking about death, loss of family networks, and changes in societal structure and supports. Much discussion across Canada is needed to change current approaches to be more patient, family and community-centered.

5. What are your own feelings about death? Your experiences within your own family?

How will these experiences impact your work in the community?

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It’s very important to engage in personal reflection

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Chapter 25 Chronic Care, Long-Term Care, and Palliative Care Further Resources Health Council of Canada. (2013). Canada’s most vulnerable: Improving health care for First Nations, Inuit, and Métis seniors. Ottawa, ON: Retrieved from http://www.healthcouncilcanada.ca/content_ab.php?mnu=2&mnu1=48&mnu2=30&mnu3=55 Hudson, P., Remedios, C., Zordan, R., Thomas, K., Clifton, D., Crewdson, M., et al. (2010).

Clinical Practice Guidelines for the Psychosocial and Bereavement Support of Family Caregivers of Palliative Care Patients. Melbourne, Aus: Centre for Palliative Care.

Low, L., Yap, M., & Brodaty, H. (2011). A systematic review of different models of home and community care services for older adults. BMC Health Services Research, 11:93.

Registered Nurses Association of Ontario: End of life care during the last days and hours, Retrieved from: http://rnao.ca/sites/rnao-ca/files/End-ofLife_Care_During_the_Last_Days_and_Hours.pdf Tu, D., Belda, P., Littlejohn, D., Pedersen, J. S., Valle-Rivera, J., & Tyndall, M. (2013).

Adoption of the chronic care model to improve HIV care. Canadian Family Physician, 59, 650657. http://www.alzheimer.ca/en?c=1 http://www.cdnhomecare.ca/ http://www.chpca.net/ https://www.ehospice.com/en-gb/home.aspx http://www.virtualhospice.ca/en_US/Main+Site+Navigation/Home.aspx National Film Board of Canada, & Wilson, T. (2008). Griefwalker, 70 minutes, See: https://www.nfb.ca/film/griefwalker

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Chapter 26 Correctional Health

Chapter 26: Correctional Health Suggestions for Guest Speakers 1. Invite a correctional nurse to visit or speak to the class via Skype or teleconference.

2. Invite a nurse who is involved in making policy related to incarcerated people to speak with the class.

3. Invite a former inmate to come to class or Skype or teleconference with her/him.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Divide the students into groups of 4. Provide them with poster paper and coloured pens. Ask the students to create three sections on the paper and label them “before”, “during” and “after”. Direct the students to reflect on three states in the life of an inmate (before, during and after incarceration). Ask them to draw or write words to represent answers to the following question: “What are some of the public health issues that may be facing the person at each phase?” using one coloured pen. Answers might be poor parenting, poor mental health, illiteracy, etc. Ask them to use another coloured pen to write what the healthcare system could be doing at each phase to intervene (early identification, substance abuse rehabilitation, etc.). Invite the students to share their posters with the larger group.

2. Ask the students to think about how our legal system deals with people who live with mental illness. Have them brainstorm ways to improve the system. As a group, devise a letter to your Member of Parliament asking about what they are doing to address mental illness in your community.

3. Organize a debate in the class with one group supporting using needle exchange harm reduction practices in prison and the other side opposing it. Write on the front board, “All inmates in Canada should have access to needle exchange.” Divide the class into two groups (Affirmative and Opposed) and provide them with 1/3 of the class time to research and organize their arguments. Next, pair off the students and give them one minute each to present their arguments and one minute each for rebuttal. Then give the group five minutes to elect someone from their group to represent them. Ask them to share ideas and prepare the representative for rebuttal. Next, have each representing student come to the front and outline their position in less than five minutes (you can appoint a student to act as the Timer). Allow another 2 minutes afterwards for rebuttal. The purpose of this exercise is to outline the issues as well as make evident the fact that there are two sides to every argument. Then ask for feedback on how the information impacted their initial impression of needle exchange in prisons, the process and how the debate made them feel.

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Chapter 26 Correctional Health Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Ask the students to think about how our legal system deals with people who live with mental illness. Have them brainstorm ways to improve the system. Instruct them to prepare a letter to their Member of Parliament asking about what they are doing to address mental illness in your community. Whether they send the letter or not is of course optional.

2. Ask the students to read the article, “Criminalization of the Mental illness” by the Canadian Mental Health Society, found at: www.cmha.bc.ca/files/2-criminalization.pdf Ask the students to highlight all of the ways that mental illness is criminalized.

Seminar Discussion Questions Ask the students to consider their community placement and the population that they are working with. Does that placement area serve people who are currently involved in the legal system? If so, are there special considerations for this? Does the agency address issues that may lead to a person being at risk of incarceration? Is there anything that your placement could be doing that would decrease the risk of their clients entering the legal system?

Case Study Questions 1. What are your thoughts, feelings, and beliefs about providing palliative care within the correctional milieu? What challenges might be encountered?

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•

•

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Nurses providing palliative care within a correctional facility, do so at the shifting interface of the criminal justice system and the health care system, and their ability to provide competent and ethical end-of-life care is often compromised by personal, social, and political animosity regarding crime and criminality and the meaning of life and endof-life care for those who are incarcerated.

Nurses as members of their communities, like others, may experience a full range of emotions regarding the provision of palliative care to offender populations. Some may believe, that regardless of the offender’s health condition, they did the crime so they need to do the time; and depending on their criminal histories, some nurses may harbor negative feelings about the offender. Others may believe, that a prison, regardless of one’s criminal history is no place to be providing palliative care. The important thing to remember is to be able to recognize one’s feelings, and to be able to separate feelings from intellectual responses, and to not let one’s feelings impact on care of the offender receiving palliative care. Nurses should strive to provide care in a non-judgmental compassionate and non-condemnatory manner.

Correctional facilities are not sufficiently resourced to provide for the end-of-life needs of prisoners. o The physical environment is custodial by nature and not conducive to providing end-of-life care. Tensions may exist between correctional staff who 210

Chapter 26 Correctional Health see security as their primary mandate and nursing staff who wish to provide holistic care of the palliative patient. Correctional officers may not understand o Family members are rarely able to visit or attend to their dying relatives, particularly if they too have a criminal history. o Nurses and other health care professionals struggle with pain management and fear being manipulated for medication and other comfort measures.

Furthermore… a. Students need to recognize the It is important when caring for this person, as with other clients within correctional facilities, to reach the point where they are able to separate the client’s behavior (offenses) from the client as a person (inmate) b. Students should discuss their feelings with trusted colleagues in a confidential manner (for example other nursing staff and their instructor) c. Consulting the Canadian Nurses Association (2017) Code of Ethics for Registered Nurses or other provincial standards regarding relationships can provide assistance.

For example, the College of Nurses of Ontario (2002) state: i. It is the responsibility of the nurse to establish and maintain therapeutic relationships ii. Nurses should demonstrate respect, empathy and interest for clients iii. Nurses should also maintain boundaries between professional therapeutic relationships and non-professional, personal relationships iv. Ensure client needs remain the focus for the nurse-client relationship 2. What barriers might be faced when an application for compassionate release is made?

•

Limited beds in long-term care or in community-based hospices; public perceptions that an offender is using health resources needed by a “law abiding” citizen.

•

Concerns about safety and security of other residents and their families.

•

Political animosity, particularly if the offender had a heinous criminal background.

•

Potential community-based placements may not feel they are equipped to deal with a patient with a criminal history.

•

Lack of family and/or community support

3. What community-based resources are available in your area to assist with providing care for this person?

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Local community-based hospices can be an excellent resource for nurses providing palliative care in a correctional facility. Often correctional palliative care nurses experience professional isolation, and desire increased knowledge regarding best practices.

•

The Canadian Hospice Palliative Care Association is an excellent resource for professionals, families, and volunteers.

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A number of provincial hospice palliative care associations also exist, and can provide support for nurses providing palliative care within correctional environments, as well as volunteers who can work with the offender and his/her family members.

Canadian Research 26.1 1. Why are the learning needs identified in the study important for correctional nursing practice?

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•

•

Little is known about correctional nurses in Canada, and even less about provincial correctional nurses. To date very few researchers have explored correctional nursing as a specialty area of practice. This study was important from an occupational, educational, and professional practice perspective; one that is essential to nurses and their ability to competently provide offenders with evidence-informed care.

Correctional nurses in many ways are expected to be “jack/jill of all trades” as the health care concerns experienced by incarcerated persons mirrors the concerns experienced by members of the community. It was clear from the results that Correctional nurses in Saskatchewan, that providing care to offenders experiencing mental health issues and disorders was important to their continuing professional development. Form a correctional assessment perspective, 88% identified mental status assessment; while 94 % identified suicide assessment. Special populations of concern included mentally ill persons, persons with addiction issues, those with fetal alcohol spectrum disorder, and those with bloodborne infectious diseases. In many ways these findings are not surprising, as the complexity of mental health issues among incarcerated persons have been noted globally as well. What is perhaps more unique to Saskatchewan, is the need for more knowledge and skills regarding the care of incarcerated persons with FASD and bloodborne infectious diseases, given the provincial demographics.

The learning needs identified in the study, not only validate the areas of practice that correctional nurses in one provincial correctional system believe they require additional knowledge and skill, such information can assist correctional authorities in tailoring continuing education efforts by focusing specifically on these needs.

2. How might correctional nurses incorporate interventions from the five skill sets into their everyday practice as a way of supporting ongoing practice development?

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To recap, the five skill sets include: 1) promote and implement principles which underpin effective quality and practice; 2) Assess, develop, implement and improve programs of care for individuals; 3) create and maintain environments where relationships with individuals which value them as people and support their therapeutic

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goals; 4) Provide and improve resources and services which facilitate organizational functioning; and 5) develop the knowledge, competence, and practice of self and others.

It is important for nurses to review the skills within each of the skill sets, and identify which they are already achieving (current state) and which they would like to achieve (desired state). Correctional nurses often work in isolation. Nurses could run a “skill of the week” campaign, as a way of bringing awareness to the different skill sets, particularly those that have not yet been achieved. Nurses could also work in small professional development committees, in an attempt to address the skill sets.

Collaborating with nurses in the community, and moreover, nurses in academic positions, can further assist, with professional development (in-service education), and jump starting, a review and integration of the various skill sets. Small awards (coffee cards etc.) could be given out to teams who have actively incorporated interventions based upon the skill sets.

3. Based on these findings, what areas for further research should be explored?

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•

•

Given the diversity of Canada as a whole, further research that includes correctional nurses employed in with other provincial correctional facilities in Canada is warranted.

A replication study is currently underway in Alberta and Manitoba. Of note, in Alberta, health care in provincial correctional facilities falls under the jurisdiction of Alberta Health Services, and not the Alberta Solicitor General. Furthermore, given the differences between provincial and federal facilities (e.g. length of sentences; acuity of illnesses that incarcerated persons present with in provincial facilities as opposed to federal facilities) it would be interesting to compare the differences between provincial correctional nurses and federal correctional nurses.

A second paper, based upon focus group discussions with provincial correctional nurses (phase 2 of the same research study) is in development, and may provide additional information regarding the experiences of nurses employed in provincial correctional facilities.

Given the implications for ongoing professional development, further research could also explore preferred modes of continuing education delivery – such as face to face workshops and conferences, online webinars, and self-study modules.

Individual Critical Thinking Exercises 1. Define “vulnerability” within the context of nursing research. How is this definition relevant to persons who are incarcerated? What guidelines exist to protect incarcerated persons as research participants?

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From a research perspective, vulnerability is a multidimensional concept that includes theoretical and practical factors that may interfere with a research participant’s ability to give true and informed consent. Some wonder if voluntary consent is ever possible, given the restrictive and coercive nature of correctional facilities 213

Chapter 26 Correctional Health •

Three sources of vulnerability have been identified that can contribute to our understanding of vulnerability: i.

intrinsic vulnerability – individual attributes that limit freedoms e.g. age, intelligence, cognitive impairment and psychosis

ii.

extrinsic vulnerability – situational factors that limits freedoms, which may be manifested in those who are hospitalized, imprisoned, or who are financially dependent

iii.

relational vulnerability – whereby autonomy is limited by a relationship with another person, for example the power differential that exists between an inmate and a correctional officer, or an inmate and a nurse

•

Note: These categories are not mutually exclusive

•

In Canada, research is governed by the Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans, the latest version was released in 2014. Core principles include respect for persons, concern for welfare, and justice, Chapter 3 addresses consent, which must be voluntarily given, without undue influence, coercion, or incentives.

•

Specific safeguards include: Informed consent – the cornerstone of ethical research; integrity and expertise of the researcher; formal scientific and ethics review; and the inclusion and the promise of confidentiality.

•

In 2002, The Canadian Nurses Association published Ethical research guidelines for registered nurses, a useful guide to nurses working and conducting research within correctional facilities.

2. What would be the advantage of having standards for practice for Canadian nurses who work in correctional facilities?

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Standards of practice, if they existed, would represent the unique body of knowledge specific to correctional nursing practice in Canada. In general, standards are the authoritative statements which reflect the current knowledge and understanding within the discipline, in this case, correctional nursing as a specialty.

•

Standards articulate the professions’ values and priorities and describe the responsibilities for which its practitioners are accountable in order to provide safe, competent, and ethical care

•

Standards facilitate evaluation and measurement outcomes and speak to professional accountability within the specialty, the profession and the public at large. Ultimately, standards are important because they inform and guide practice.

3. If you were a correctional nurse in your community, what community-based organizations and resources would you collaborate with in meeting the needs of those in your care?

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Depending on the health and psychosocial needs of the incarcerated persons in your care, it would be important for you to learn about, and work with, community-based organizations (CBOs). Look for CBOs that are “offender friendly” and whose services

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Chapter 26 Correctional Health can assist you in meeting offender’ health care needs. Some examples of groups that have offices across the country follow: •

Advocacy groups such as the John Howard Society, the St. Leonard’s Society, and the Elizabeth Fry Society provide best practice services to: assist persons in conflict with the law: assist offenders with reintegration into society following a sentence; prevent recidivism; and also work at preventing people from coming into conflict with the law in the first place.

•

The Canadian Mental Health Association, the Salvation Army, HIV/AIDS Legal Network and local HIV/AIDS organizations can assist with education and awareness programming while the offender is imprisoned, and often have support groups and oneto-one services following release from prison.

•

In general, it is important for correctional nurses to get to know their community, and the services that are provided that can best meet the needs of the offender while incarcerated and upon release.

Group Critical Thinking Exercises 1. Nurses who chose to work in correctional environments are often asked the following questions: “Why would you want to work there?” “How can you stand working with those criminals?” “Aren’t you afraid of getting hurt?” What are your initial thoughts about these questions? What do you think is behind such questions?

•

Such questions often reflect fear and ignorance. Fear of the unknown and a lack of understanding of the factors that contribute to incarceration coupled with stigmatizing and prejudicial attitudes to those who have committed crimes against society are often the root of such comments. Nurses who choose to work in correctional environments have to be able to honestly answer these questions. They need to know why they have chosen to work in correctional environments. They also have to be able to see the person as a person, and not the crime that they committed.

2. In comparison to other Western countries, Canadian statistics regarding youth incarceration, especially First Nation, Inuit, and Métis youth, are particularly alarming. What factors contribute to this phenomenon in Canada?

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A combination of interactive factors has led to increased numbers of Indigenous youth who find themselves involved with the criminal justice system. The ongoing legacy of colonization, the residential school system, and the 60s scoop, has led to high rates of poverty among many Indigenous families (with many families living on social assistance); substance abuse and victimization often leading to family breakdown, and high involvement with child protection agencies (reports now showing that delinquency is positively correlated with negative parenting); early involvement with the criminal justice system; poor school attachment and limited work skills; and possible discrimination with thin the youth criminal justice system.

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Chapter 26 Correctional Health i.

A broad range of solutions is required to turn this phenomenon around, especially in relation to primary prevention activities and intersectoral collaboration between health, justice, education, and community-based organizations.

ii.

“Zero tolerance” policies are also being promoted in many sectors, however it is of the most vulnerable members of society who are impacted by such policies (e.g., bullies get kicked out of school and those in rehabilitation who relapse may lose their opportunity to continue with treatment). The consequences of such policies – those with the greatest need are pushed furthest from the resources that may be able to help them.

3. How would you describe contemporary public opinion regarding crime, criminality and criminals?

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Your response to this question will likely reflect your personal beliefs and attitudes toward crime and criminality, and criminals, which likely have been influenced by your family, your friends, and what you see in new reports, and social media.

•

For many, a “lock the door and throw away the key” mentality prevails. For others there is a belief that too much money is being spent on offenders, and that their time while imprisoned is easy – that they have gotten off “scot free”.

•

Some other thoughts might include: i. “you did the crime, now do the time” for those opposed to community-based sentences, or alternatives to incarceration ii. That the legal system doesn’t work; the courts are too lenient on criminals iii. That there is too much crime, and the answer is more jail time rather than intersectoral primary prevention initiatives

Further Resources Canadian Association of Elizabeth Fry Societies http://www.elizabethfry.ca Canadian HIV/AIDS Legal Network http://www.aidslaw.ca Correctional Nurse.net http://correctionalnurse.net/ Correctional Service Canada http://www.csc-scc.gc.ca Corrections and Conditional Release Act http://www.laws.justice.gc.ca/eng/acts/C-44.6/index.html

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Chapter 26 Correctional Health Custody and Caring: International Conference on the Nurse’s Role in the Criminal Justice System http://custodyandcaring.usask.ca/ Forensic Nurses Society of Canada http://www.forensicnurse.ca/ Human Rights Watch http://www.hrw.org John Howard Society of Canada http://www.johnhoward.ca Ministry of Community Safety and Correctional Services (Ontario) http://www.mcscs.jus.gov.on.ca/English/english_default.html National Commission on Correctional Health Care http://www.ncchc.org Office of the Correctional Investigator http://www.oci-bec.gc.ca/index-eng.aspx Prisoners’ HIV/AIDS Support Action Network http://www.pasan.org Registered Nurses’ Association of Ontario Correctional Nurses Interest Group http://www.rnao.org/Page.asp?PageID=122&ContentID=1452&SiteNodeID=113&BL_ExpandI D= Royal College of Nurses Nursing in Criminal Justice Forum http://www.rcn.org.uk/development/communities/rcn_forum_communities/prison_nurses St Leonard’s Society of Canada http://www.stleonards.ca/?s=announcements&p=currentannouncements Youth Criminal Justice Act http://www.laws.justice.gc.ca/en/Y-1.5/

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Chapter 27 Ecological Determinants of Health and Environmental Health Inequities

Chapter 27: Ecological Determinants of Health and Environmental Health Inequities Suggestions for Guest Speakers 1. Invite an environmental health nurse to attend your class.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Read the article, “Lead Poisoning from Homemade Wine: A Case Study” from the journal Health Perspectives Volume 109, Number 4, April 2001. It can be downloaded from the NIH website: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1240286/pdf/ehp0109-000433.pdf Ask the students to discuss the environmental investigation and the steps that took investigators from the patient history through to diagnosis and protection of others who were potentially at risk. What is the nurse’s role in such an investigation?

2. Ask the students to list as many of the environmental influences on health as they can recall in the figure outline, below.

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Chapter 27 Ecological Determinants of Health and Environmental Health Inequities Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Invite the students to read the article, “Lead Poisoning from Homemade Wine: A Case Study” from the journal Health Perspectives Volume 109, Number 4, April 2001. It can be found on the NIH website at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1240286/pdf/ehp0109-000433.pdf. Ask the students to list the environmental investigation and the steps that took investigators from the patient history through to diagnosis and protection of others who were potentially at risk. Which steps could have been completed by a nurse in such an investigation?

Seminar Discussion Questions Does your clinical placement organization contribute to the improvement of the environment?

Are there considerations to create a safe working environment? Do staff members take a WHIMIS course?

Case Study Questions 1. Discuss the insights you have gained and what are you going to do about them?

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•

Insights may vary on your previous understanding of how much natural resources you use during the course of a usual day. You may be surprised about your water consumption, or your transportation practices, your food choices, or how much energy you consume and from what sources. Discussions with your fellow students about opportunities to reduce your daily consumption of resources may include strategies for cleaner transportation modes, eating less or no red meats, taking shorted showers, putting on a sweater instead of increasing indoor heating, etc.

Discussions can also extend to practices as a nurse and what you can do to reduce resource consumption within healthcare institutions.

2. How can CHNs use this tool in their practice?

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Community health nurses can use this tool in their teaching of health promotion with youth in teen health centres, with families during prenatal classes or home visits, or community groups who are concerned about nutrition, traffic safety, or environmental health concerns in general.

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Chapter 27 Ecological Determinants of Health and Environmental Health Inequities Canadian Research 27.1

1.

How might the actions in this study contribute to co-benefits for humans and the environment?

Answers should identify actions that promote or have a benefit to the environment and human health at the same time. For example: Collaboration between local waste management and school gardens to use compost which benefits the waste management system to turn waste into a useful resource (compost) required to grow fruit and vegetable in the school garden. Working in the school garden provides physical activity outdoors, the harvest of fruit and vegetables contributes to healthy nutrition.

Assuming that no pesticides are used in the garden benefits human health as well as insects, particularly bees needed for pollination to grow food.

2. How might CHNs ensure that populations rendered vulnerable have equal access to projects like this?

Discussion can focus on how CHN need to know the community and identify vulnerable populations, so they can actively reach out and invite them; or support vulnerable populations to apply for funding of similar projects in their neighborhoods.

CHN need to be aware that community gardens are physically accessible, culturally acceptable, and affordable of free of cost.

3. What values can a project like this teach children and future generations?

Discussion can include: appreciation of a clean environment; valuing the relationship between the environment and humans where the environment is respected and not only exploited by humans; values of collaboration, sharing, teamwork; intergenerational collaboration; intergenerational justice; diversity; reciprocity, sustainability, etc.

Individual Critical Thinking Exercises 1. Reflect on you daily personal practices related to carbon-generating energy consumption and identify one co-benefit of reduced consumption • Use public transport, carpool, make your home more energy efficient, use reusable energy sources – all will contribute to a reduction in CO2 and contribute to cleaner air • Reduce meat and dairy products in daily diet – will contribute to a reduction of methane, one of the greenhouse gases implicated in global warming 2. Reflect on how much waste your daily personal and nursing practices generate and how you can reduce it.

• Be mindful of the packaging for the products you purchase and try to avoid unnecessary plastic packaging by buying in bulk, or using re-usable or recyclable packaging, the same practice can be implemented in nursing and it will contribute to .

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Chapter 27 Ecological Determinants of Health and Environmental Health Inequities less plastic waste that ends up in the oceans as micro-plastics which comes back to harm human health 3. Take a position and discuss why you agree or disagree with the argument that in order to make progress for a clean, just, and sustainable future we need to address resource depletion and environmental degradation while we also address oppression and exploitation of vulnerable and marginalized populations.

• A rational for agreement with this argument is that the forces that support the exploitation of natural resources and oppression of marginalized populations are the same and therefore if we want to make progress for a healthier environment, we also need to make progress for health equity. Addressing one without the other will not lead to desired change.

Group Critical Thinking Exercises 1. Discuss how your personal responsibility and professional nursing obligations to become a steward for the ecological determinants of health and environmental health equity overlap and support each other.

• You are exposed to the same ecological determinants of health as private person and as professional nurse • Whatever action you take as Stewart for a clean, just and sustainable future as private person will benefit you/client population and vice versa • It would be unreasonable to justify, on ethical grounds, to be environmentally conscious as a private person only or as a professional nurse only 2. Discuss how you can incorporate the proposed framework and concepts for planetary health in your daily nursing practice at the individual, family, community, and population level.

• Practice and encourage others to practice reflection about our relationship as humans with nature • Be respectful and integrate different ways of knowing • Educate yourself and others on issues related to the ecological determinants of health and environmental health inequities • Implement and encourage other nurses to implement a co-health benefit approach to health promotion and prevention with an equity lens.

3. Draft a policy brief to the prime minister of Canada for his next visit to an international climate change conference on the importance of reducing global warming to protect, in particular, Northern First Nation and Inuit health.

• You may use the “Yes, but Why?” activity as a template

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Chapter 27 Ecological Determinants of Health and Environmental Health Inequities Further Resources Lalonde, M. (1981). A New Perspective on the Health of Canadians. Health Canada Catalogue #H31-1374. www.phac-aspc.gc.ca/ph-sp/pdf/perspect-eng.pdf Community Based Environmental Monitoring Network. Offers assistance to individuals, community groups and organizations in the initiation of environmental monitoring. http://www.envnetwork.smu.ca/ Canadian Environmental Sustainability Indicators https://www.ec.gc.ca/indicateurs-indicators/ Creating a Healthy Environment for Kids http://www.healthyenvironmentforkids.ca/english/ Health Canada: Environment and Workplace Health http://www.hc-sc.gc.ca/ewh-semt/index-eng.php O’Connor, D.R. (2002). The Report of the Walkerton Inquiry, Part One: The Events of May 2000 and Related Issues. Queen’s Printer for Ontario. http://www.attorneygeneral.jus.gov.on.ca/english/about/pubs/walkerton/ O’Connor, D.R. (2002). The Report of the Walkerton Inquiry, Part Two: A Strategy for Safe Drinking Water. Queen’s Printer for Ontario. http://www.attorneygeneral.jus.gov.on.ca/english/about/pubs/walkerton/ Public Health Agency of Canada: Environment and Public Health http://www.phac-aspc.gc.ca/chn-rcs/eh-es-eng.php?rd=environ_eng United Nations Economic Commission for Europe. Globally Harmonized System of Classification and Labelling of Chemicals (GHS). http://www.unece.org/trans/danger/publi/ghs/ghs_welcome_e.html

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Chapter 28 Violence and Health

Chapter 28: Violence and Health Suggestions for Guest Speakers 1. Invite a nurse who works in the emergency room to discuss issues of domestic violence identification, treatment and prevention with the students.

2. Teleconference with a volunteer from your local Women's Helpline to ask about some of the resources available and some of the issues that they face in their work.

3. Ask a public health nurse who works with families in crisis to visit the class.

4. Ask a person who was involved in an abusive relationship to discuss how nurses could have been helpful and give some insight into a difficult situation.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. The issue of violence against Indigenous women has been studied and documented extensively in a number of Federal, Provincial and Territorial documents, the most recent being the 2014 Report on the Special Committee on Violence against Missing and Murdered Aboriginal Women Available at: www.parl.gc.ca/HousePublications/Publication.aspx?DocId=6469851 Ask the students to read the report. Have a discussion using the following questions as a guide: what social determinants might be underlying causes that are being addressed (gender, poverty, education, etc.)? If you had unlimited resources and were in a position of influence, what actions would you take as a community health nurse to address this issue?

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. The issue of violence against Indigenous women has been studied and documented extensively in a number of Federal, Provincial and Territorial documents, the most recent .

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Chapter 28 Violence and Health being the 2014 Report on the Special Committee on Violence against Missing and Murdered Aboriginal Women Available at: www.parl.gc.ca/HousePublications/Publication.aspx?DocId=6469851 Ask the students to read the report. Have an online discussion using the following questions as a guide: what social determinants might be underlying causes that are being addressed (gender, poverty, education, etc.)? If you had unlimited resources and were in a position of influence, what actions would you take as a community health nurse to address this issue?

Seminar Discussion Questions 1. Ask the students how violence influences the health of clients who they serve in their community placements. How would violent relationships be identified? How would they be addressed? What might some of the challenges be to identifying and addressing issues of violence in your clinical placement?

2. Are the staff at risk for becoming victims of violence in your placement? Is there potential for violence to take place between staff members? What safeguards are in place to protect clients and staff against violence? Are there resources available to students who are involved in violent relationships?

Case Study 1. Why and how did Christopher Husbands become involved in violent acts in his community?

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Criminality is a consequence of the social complexities of people’s lives, and not just about the choices that people make. It is the complex interaction between a range of economic and social factors such as poverty, systemic discrimination, unemployment, racism, fatherless homes, truancy, neighbourhood effect, and a lack of supportive social structures, such as family and community support. Racism, in particularly intersect with a range of these factors to dominate Black youth experience with gun violence, especially those living in disadvantaged neighbourhood. Many Black youth grapple with police profiling, struggle with reintegration challenges, and are witnesses to the violent death of family and friends in these neighbourhoods. The mental health impact of these interactions is devastating without available and accessible mental health services. As evident in the case study of Christopher Husbands, many of these factors dominated his lived experience.

2. In what ways can CHNs take action to decrease gun violence in communities?

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Gun violence is intertwined with various determinants of health--race, stigma, poverty, lack of resources, and mental health issues. It affects the resilience of individuals and communities. Community Health Nurses can take action on these determinants of health by working in partnership with various stakeholders in different sectors, levels of government, and community organizations, using health promotion strategies grounded in trauma-informed care and in public health values.

This might involve facilitating the development of community support programs for victims and survivors of violence, supporting families with children and youth, building capacities for empathy and problem-solving in schools and agencies working with youth.

Canadian Research 28.1 1. What are the intersecting macro, structural elements that First Nations, Inuit, and Métis trans sex workers might experience?

• Colonialism, racism, oppression, poverty.

2. How would the decriminalization of sex work promote trans sex workers’ occupational health and safety?

• Improve sex workers working conditions and relationship between sex workers and police.

• Improved relationship with police would remove stigma and lack of trust, which may help to increase reporting of violent events.

• Increased reporting and higher rates of prosecution of events may reduce incidences of violence, thus improving working conditions for trans sex workers.

3. What are some of the root, structural interventions that address transphobia (e.g., healthrelated public policy)?

• Implement interventions and policies that remove barriers to economic opportunities and that support transition-related healthcare for those interested in transitioning out of sex work.

• Implement anti-stigma education programs and policies to reduce transphobic violence. For example- gender education in schools.

• Improve access to healthcare for trans sex workers by addressing structural and cultural safety issues for this population.

Individual Critical Thinking Exercises 1. Critically examine the difference between using the terms people under threat versus vulnerable populations to describe populations that are more likely to experience violence.

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Vulnerability implies we are more prone to experience violence, and it reinforces the idea that a nebulous force is causing the issue.

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“People under threat” satisfies the need to identify specific threats that are causing ill health, such as colonization and the corporatization of healthcare delivery.

2. A fellow student came to you and revealed she was sexually assaulted. She didn’t want to have an examination as she was worried the police will be called. It was someone from her dormitory and she saw him often. She was worried the school would become involved if she spoke out and that her education would be affected. a. What could you tell her?

• This is difficult, depending on the school’s reporting practices. At the very least she should seek health care on or off campus, to obtain emergency contraception and protection from sexually transmitted infections. This information must be kept confidential and they cannot report on her behalf. Ultimately it is up to her to disclose or report. Her safety is important and she may be exposed to him again in the dormitory. Do not tell her what to do but explore how she thinks she can stay safe if she doesn’t report to police or campus security. Universities and colleges are increasingly becoming accountable for reporting rates of abuse on campus, but at the same time the identity of the victim must be protected. They are also obliged to determine if they need to expel the student or if other students are at risk. b. What resources are available to you?

• This answer should include on campus and off campus services for health care, counseling and police/security services. Students are most likely to disclose to peers so students should familiarize themselves with the local resources.

Emphasize the importance of identifying her support people in her life to help her recovery.

• If she wishes to seek professional assistance, tell her about all her accessible, and ideally, trauma-informed options on and off campus (e.g. medical support to obtain emergency contraception and protection from sexually transmitted infections, legal and security support if she chooses to involve the police, spiritual and psychological support, the local women’s center, the Sexual Assault Nurse Examiner if one is available in your area). Students are most likely to disclose to peers, so it is very important that students are knowledgeable about specific local resources. Talk to her about her available support people and support resources in her life. These resources can be pivotal in coping with the assault, and in the recovery process. c. How would you know if she needed further assistance?

• She may tell you that she needs more support. Signs of distress and traumatic stress are usual indicators that she needs more help. In keeping with the results of traumatic stress, she may be missing more classes, unable to return to her part time job, abusing drugs or alcohol, or harming herself. These signs may happen immediately, or they may be delayed. Encourage her to seek professional counselling if she has not already done so.

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3. What is the CHN’s role in caring for a woman who is experiencing IPV? • Universal screening for IPV is recommended as best practice for all girls and women above the age of 12 years old.

• Create a practice environment that facilitates disclosure, which requires that they ask key questions about IPV as well as respond appropriately to disclosure.

• Engage in reflective practice to examine their own values and beliefs, as well as know their legal obligations regarding reporting abuse.

• When asking women about IPV, it is important to do this in a private location when the woman is alone.

4. Identify the key targets from the UN’s SDG that address the risk factors for violence. As a CHN, identify interventions at the macro, community, and intrapersonal levels that would be priority interventions for action on preventing violence in your community.

• Key targets that address risk factors: 1,3,4,5,11,16.

Group Critical Thinking Exercises 1. Discuss as a group the role of social media in perpetuating, addressing, and preventing sexual violence. How can CHNs embrace the positive attributes of social media while also mitigating the risk?

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#MeToo is an example of using social media for advocacy and creating awareness of the magnitude of the issue.

Online bullying and sexting is an example of ways that social media can contribute to violence.

CHNs can use social media in positive ways to promote advocacy and awareness.

It is also important for CHNs to educate parents, children and youth how to protect themselves on the internet, and implement other interventions to prevent bullying.

2. You have been invited to a local high school to help work on a violence prevention program for grade 10 girls. So far you are the only professional who has been invited to set this up. a. What types of messages would you want to convey, and why?

• Messages related to healthy versus unhealthy relationships are important as they may be getting mixed messages in the media/community. Talk of resiliency to abuse, resources available to them and importance of self-esteem and peer support are important.

• Some of the most important messages would be related to learning about healthy versus unhealthy relationships. We are all exposed to multiple and persistent mixed messages in areas such as gender and power relations. Another key message involves how to create and .

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Chapter 28 Violence and Health maintain sexual and emotional safety in relationships. Strategies to enhance resiliency and self-esteem are central. Peer support networks can provide on-the-ground immediate support, as well as on-ground resources b. What types of activities might you have for the program, and why?

• Having students actively engage in their own learning is substantially more effective than lecturing. Activities should be age appropriate and student led possible. Ideas might include looking at popular media and having them rewrite ads or music lyrics to be less disrespectful, racialized, and stereotypical. Another activity could involve having students identify abusive behaviours in movies or YouTube videos or in samples of anonymous text messages. c. Who else should be involved in the program? Why? • You may include school counselors; experts from local women’s centers, sexual health centers, and counseling centers; sexual assault nurse examiners or physicians and police. It is very important to ensure that as many of these people as possible are trauma-informed.

There may also be someone in the community who was a victim of dating violence and who is willing to talk with the students.

3. The provincial government is trying to establish a family violence prevention network. It has asked for representatives from various sectors to become involved, and you are representing CHNs on the advisory group. There are lawyers, policy makers, health services administrators, police, and social workers in attendance. a. If you only were able to start with one type of violence or age group to develop interventions, what would be important for your community, and why?

• Think about the violence in your own community. Who is at most risk or under threat and why? What social determinants or other risk factors are involved that may be addressed through such a network? b. What types of funding, laws, or policies do you think would be needed at the provincial level to support the violence prevention efforts?

• Given the answer to “a”, what type of policies would be needed? For instance, if the issue was violence against women in intimate partner relationships in your community, then what policies already exist in various agencies? Can police lay charges without the woman’s consent or cooperation? Is there universal screening for abuse in different agencies? Is funding needed for a specific type of resource?

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Chapter 28 Violence and Health c. How could you disseminate the information so the public and other professionals will be aware of the efforts? (Consider the age group, community, and existing services in your area.)

• The answer should include more than one method of dissemination to raise awareness and in a format appropriate to age. Are there resources that can be pooled? Joint or cross-sectoral initiatives that can be implemented across agencies?

Further Resources MeToo Movement https://metoomvmt.org Public Health Agency of Canada Best Practices Portal on Violence Prevention http://cbpp-pcpe.phac-aspc.gc.ca/public-health-topics/violence-prevention/ PrevNet: Promoting Relationships and Eliminating Violence Network https://www.prevnet.ca/partners/organizations/prevention-of-violence-canada Native Women’s Association of Canada https://www.nwac.ca/home/policy-areas/violence-prevention-and-safety/ Canadian Women’s Foundation https://www.canadianwomen.org/out-of-violence/ World Health Organization: Violence Prevention http://www.who.int/violence_injury_prevention/violence/en/ National Inquiry into Missing and Murdered Indigenous Women and Girls http://www.mmiwg-ffada.ca

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Chapter 29 Poverty, Homelessness, and Food Insecurity

Chapter 29: Poverty, Homelessness, and Food Insecurity Suggestions for Guest Speakers 1. Invite a nurse who works with people who live in poverty to speak to the class.

2. Ask a client who has struggled financially to speak with the class about how the experience impacted their health and relationship with the healthcare system. You may find an advocate who has personally struggled with poverty who is now working at a homeless shelter or a related agency.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students to read the first-hand story of life with poverty found from the Vibrant Canada website: http://vibrantcanada.ca/blogs/waterloo/poverty-personal-story Ask the students to critically reflect and answer the following questions. This is for their own learning, and not to be shared with the rest of the group: What factors contributed to Marianne’s economic situation? What challenges have you or your family experienced that may contribute to economic insecurity? Why did (or did not) those factors impact your economic situation? What can be learned from Marianne’s situation for your personal life and how you interact with clients?

Ideas for Self-Study and Distance Students 1. Read the chapter. Clarify any questions over the phone Practice Application 1. Ask the students to read the first-hand story of life with poverty found from the Vibrant Canada website: http://vibrantcanada.ca/blogs/waterloo/poverty-personal-story Ask the students to critically reflect and answer the following questions. This is for their own learning, and not to be shared with the rest of the group: What factors contributed to Marianne’s economic situation? What challenges have you or your family experienced that may contribute to economic insecurity? Why did (or did not) those factors impact your economic situation? What can be learned from Marianne’s situation for your personal life and how you interact with clients?

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Chapter 29 Poverty, Homelessness, and Food Insecurity Seminar Discussion Questions 1. How does a client’s economic situation impact his/her ability to access your clinical placement organization? Do people need to pay for the services? How do most people access the service (nurse comes to their home, client takes the bus or drives a car, etc.)?

In a hospital setting, clients wear gowns, and it is sometimes difficult to ascertain their economic status. In the community, their economic status may be more obvious. How might this influence how people are treated?

Case Study Questions 1. Working with the interdisciplinary team of providers at your clinic, such as the Registered Dietitian and Social Worker, what are some strategies you could devise to make the program more accessible for all of the women in the group?

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Explore the feasibility of providing transportation to the group, such as securing funds for a taxi van or to hire someone with a van to transport participants who cannot afford to travel to the group.

2. What are some strategies you and your colleagues could develop to increase access to the social determinants of health for the families in the group?

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Approach local businesses to contribute funds to your group so you can provide a full lunch for all participants, or a food voucher worth more value.

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Explore whether the women in your group are receiving all the financial entitlements for which they qualify. For those women who have not done their income taxes, provide assistance to them to do so since you know that this step leads to important income increases such as tax rebates.

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Explore with other community groups the feasibility of organizing a breakfast program at your local school for hungry low-income children.

3. What are some upstream interventions you could use in this situation to reduce the impacts of health inequities related to food insecurity, lack of transportation, and lack of affordable housing?

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Arrange a visit to your local provincial or territorial representative’s local office to discuss the women’s first-hand experience with poverty and the inadequacy of social assistance. Have the women in the group make a food diary of foods they have during the first and last weeks of the month and compare it for nutritional value with the help of your dietitian colleague. Assess for adequate iron, calcium, folate, etc. The results can be presented during the meeting with the politician.

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Organize and empower the women in your group to participate in, for example, a relevant demonstration calling for increased social assistance rates. Use group 231

Chapter 29 Poverty, Homelessness, and Food Insecurity time to make creative signs or banners and then facilitate attendance by, for example asking a local business to donate the cost of a bus to transport the women and kids to the event, provide lunch, etc.

Canadian Research 29.1 1. What are some of the ways you, as a CHN, could advocate for appropriate post-partum discharge planning for a homeless pregnant patient?

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Ideally you begin working with your pregnant patients with a community social worker well in advance of the delivery to obtain affordable housing with any necessary supports. When this is not possible, it is important to develop a process of discharge to a supportive environment such as a women and children’s shelter by helping to create a protocol which is shared with hospital staff including nurses and hospital social workers so that they will be able to work with a homeless woman to find a place for discharge.

You could work with community partners to create a “welcome baby” package of supplies for homeless mothers which contains baby clothes, diapers, bathing supplies, developmentally appropriate infant toys as well as a care package of supplies for moms.

2. You and your CHN colleagues have begun to notice a pattern of discriminatory attitudes by nurses being reported by homeless pregnant women admitted to the labour and delivery unit at a local hospital. What are some strategies you and your colleagues could employ to try to improve access to appropriate, compassionate, non-judgmental care for your homeless pregnant patients?

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You could approach the manager of the labour and delivery unit to see if they would be open to a “lunch and learn” workshop on homelessness and the high prevalence of stigma which homeless people often experience in the health care system. You could incorporate anti-stigma training as well as networking to build relationships with the nurses on the unit, inviting them to call your agency anytime they encounter a homeless woman to help problem solve discharge to the community. Bring with you some “welcome baby” packages (see question 1) for the unit nurses to provide to homeless women, which may reduce any feelings of helplessness they may be experiencing.

3. Stereotyping and discriminatory attitudes towards people who are homeless or living on low income are common in both acute care and community care settings. What are some of the ways you could support the creation of “conversational spaces” for discussion and learning in a community health nursing setting?

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You could suggest to your team and manager hosting interdisciplinary community rounds every month or two to discuss case scenarios involving homeless clients, reviewing what worked well and what may not have worked as well, facilitating a brainstorming session on strategies to provide expert care. This tactic may allow 232

Chapter 29 Poverty, Homelessness, and Food Insecurity nurses and other clinicians to be more receptive to changing their behaviours in the interest of building clinical expertise.

Individual Critical Thinking Exercises 1. What does it mean to consider that health is political?

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When we think about health using the upstream, downstream metaphor, we see that all “downstream” health issues have “upstream” primordial or primary antecedents which can only be changed by political processes. For example, high rates of diabetes in low income populations are directly related to the effects of poverty, including the inability to afford fruits and vegetables and frequently having to work several precarious low-paying jobs allowing no time for exercise.

Raising social assistance rates, lobbying for higher minimum wages and protection for workers in precarious jobs are all political issues.

2. How does looking through a critical social theory lens help CHNs to provide ethical nursing care to people living in poverty?

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Critical social theory helps us understand that what is perceived to be real is shaped by sociopolitical, economic, cultural and ideological contexts. Using a critical social theory lens allows CHNs to see and thus consider the broader socioeconomic and political influences which affect the health of marginalized groups of people.

3. Indigenous people are disproportionately overrepresented among homeless populations in Canada. What is the link between Indigenous homelessness and colonization?

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Thistle’s (2017) Indigenous definition of homelessness recognizes that Indigenous homelessness must be understood as a consequence of historical and ongoing settler colonization and racism which has removed Indigenous people from their “traditional governance systems and laws, territories, histories, worldviews, ancestors and stories” (p. 6). Indigenous homelessness is caused by colonialism and its sequelae including land theft; racism; stereotypes; cultural genocide; the destruction of Indigenous languages; forced relocation to “marginal geographic spaces” (p. 8); racist policies and laws, such as the Indian Act; and unfulfilled treaties.

Group Critical-Thinking Exercises 1. You and your colleagues decide, with the support of your primary care clinic manager, to make deputations to City Council about the need for augmentation of the affordable housing program in your small municipality. Does political advocacy of this type increase the professional reputations and credibility of CHNs, or does it jeopardize it? Is the answer contingent on the particular constituency – for example, other health care professionals? homeless individuals in your community? The general public?

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In my experience, engaging in political advocacy to reduce homelessness significantly increases the credibility of CHNs in the opinion of homeless people.

Whether it does or does not for other groups is less predictable. Other health care professionals and members of the public who understand the SDOH and upstream thinking tend to see this sort of advocacy as vital. Those who do not may see it as unrelated to nursing or health and may consider it “not nursing.”

2. Homeless health care providers have created strategies to provide end of life care for homeless people with life-limiting illnesses, such as palliative care provision in a shelter.

Which is the more appropriate strategy in which to engage for CHNs: providing end of life care that maintains homelessness until death, in a setting familiar to someone; or advocating upstream for immediate housing for all homeless people diagnosed with a life-limiting illness?

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This is an interesting question that can be argued in both ways. I have had clients who were palliative who wanted to die in the shelter they had lived in for a long time to be close to important people in their lives. It is fundamentally wrong that people are forced to live in shelters for so long that this becomes their community.

I believe that homeless people with life-limiting illness ought to qualify for affordable housing at the time of diagnosis but ultimately ought to be given the choice of where they spend the end of their lives.

3. Are foodbanks an appropriate response to food insecurity in Canada? Why or why not?

What are some alternatives to food banks and other charitable responses to poverty?

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Foodbanks and other charity responses to food insecurity do help people who need food. However, some have argued that the vast dependence on charitable responses to food insecurity allows governments to avoid their responsibility to provide a livable income to people. They can be seen to let governments “off the hook” so they do not have to provide an upstream solution. Alternatives to charitable responses to food insecurity would including no-cost community garden plots so low income people can grow their own food; organizing “gleaning” outings to transport low income people to participating farms to harvest surplus produce; and any intervention that increases the amount of money available for food, such as increased social assistance rates, increased minimum wages, and increased availability of affordable housing.

Further Resources The homeless Hub https://www.homelesshub.ca/resource/homeless-nation-homepage Poor No More http://www.poornomore.ca/

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Chapter 30 Substance Use

Chapter 30: Substance Use Suggestions for Guest Speakers 1. Invite a nurse who works primarily with clients who have substance use issues.

2. Invite a client or a nurse who has recovered from a substance use issue to share their experiences.

3. Invite a community or public health nurse to discuss FASD prevention and treatment.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Instruct the students to watch the documentary called “Dopesick” found at https://video.vice.com/en_us/video/fentanyl-the-drug-deadlier-thanheroin/57169d30dbb30e8656f09c76?latest=1 Ask the students to list the factors that contribute to issues with problematic substance use from the people in the film who use substances. Create a mind map on the board, using black pen.

Describe how the issues are linked to the social determinants of health. Next ask the students where parents, friends, teachers, nurses, law enforcement etc. may have intervened, when it would have had to happen, and what they might have done.

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Instruct the students to watch the documentary called “Dopesick” found at https://video.vice.com/en_us/video/fentanyl-the-drug-deadlier-thanheroin/57169d30dbb30e8656f09c76?latest=1 Ask the students to list the factors that contribute to issues with problematic substance use from the people in the film who use substances. Create a mind map on the board, using black pen.

Describe how the issues are linked to the social determinants of health. Next ask the students

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Chapter 30 Substance Use where parents, friends, teachers, nurses, law enforcement etc. may have intervened, when it would have had to happen, and what they might have done.

Seminar Discussion Questions 1. Ask the students how substance use influences the health of clients who they serve in their community placements. How are clients with addiction issues treated? How are substance issues assessed? How would you like to treat a client with substance abuse issues? What might some of the challenges be?

2. Are the staff at risk for substance issues? How are their needs met if they identify a substance abuse issue in themselves? How can student nurses mitigate substance abuse issues in their own lives?

Case Study Questions 1. How might a CHN address community resistance to managed alcohol programs?

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Developing prevention and enforcement strategies such as an alcohol management policy is consistent with the recommended health promotion concepts, and harm reduction and resiliency theories presented in the chapter. Students should understand that a policy helps to create and maintain an environment that is conducive to the safe consumption of alcohol and helps to maintain a healthy sociocultural and recreational environment. Alcohol management policies are rendered more effective when combined with education – knowing the rules will help people play by the rules.

Policy development also creates unique opportunities for community health nurses to lead and facilitate the development of complementary educational activities and other initiatives that promote the adoption of healthy attitudes and behaviours.

Facilitating the development of policies also gives community health nurses the opportunity to promote and apply evidence-based solutions. Current research tells us that Canadian communities with policies that control and manage the service of alcohol in municipal facilities, report the following positive outcomes: fewer people drive after drinking at community events; there are fewer visits to emergency rooms; rowdy people appear to modify their behaviour in order to participate in events; and an increase in the attendance/participation of people who drink moderately or abstain from alcohol.

For this question students are encouraged to generate strategies that can be adopted to minimize the risks described above. Strategies should include a clear list of the areas/facilities where alcohol can be served; a safe transportation strategy (i.e., designated drivers, sponsored cab service); explicit control measures (i.e., number of 236

Chapter 30 Substance Use drinks that can be purchased); server training; and enforcement strategies for those who do not comply (i.e., participation is suspended). Essentially, a good policy sets out practical operating procedures to: facilitate better planning and management of alcohol related events; promote responsible service; reduce and prevent situations that may lead to injury, property damage even death; and minimize the liability. More and more, community health nurses are being called upon to help resolve alcohol related problems. Regardless of where a policy is developed, it should complement regional/provincial/federal laws.

2. From a cost perspective, how do you think managed alcohol programs compare to usual care?

• Individual responses will vary 3. What do you think are some of the health consequences of long-term consumption of non-beverage alcohol? Look to the research literature to see if your guesses are accurate.

• Individual responses will vary Canadian Research 30.1 1. Review the questions about your own substance use at the opening of the chapter, and reflect on your responses. After reading the case study and the chapter so far, would you change any of your answers?

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It is natural to feel discomfort regarding substance use, and concerns around working with individuals who use substances problematically. For some of us, this concern can come from being unfamiliar with substance use, for others this concern can be from our own personal or familial experiences with substance use.

We acknowledge these concerns and value your honesty in exploring them.

Through this chapter, you should develop a more complex understanding of the nuances of substance use, why particular populations are at higher risk, and so socio-environmental factors at the root of much substance use. As you precede through the chapter, you should become more comfortable to pragmatic approaches to substance use, such as harm reduction, which allow for the CHN to provide support where the community member is at.

2. Do you feel well-equipped to provide care within a harm reduction framework with people who use illicit substances? If so, why? If not, what would help you take the next steps in being equipped to work with people who use substances?

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While working in the context of problematic substance use can be a specialty area in nursing, we highlight that all CHNs will encounter substance use in their practice. Therefore, you should have a basic level of skill to at least assess and 237

Chapter 30 Substance Use respect that challenges that individuals, families, and populations face. If you would like to enhance your skills, there are a number of continuing education opportunities open to nurses such as through www.intnsa.org Individual Critical Thinking Exercises 1. Registered nurses and other health care providers have been found to hold negative attitudes concerning people who use substances, particularly illegal drugs. Privately explore the first thing that comes to mind when you read each of the following expressions. Then explore your reactions to each expression. Do they differ from one another? If so, consider the reasons why. Did any of your reactions surprise you? If yes, reflect on how your personal values may influence your professional practice.

• homeless alcoholic • needle exchange program • abstinence-based treatment • problem drinker • methadone treatment • parent with hangover • IV drug user • crack dealer • professor smoking marijuana • pregnant methadone client • crystal meth addict • chain (tobacco) smoker • female cocaine user • drunk driver • 20-year-old buying booze for underage sibling • person with HIV • gas sniffer • underage drunk • coffee drinker Through our discussion questions and critical thinking activities, we hope that you have seen how context can significantly impact your own personal perceptions regarding substance use. However, two points are important here: Firstly, language is very important in framing our perceptions of substance use. As CHNs we must be sure not to use language that further stigmatizes individuals, families, or populations. Secondly, we need to be cautious that our own biases do not impact upon the care we provide. By understanding forms of substance use that we personally find more offensive, we can work to address our perceptions and ensure quality of care with all people. .

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2. Read your local newspaper or a magazine, or watch the news, a television program, or a movie. Pay attention to the images and messages about the consumption of alcohol, tobacco, and illicit or licit drugs. At whom are these messages aimed? What are they portraying? Consider the degree of influence these images and messages have on substance use patterns in society.

•

One example of competing messages that we note around substance use is advertising that glorifies the experience of drinking alcohol as fun and exciting, versus shows that vilify individuals who are deemed ‘alcoholics’. It is noteworthy that wealthier populations are actually more likely to binge drink than low income populations, yet low income populations are more likely to experience negative social consequences of binge drinking. There is classism involved in the perception that it’s ok to drink excessively as long as you have the resources to do so and still maintain your employment, housing, and relationships. The same behaviours which are promoted among middle- and upper-class populations are vilified among those living in poverty.

3. Think of a community you have lived in, and consider the factors that were attributed to that community’s health status. What was the prevalence of psychoactive substances in that community? You may want to focus on one or more substances. Explore the factors that placed that community at risk and those that protected it or acted as buffers.

•

It is notable that our general perceptions around substance use in our communities are strongly influenced by media reporting. You may have heard about an overdose crisis, or opioid crisis, or fentanyl crisis, or crystal meth crisis, and underage drinking crisis in your community. It is interesting to compare these public declarations against statistics of substance use where they are available, and to consider the complex social and political factors that go into highlighting which substances are perceived as most problematic in any given community.

Group Critical Thinking Exercises 1. Select a particular issue or harm that is associated with substance use in your community (e.g., the problematic use of opioid prescription drugs, impaired driving, FASD). How would you seek to understand the issue across individual, family, community, and societal levels?

•

.

Because of the complex nature of problematic substance use, CHNs should access diverse sources to understand use. This can include qualitative components, such as talking with individuals who use substances, those who provide services, and those who provide enforcement. This can also include public consultation with the broader community. This qualitative data can be enhanced with quantitative data, such as local statistics, and comparing these against provincial/territorial or federal statistics.

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Chapter 30 Substance Use 2. For the issue identified in Question 1, have your group map your community’s current capacity in terms of prevention and treatment services and programs. You may use the internet or contact local health and social service agencies. For example, you should highlight any existing screening and prevention programs, how people access general information about the issue, and, if appropriate, where people access treatment services.

Make note of any service or program gaps your group observes.

•

Gaps may be around supports related to particular substances, or lack of supports for particular populations. Are all of the supports in your community generic? If so, what might be barriers to access for youth, women, Indigenous people, those who live outside the city limits? Gaps may also be in service hours, are crisis supports only available during business hours? Also, consider whether existing services include a full spectrum of harm reduction modalities, or if they are only focused on abstinencebased treatment.

3. Using the results of the mapping exercise in Question 2 and referring to the levels of prevention, discuss and analyze as a group the risk factors you believe have contributed to the development of the issue or harm identified in Question 1. Additionally, your group should explore the protective factors that have acted as buffers or that will have the capacity to create positive outcomes for your target population or for the community.

•

Ask yourself, why this particular substance? Why now? Why in this community?

Why with this particular population? These should help you uncover factors you may not have considered that might be points of intervention by a CHN.

Further Resources https://www.cna-aiic.ca/en/policy-advocacy/harm-reduction http://www.cno.org/en/learn-about-standards-guidelines/magazines-newsletters/thestandard/august-2017/harm-reduction/ https://www.nursesforsis.com/ https://www.nnvawi.org/ http://www.thinkupstream.net/ Canadian Centre for Ethics in Sport www.cces.ca Canadian Centre on Substance Abuse (CCSA) www.ccsa.ca Canada’s Drug Strategy www.parl.gc.ca/information/library/PRBpubs/prb0615-e.pdf

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Chapter 30 Substance Use Canadian Foundation for Drug Policy www.cfdp.ca Drug Rehabilitation Centres in Canada www.drugrehab.ca Health Canada, First Nations and Inuit Health, Treatment Centre Directory www.hc-sc.gc.ca/fniah-spnia/substan/ads/nnadap-pnlaada_dir-rep-eng.php MADD Canada Mothers Against Drunk Driving www.madd.ca National Native Alcohol and Drug Abuse Program (NNADAP) www.hc-sc.gc.ca/fniah-spnia/substan/ads/nnadap-pnlaada-eng.php

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Chapter 31: Sexually Transmitted and Blood-Borne Infections Suggestions for Guest Speakers 1. Ask a nurse researcher who is studying issues related to STBBIs to visit the class.

2. Invite a nurse who works in a sexual health clinic to speak with the class.

3. Interview, Skype, or teleconference with a nurse who has worked in HIV prevention in Canada or overseas.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Discuss the following question: what factors are needed to create trust and rapport with a person seeking information on or STBBI testing and treatment?

2. Role-play a respectful interaction between a nurse and client when speaking about STBBI information, screening and treatment. The interaction takes place in a health clinic. The nurse has never met the client before.

• • • • • • • • • • • •

.

welcome the client naturally, as you would all clients (introduce yourself, offer the client a seat) ask the client what name they want to be called and what pronoun they go by take a history in a private setting ensure privacy and confidentiality make eye contact and be aware of your body language use language that is positive, inclusive and non-judgmental be respectful, understanding and build trust ask the client what brought them in to the clinic the client responds that they either require information or have need for testing and treatment of an STBBI normalize sexuality and sexual health as being an important part of overall health listen carefully, ask questions to clarify and summarize for mutual understanding ask general health questions first (e.g., do you have any allergies or take any medications?)

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• •

• • • • •

•

ask permission to ask questions about sexuality (e.g.,. to help me understand what you might need, may I ask you some questions about your sexual history?) sexual health history taking often involves asking questions about partners, sexual practices, history of infections, if pregnancy is a concern and if sexuality activity has been consensual? if the client is reporting symptoms, ask them to describe them find out what the client already knows about STBBIs and what questions they have use both open and closed questions use empathetic words and gestures to encourage the patient to continue speaking (e.g., nods) If the person proceeds with testing, informed consent is required which includes what STBBIs are being tested, if they are notifiable infections, the partner notification process, how to access results and treatment and future screening recommendations Remember to ask the person if they have any questions or other information they would like to share.

Tips for sexual health history taking can be found at: Canadian Public Health Association (2017). Discussing sexual health, substance use and STBBIs: A guide for service providers found at: https://www.cpha.ca/sites/default/files/uploads/resources/stbbi/discussionguide_e.pdf List 3 open-ended questions that will help the nurse to assess the clients’ risk of acquiring an STBBI using for each of the following areas:

Personal practices

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Partners

-

Substance Use

-

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Ideas for Self-Study or Distance Students 1.

Clarify any questions about the information from the text.

Practice Application 1. Discuss the following question: what factors are needed to create trust and rapport with a person seeking information on or STBBI testing and treatment?

2. Role-play a respectful interaction between a nurse and client when speaking about STBBI information, screening and treatment. The interaction takes place in a health clinic. The nurse has never met the client before.

• • • • • • • • • • • • • •

• • • •

.

welcome the client naturally, as you would all clients (introduce yourself, offer the client a seat) ask the client what name they want to be called and what pronoun they go by take a history in a private setting ensure privacy and confidentiality make eye contact and be aware of your body language use language that is positive, inclusive and non-judgmental be respectful, understanding and build trust ask the client what brought them in to the clinic the client responds that they either require information or have need for testing and treatment of an STBBI normalize sexuality and sexual health as being an important part of overall health listen carefully, ask questions to clarify and summarize for mutual understanding ask general health questions first (e.g., do you have any allergies or take any medications?) ask permission to ask questions about sexuality (e.g., to help me understand what you might need, may I ask you some questions about your sexual history?) sexual health history taking often involves asking questions about partners, sexual practices, history of infections, if pregnancy is a concern and if sexuality activity has been consensual? if the client is reporting symptoms, ask them to describe them find out what the client already knows about STBBIs and what questions they have use both open and closed questions use empathetic words and gestures to encourage the patient to continue speaking (e.g., nods)

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•

•

If the person proceeds with testing, informed consent is required which includes what STBBIs are being tested, if they are notifiable infections, the partner notification process, how to access results and treatment and future screening recommendations Remember to ask the person if they have any questions or other information they would like to share.

Tips for sexual health history taking can be found at: Canadian Public Health Association (2017). Discussing sexual health, substance use and STBBIs: A guide for service providers found at: https://www.cpha.ca/sites/default/files/uploads/resources/stbbi/discussionguide_e.pdf List 3 open-ended questions that will help the nurse to assess the clients’ risk of acquiring an STBBI using for each of the following areas:

Personal practices

-

Partners

-

Substance Use

-

Case Study Questions 1. Discuss the importance of collaborating with local Indigenous groups for improving access to services.

Local Indigenous groups should be consulted and play an active role in providing perspective about how to improve services including educating healthcare providers on the needs of the local community including what cultural practices and considerations are needed for culturally safe care. Indigenous groups can also support collaborations with other community serving agencies to address determinants of health including housing, employment and social supports.

2. What social determinants of health will the CHN need to be aware of when planning services?

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CHNs will need to be aware of the following social determinants of health: • Income and Social Status – e.g., the youth of the community may be living in poverty, under or unemployed, sex work or exchanging sexual favour for money or have limited access to other resources such as health benefits. Status and non-status Indigenous youth will have different access to supplemental health benefits and should be provided free or low cost with access to compassionate programs, for those people who need them.

• Social Support Networks - e.g., youth may have a supportive extended family network, peer or cultural groups or limited social support, unstable housing, limited opportunity for school or community ties. Youth who have large amounts of unsupervised time have a higher association for sexual risk taking, whereas parental monitoring is associated with lower sexual risk-taking behaviour. Collaboration should be formed with school health programs, Indigenous and youth serving agencies. Consider that some youth may have experienced sexual or intergenerational abuse.

• Education - e.g., the youth may have unstable housing or may come from families that experienced residential schools and didn’t place emphasis on school attendance. In turn, the youth may have low literacy and limited exposure to comprehensive sexual health education delivered at school. Consideration should be given to developing education materials that are culturally safe, plain and inclusive in language and portray diverse populations.

• Biology and Genetics - e.g., planning services for adolescences (generally 12-19) and youth (up to age 24) encompasses a vast range of physiological and psychological maturity levels and needs. Youth who come from families where physical, emotional or sexual abuse occur, are at risk for low self-esteem and is associated with higher risk sexual behaviours and interpersonal violence.

• Physical Environments – e.g., characteristics of youth friendly services include trained staff, separate spaces, convenient hours and location with comfortable surroundings and culturally respectful care where Indigenous youth feel spiritually, emotionally and culturally safe.

• Personal Health Practices - e.g., substance use (alcohol and drugs) is associated with early initiation of sexual activity and unintended pregnancy. Youth who use substances prior to sexual intercourse are less likely to use condoms or birth control. Low self-esteem in youth, especially girls is associated with high-risk sexual behaviours. Resources must include capacity to deal with substance use, addiction and mental health concerns.

• Health Services - e.g., health services are provided to all genders regardless of sexual orientation, gender identity or gender expression, drop in-services are available, wait times are short, parental/guardian consent is encouraged but not required, confidentiality is honored, services are well promoted in the area and where youth gather.

• Culture and Gender - e.g., services for Indigenous youth need to be culturally safe and welcome all genders regardless of sexual orientation, gender identity or gender expression.

Consideration should be given to acknowledge imposed gender roles including patriarchal social structure which may perpetuate a belief of the inferiority of women or invisibility of

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genders outside of the binary (male/female) and not inclusive to non-binary or two-spirit identities.

3. What health promotion strategies can CHNs implement to improve accessibility?

CHNs can be involved in the following health promotion strategies: •

• •

•

•

Strengthen Community Action - e.g., build partnerships and collaborate with local Indigenous communities and youth serving agencies to strengthen protective factors such as creating peer support groups for LGBTQ2S youth or access to community elders for guidance and support. Offer sexual and reproductive health information and support online through popular local social networking sites and other electronic technologies.

Build Healthy Public Policy - e.g., work in a coalition to increase resources and access to local sexual and reproductive services.

Create Supportive Environments - e.g., collaborate with Indigenous leadership to create professional education sessions to healthcare providers to build capacity around youth friendly and culturally safe care. Create and maintain culturally appropriate patient health information and resources.

Develop Personal Skills - e.g., develop social media campaigns with harm reduction messages to promote safer sexual practices and increase awareness about STBBI testing and treatment.

Reorient Health Services - e.g., Offer mobile and integrated services with Indigenous youth serving agencies. Implement opportunities for anonymous online self-testing and treatment services.

Canadian Research 31.1 1. How can stigma impact the health of individuals living with HIV? • Stigma may stop individuals from seeking care and complying with recommended treatment plan.

2. What are some institutional practices that could promote stigma?

Institutional practices that may promote stigma include: • Making assumptions about one’s sexuality or gender • Making assumptions about drug use • Using forms that are not inclusive (e.g., forms that promote the gender binary) 3. How can CHNs assist in stopping the cycle of stigma?

• On a personal level, nurses can stop making assumptions about how a person acquired HIV. .

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• •

Nurses can participate or lead institutional stigma training programs to raise awareness about stigma and its negative effects.

Nurses can get involved in the development of policies to ensure they are not stigmatizing

Individual Critical Thinking Exercises 1. Reflect on your personal values related to sexuality. How do personal values impact sexual health education?

Answers will vary. Some individuals may learn: • They are/are not open to sexual health education.

• They are/are not confident in their knowledge regarding sexual and reproductive health.

• They do/do not support comprehensive sexuality education.

• About their personal biases related to sexuality education.

• They are/are not comfortable with issues pertaining to sexual and reproductive health.

Sometimes, unknowingly, personal values impact sexual health education provided by CHNs or other service providers. For example, an individual who does not believe in premarital sexual intercourse may be reluctant to educate teenagers on contraception. Acknowledging our values and biases related to sexuality may make it easier to hold them at bay when providing sexuality education.

2. STBBI rates are increasing in males 15–24 years old. The Public Health Agency of Canada states that testing and education are important to prevent STBBIs. Unfortunately, many youth at risk for STIs leave school early and become street involved, thus missing the benefit of sexual health education. What determinants of health could be addressed by CHNs related to the issues of street youth and STBBIs? CHNs can be involved in addressing the following determinants of health related to street youth and STI: • Income and Social Status - e.g., offer free STBBItesting and treatment at street youth agencies • Social Support Networks - e.g., use peer education strategies to build knowledge and skills levels in service providers who work with street youth • Education - e.g., support coalitions that promote alternative school settings for youth at risk • Working Conditions - e.g., provide age appropriate STBBI educational materials to youth temporary employment agencies • Physical Environments - e.g., provide free condoms and needle exchange programs in places where street youth hang out .

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• • • •

Biology and Genetics - e.g., consider adolescent developmental stages when creating programs for STI prevention in street youth Personal Health Practices - e.g., work with youth agencies to develop street youth survival kits including condoms and information on STBBI testing and treatment Health Services - e.g., develop a directory of street youth agencies and highlight health services that provide STBBI testing and treatment Culture and Gender - e.g., consider the influences of Aboriginal culture in a street involvement recovery program for Aboriginal young women

3. Search the Internet and find one STBBI prevention resource that can be used with teens. How can CHNs use this resource in a teen clinic?

A web resource that addresses STBBI prevention is sexualityandu.ca • The resource provides accurate information regarding STBBI prevention; there is information for teens, parents, teachers, and service providers.

• The resource provides detailed instructions and diagrams of how to correctly use male and female condoms. It also provides an interactive demonstration of how to use a male condom.

• A CHN working in a teen clinic can educate teens about STBBI prevention by discussing the benefits of using condoms, where to find condoms, and how to use condoms. The CHN can show the interactive condom demonstration.

4. The recommendation to vaccinate elementary schoolchildren against HPV has caused controversy in Canada. What can CHNs say to parents who are uncertain of whether or not to have their children vaccinated?

Parents will make decisions regarding their children’s health (including their decision to vaccinate or not vaccinate) based upon their level of knowledge, their values and beliefs. If a parent was uncertain of consenting to the vaccination • Ask parents about their values and beliefs.

• Ask parents what their concerns are. Try to address the parent’s concerns in a nonjudgmental and supportive manner.

• Provide the facts about the vaccination, including the vaccination schedule, the rationale for the targeted age group and the potential side effects.

• Dispel myths surrounding HPV and the vaccination.

• Refer parents to additional resources, such as the SOGC website (hpvinfo.ca).

5. People involved in the sex work may participate in high risk sexual behaviours (e.g., condomless sex, sex with multiple partners), placing them at risk for STBBIs. How can CHNs protect and promote the sexual health of this population?

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• • • • • • • • •

Ensure access to condoms – penile and vaginal Encourage use of female controlled preventive methods (e.g., vaginal condoms) Ensure easy access to STI and HIV testing, counseling, and treatment (e.g., mobile sexual health service, street outreach) Advocate for policies that protect the rights of people in sex work.

Encourage safer sex with personal partners as well as paying partners Harm reduction (e.g., injecting drugs with clean needles) Skill building opportunities for people who are doing sex work (e.g., condom negotiation) Peer education/mentorship (e.g., experienced sex workers can educate newer workers about harm reduction, condom negotiation, and safer sex) Provide training opportunities for service providers to be educated about STI and HIV

Group Critical Thinking Exercises 1. LGBTQ2S youth often face rejection from significant support systems such as family and friends when they “come out.” Some youth quit school and leave home to live on the street. Some rely on panhandling and sex work to support themselves or to pay for drugs that help them cope. High-risk activities and a lack of resources increase LGBTQ2S youths’ risk for STIs and HIV. How can a CHN use the Canadian Community Health Nursing Standards of Practice (CCHNSP) to plan care for LGBTQ2S youth within a sexual health clinic?

CHNs can use the CCHNSP to plan care for LGBTQ2S youth within a youth clinic by: • Promoting Health o Health Promotion e.g., collaborate with an interprofessional team to holistically assess the needs of the LGBTQ2S youth who present at the clinic as well as the larger LGBTQ2S youth community o Prevention and Health Protection e.g., help LGBTQ2S youth to make informed choices about STI prevention, testing and treatment o Health Maintenance, Restoration and Palliation e.g., develop a collaborative plan of care for LGBTQ2S youth who are at risk of HIV • Building Individual/Community Capacity e.g., use community development strategies to work with the LGBTQ2S youth community on sexual health issues • Building Relationships e.g., maintain awareness of LGBTQ2S youth community resources through attending interagency youth meetings • Facilitating Access and Equity e.g., make appropriate referrals for LGBTQ2S youth to access support services • Demonstrates Professional Responsibility and Accountability e.g., Seek professional development opportunities related to LGBTQ2S youth and sexual health

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2. To address the complications associated with STI and HIV, healthy public policy has been initiated and developed by policy-makers and health professionals, but often with little input from the public. How can CHNs use primary health care’s principle of public participation to inform the development of healthy public policy related to STI and HIV? CHNs can use public participation to inform the development of healthy STI and HPV public policy by: • •

Encouraging clients to participate in decisions about their own health e.g., offer feedback forums for the public on proposed STI and HIV prevention policies in schools Identify the health needs of communities e.g., work with a seniors community group to assess their needs related to STI and HIV 3. Social marketing campaigns can be effective in raising awareness about public health issues.

a. Create an idea for a social marketing campaign addressing rising rates of STBBIs. One idea for a social marketing campaign addressing STBBI is a campaign surrounding the importance of STBBI testing. b. What are the objective(s) of the campaign?

The objectives of the campaign are: • To increase awareness regarding the importance of STBBI testing • The importance of early detection of STBBIs • To promote the adoption of safer sex practices c. What is the message of the campaign?

The main message of the campaign is to get tested, if you’re sexually active d. How will the message be delivered?

The message can be delivered via: poster, pamphlet, transit, radio and television public service announcements, coasters, postcards, etc.

Further Resources Alberta Health Services - Talking About Sexuality in Canadian Communities Tascc.ca Alberta Health Services – Teachingsexualhealth Teachingsexualhealth.ca Canadian Public Health Association – STBBIs and Stigma .

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https://www.cpha.ca/sexually-transmitted-and-blood-borne-infections-and-related-stigma Action Canada for Sexual Health and Rights https://www.actioncanadashr.org/ Alberta Health Services www.ahs.ca/srh Canadian Public Health Association (2017). Discussing sexual health, substance use and STBBIs: A guide for service providers found at: https://www.cpha.ca/sites/default/files/uploads/resources/stbbi/discussionguide_e.pdf CATIE, Canada’s source for HIV and hepatitis C information. CATIE strengthens Canada’s response to HIV and hepatitis C by bridging research and practice. They connect healthcare and community-based service providers with the latest science, promote good practice for prevention and treatment programs. For more information: http://www.catie.ca/en/home Public Health Agency of Canada: Canadian Guidelines on Sexually Transmitted Infections http://www.phac-aspc.gc.ca/std-mts/sti-its/guide-lignesdir-eng.php Public Health Agency of Canada, Sexual Health and Sexually Transmitted Infections www.phac-aspc.gc.ca/std-mts Rainbow Health Ontario (RHO) is a program working to improve access to services and promote the health of LGBTQ2S communities. They provide valuable resources for all stakeholders including community groups, service providers, researchers, policy makers and educators. https://www.rainbowhealthontario.ca/about-us/ Sex Information and Education Council of Canada www.sieccan.org The Society of Obstetricians and Gynaecologists of Canada www.sexandu.ca TransCare BC aims to enhance coordination of transgender health services across British Columbia. Information for patients and health professionals. http://www.phsa.ca/ourservices/programs-services/trans-care-bc

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Chapter 32 Emergency Preparedness and Disaster Nursing

Chapter 32: Emergency Preparedness and Disaster Nursing Suggestions for Guest Speakers 1. Ask a nurse who works in emergency management to speak to the class.

2. Contact a staff member of the Centre for Excellence in Emergency Preparedness in Ottawa to Skype or teleconference with the class. http://www.ceep.ca/.

3. Ask a nurse who has been involved in a relief effort (hurricane, earthquake, war, etc.) to speak to the class about their experience.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students to list what they believe should be in a household emergency disaster kit.

Give them 5 minutes to list what they think each household should gather and store, in the event of an emergency. Then, give them 5 more minutes to discuss with a partner what they wrote and why they do/do not have a personal emergency response kit in their house or car.

Invite them to share their thoughts with the larger group.

The Government of Canada recommends a kit that is: Easy to carry – think of ways that you can pack your emergency kit so that you and those on your emergency plan can easily take the items with you, if necessary and contains: • • • • • • • • • •

.

Water – two litres of water per person per day (include small bottles that can be carried easily in case of an evacuation order) Food – that won't spoil, such as canned food, energy bars and dried foods (remember to replace the food and water once a year) Manual can opener Flashlight and batteries Battery–powered or wind–up radio (and extra batteries) First aid kit Special needs items – prescription medications, infant formula or equipment for people with disabilities Extra keys – for your car and house Cash – include smaller bills, such as $10 bills (traveller’s cheques are also useful) and change for payphones Emergency plan – include a copy of it and ensure it contains in–town and out–of–town contact information.

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Chapter 32 Emergency Preparedness and Disaster Nursing 2. Select an article to read and discuss from the Centre for Excellence in Emergency Preparedness Website. http://www.ceep.ca/publications.html 3. Locate your educational institution’s emergency preparedness plan. Divide the students up by specific hazard (earthquake, flood, chemical spill, power outage, etc.) and ask them to list what the institution is doing: • •

Before the disaster- in preparation and During the disaster- recommendation on what students should do, and not do, and how to get help.

If your institution does not have a plan, an example can be found at: http://umanitoba.ca/admin/vp_admin/risk_management/media/UMERPlanAug08.pdf Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text.

Practice Application 1. Ask the students to list what they believe should be in a household emergency disaster kit. Give them 5 minutes to list what they think each household should gather and store, in the event of an emergency. Ask them to identify what is missing from their personal household emergency kits.

The Government of Canada recommends a kit that is: Easy to carry – think of ways that you can pack your emergency kit so that you and those on your emergency plan can easily take the items with you, if necessary and contains: • • • • • • • • • •

.

Water – two litres of water per person per day (include small bottles that can be carried easily in case of an evacuation order) Food – that won't spoil, such as canned food, energy bars and dried foods (remember to replace the food and water once a year) Manual can opener Flashlight and batteries Battery–powered or wind–up radio (and extra batteries) First aid kit Special needs items – prescription medications, infant formula or equipment for people with disabilities Extra keys – for your car and house Cash – include smaller bills, such as $10 bills (traveller’s cheques are also useful) and change for payphones Emergency plan – include a copy of it and ensure it contains in–town and out–of–town contact information.

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Chapter 32 Emergency Preparedness and Disaster Nursing 2. Select an article to read and from the Centre for Excellence in Emergency Preparedness Website. http://www.ceep.ca/publications.html 3. Locate your educational institution’s emergency preparedness plan. Divide the students up by specific hazard (earthquake, flood, chemical spill, power outage, etc.) and ask them to list what the institution is doing: • •

Before the disaster- in preparation and During the disaster- recommendation on what students should do, and not do, and how to get help.

If your institution does not have a plan, an example can be found at: http://umanitoba.ca/admin/vp_admin/risk_management/media/UMERPlanAug08.pdf Seminar Discussion Questions Ask the students how a major emergency event (such as an earthquake or flood) would impact the populations that they are serving through their community programs. Consider how the age of clients, disability, language ability, economic situation and gender may affect their risk of surviving and thriving in the event of a disaster. Consider how you would react if a disaster occurred while you were working at your community placement. If you are responsible for children or dependent relatives, what would happen to them? Does your placement organization have a community plan?

Case Study 1. What type of disaster was the H1N1 influenza outbreak?

•

The 2009 H1N1 virus outbreak was a pandemic influenza.

2. What did the public health agencies’ IMS structures have to plan for when preparing mass vaccination clinics?

•

Public health agencies’ IMS structures had multiple elements to plan for when organizing the mass vaccination clinics. They had to secure appropriate locations to use for clinics, and they also had to ensure they had an adequate number of resources to run the clinics.

These resources included having adequate amounts of the vaccine, and supplies necessary to actually give the vaccine (syringes, needles, alcohol swabs, and refrigerators to ensure the continuum of the cold chain). Also, agencies had to ensure that they had adequate nursing staff who were prepared to vaccinate the population, and to run the overall clinics’ operations.

3. How can PHNs be better prepared to work in future pandemic influenza mass vaccination clinics?

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In future pandemic influenza mass vaccination clinics, training should be provided to those public health nurses who do not work in departments that are not related to providing vaccinations. This training should be specific and review procedures to vaccine administration, and how to follow up with clients for adverse outcomes. This training should be implemented during the mass vaccination clinic planning process, with adequate time for nurses to prepare prior to clinics actually opening to the public.

Canadian Research 32.1 1. Give examples of at least three types of MGs. •

Music concerts/events, parades, religious festivals/pilgrimages, political events/protests, sporting events, fireworks, schools, etc.

2. Give at least three examples of categories of mass casualties or incidents.

•

Gunman/shooting, fires/smoke inhalation, building/stage/barrier collapses, plane/train/car/bus crashes, human stampedes/riots, etc.

3. What are the possible actions and implications to prevent mass MCIs? •

Mass casualty incidents such as thermal, mechanical, electrical mechanical, explosives, toxic exposure, crowd management/control, and structural collapses can be prevented.

There needs to be rigorous research framework and good data collection about specific events to develop further knowledge of what caused the casualties. Multidisciplinary team needs such evidenced-based information to work collaboratively to shape the communication plans to ensure that the proper equipment will be used and traffic patterns and crowd control will be optimized. The medical professionals can focus on life saving measures and damage containment to prevent and/or to minimize mass casualty incidents or injuries.

Individual Critical Thinking Exercises 1. List the community health nursing competencies and skills required in order to participate in health emergency planning, such as for an outbreak or pandemic.

•

CHNs are accountable for having a basic understanding and knowledge of competencies related to emergency preparedness, management, and response activities.

They need to be knowledgeable of current emergency preparedness frameworks, structures, and responses within their own professional practice and place of employment. CHNs must apply the nursing process and be competent to respond in an emergency in areas such as leadership, communication and managing information, planning for and improving practice, and protecting worker health and safety.

2. What are the ethical issues a nurse must consider when preparing to respond to a disaster or emergency situation? .

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Nurses must ensure that the needs of vulnerable populations are addressing during disaster/emergency planning. The need for information exchange is significant in all phases of emergency management and particularly important in the case of vulnerable populations. Nurses play a critical role in facilitating this exchange of knowledge and information and must advocate for at-risk individuals and vulnerable populations to be present during disaster planning discussions to influence emergency preparedness and policies.

CHNs need to become familiar with local agency emergency plans and key agency personnel, and utilize their community mobilization skills to assist in identifying and developing the required health infrastructure to ensure emergency response readiness, surge capacity, and sustainability for these populations.

3. Discuss what CHNs must consider following a disaster.

•

Each disaster is unique. The way by which a disaster will impact a community depends upon the individual community’s social, cultural, economic, and health make-ups. Thus effective emergency preparedness and response is critical in any disaster situations. In this phase, nurses must measure the overall impact of the disaster to organize the coordination of community services to help residents in their recovery, reduce mortality rates, and reduce health care costs while improving the health status of the client/population. Positive outcomes include increased community relations, improved knowledge of disasters, improved disaster nursing plans, and decreased costs related to the disaster.

4. How does the PHAC play a key role in emergency preparedness?

•

In 2004, PHAC was created to work with Public Safety Canada to work with provincial and territorial government to coordinate unified responses to public health emergencies.

This federal agency does this by fostering collaboration across and between governments.

The agency provides leadership in promoting health, investigating and controlling disease outbreaks, and supporting public health infrastructure before and during public health emergencies.

Group Critical-Thinking Exercises 1. Due to flooding in a Northern Ontario reserve community, many First Nation families are unable to occupy their homes. Local politicians and emergency response planners have declared a disaster in the area and ordered citizens to evacuate to a shelter. a) Utilizing a health equity and social justice lens, discuss what essential public health services are needed in this situation.

•

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The public health priority would be to ensure safety for the community, in particular for those individuals who have minimal social supports and connections. Key public health safety measures focus on disease prevention such as the control of communicable diseases. In this disaster situation, it would include sanitation to provide proper waste and 257

Chapter 32 Emergency Preparedness and Disaster Nursing carcass disposal, availability of clean water supply, proper storage of food, and safe shelters for those who have minimal access to these services. Once these emergency measures are in place, other activities should focus on helping these families to focus on coping with their loss and to attain a sense of normalcy in their lives.

•

Nurses would need advocate for those individuals who are members of vulnerable populations to ensure that their needs are met. For example, nurses can help deliver clean water and food to those who do not have access. Also, they can help organize and participate in the transporting of individuals to safe shelters who have limited mobility and/or access to transportation.

b) How would nursing students assist in this response?

•

The School of Nursing would need to collaborate with local officials to deploy student nurses to assist in conducting surveillance for infectious disease outbreaks (e.g. diarrhea and vomiting), assist in educating the public about food safety, water safety, preventing injury, and provide information to community officials. Nurses will assist to sort, name and inventory supplies. Nurses will need to have knowledge on treating people in shelters during hot and cold weather. Nurses will need to assist in the removal of elderly and disabled people from their homes.

2. What special considerations need to be given when a disaster takes place in developing countries or First Nation communities?

•

For countries or communities that are already poor and/or under developed, a disaster can further add to all the burdens they are already experiencing (e.g., Jan 12, 2010 earthquake in Haiti). International efforts to form a global community to assist such communities are just humanitarian acts. The survivors of disasters will need to be cared for as quickly as possible, not just physically, but psychologically, spiritually, and economically. The social determinants of health must be considered, and Maslow’s basic needs from food, water and shelter are their fundamentals human rights. Medical, technical, human, and economic resources could help build the communities to return to their normalcy. Primary health care principles will help guide provision of essential health care to the community at every stage of its recovery period after the disaster to become self-reliant.

3. Discuss what lessons were learned from disasters such as the SARS crisis for emergency preparedness planning.

• •

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Steps must be taken to protect the health of the front-line workers. Need to develop safety culture in workplace.

Some disasters may be unavoidable or unforeseeable, but they likely could have been controlled more quickly with a stronger public health system and disease surveillance.

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Embrace precautionary principle, take reasonable actions to reduce risks, and not await scientific certainty.

Advanced outbreak planning will control spread of infection. Infection control efforts and occupational health standards must be enforced and collaborate in operation.

Mandate and properly fund surveillance standards in hospitals and public health agencies for emergency preparedness such as outbreaks or disasters.

Further Resources Canadian Nurses Association. (2008). Nurses’ ethical considerations in a pandemic or other emergency. http://cna-aiic.ca/~/media/cna/page-content/pdfen/ethics_in_practice_august_2008_e.pdf Danna, D., & Cordray, S. E. (2010). Nursing in the storm: Voices from Hurricane Katrina. New York: Springer Pub. Co. Goodwin Veenema, T. (2007). Disaster nursing and emergency preparedness for chemical, biological, and radiological terrorism and other hazards (2nd ed.).New York: Springer Publishing Health Canada. (2009). Emergency Management: Taking a Health Perspective. Retrieved from http://www.hc-sc.gc.ca/sr-sr/pubs/hpr-rpms/bull/2009-emergency-urgence/index-eng.php#a9 Sullivan T. L., Dow D., Turner M. C., Lemyre, L., Corneil, W., Krewski, D., Phillips, K. P., & Amaratunga, A. (2008). Disaster and emergency medicine: Canadian nurses' perceptions of preparedness on hospital front lines. Prehospital & Disaster Medicine, 23, 8-11.

CDC Bioterrorism Preparedness & Response www.bt.cdc.gov/www.bt.cdc.gov/Documents/Planning/PlanningGuidance.PDF Center for Research on the Epidemiology of Disasters (CRED) www.cred.be/ International Federation of the Red Cross (IFRC) www.ifrc.org Public Health Agency of Canada-Emergency Preparedness and Response http://www.phac-aspc.gc.ca/ep-mu/index-eng.php

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Chapter 33 Global Health

Chapter 33: Global Health Suggestions for Guest Speakers 1. Ask a nurse who was educated in another country to speak to your class about his/her nursing school experience, and why he/she decided to immigrate to Canada.

2. Ask a nurse who has worked for an aid organization overseas such as CARE, MSF or World Vision to discuss issues of international nursing.

3. Invite a global health nurse researcher to discuss their work and some of the challenges of working in this field.

Classroom Activities 1. Clarify any questions about the information from the text.

Practice Application 1. Ask the students to consider what it means to be a global citizen. How might they demonstrate reflexivity, moral cosmopolitanism, and narrative imagination in their lives?

What might change (or has changed) about their day-to-day living if they truly embraced global citizenship?

2. Direct the students to read the article Nurse Migration: A Canadian Case Study by Lisa Little (Health Serv Res. 2007 June; 42(3 Pt 2): 1336–1353), found at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1955372/ Discuss some of the reasons why nurses choose to move from their country of education to Canada, and why nurses educated in Canada choose to leave. Ask them to consider if there should be limits as to the number of nurses that Canada can receive from a certain country. Ask them to write a two-paragraph response to the question: What special restrictions should there be on nurses wanting to move to Canada? Who benefits? Who suffers?

Ideas for Self-Study and Distance Students 1. Have an on-line or phone chat about the information from the text

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Chapter 33 Global Health Practice Application 1. Ask the students to consider what it means to be a global citizen. How might they demonstrate reflexivity, moral cosmopolitanism, and narrative imagination in their lives?

What might change (or has changed) about their day-to-day living if they truly embraced global citizenship?

2. Direct the students to read the article Nurse Migration: A Canadian Case Study by Lisa Little (Health Serv Res. 2007 June; 42(3 Pt 2): 1336–1353), found at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1955372/ In written form discuss some of the reasons why nurses choose to move from their country of education to Canada, and why nurses educated in Canada choose to leave. Ask them to consider if there should be limits as to the number of nurses that Canada can receive from a certain country. Ask them to write a two-paragraph response to the question: What special restrictions should there be on nurses wanting to move to Canada? Who benefits? Who suffers?

Seminar Discussion Questions What are the issues related to being a global citizen at the organization that you are carrying out your clinical placement in? Consider your own nursing education experience. What would be different about your education and your lifestyle as a student if you were living in a majority country? Might you consider working in a majority country? Why? Why not? Does your agency serve people from a variety of countries of origin?

Case Study Questions 1. Which of the SDGs we discussed relate to this case study?

Goals 1, 2, 3, 4, 5, 6, 8, and 16 are particularly relevant. Students should be able to pull out details from the case study that apply to each 2. How would you as a CHN work with the community to identify three priority areas for action on health?

Individual answers will vary. Students are expected to pull through concepts presented in other chapters including capacity building, empowerment, and principles of primary health care.

Steps to include: • • .

Adopt a partnership approach from the outset Carry out a community assessment (involve key stakeholders) 261

Chapter 33 Global Health • • • • • •

Culturally sensitive approach Identify priorities in partnership with the community Build on strengths, identify and address challenges Set realistic short, middle and long-term goals Build capacity Consider a community development approach

3. Suppose the priority areas identified with the stakeholders are education, sanitation, and immunization. Suggest some short-term and long-term goals in relation to these three areas.

Individual answers will vary depending on which direction the students and community decide to take. Students must be able to provide rationale for their choices.

Points to consider during the discussion include feasibility of the goals, priority setting, how to ensure there is a true partnership with the community, economic issues, sustainability.

In addition, have all the principles in Question 2 (above) been considered when setting these goals?

Canadian Research 33.1 1. In the context of global health and working with resource-poor populations, should you as CHN be aware of power in relationships, and giving voice to at risk populations?

Explain.

•

Depending on the country and the current issues at the time of discussion, issues about power in relationships may include building: family violence, status of women, political repression, war and civil unrest, poverty, food insecurity, access to health care.

2. How can CHNs, in partnership with others, support women in the perinatal period when working in another country context?

•

Could include (among other interventions): information giving, screening for pre- and post- partum depression, advocacy, establishing women’s support groups, capacity building, referral to other agencies (social work, counseling, family physician) as appropriate.

3. How can the CHN integrate culturally safe care into practice with this population?

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Chapter 33 Global Health •

Ensure interventions are culturally appropriate (for example, depression screening tools such as The Edinburgh Post-Natal Depression Screening Tool has not been validated for use with all cultures, due to varying cultural meanings and experiences attributed to ‘depression’).

•

Consider working within a framework of Cultural Attunement (Hoskins 1999): i.

Acknowledging the pain of oppression ii. Engaging in acts of humility iii. Acting with reverence iv.

Engaging in mutuality v.

Maintaining a position of ‘not knowing’

Individual Critical Thinking Exercises 1. Define global citizenship in your own words and describe it using examples from your life story or that of someone close to you.

The key notions for global citizenship are that one must: -

have moral responsibility and professional competency to promote the health of clients beyond their personal environments. reflect on their own values and beliefs and be sensitive to the needs of clients within their cultural context. view all persons as part of our community of respect and concern, and go beyond one’s own constraints and interests. understand the how politics determines the relationships of one another across the globe, and be able to critically challenge oppressive power in relation to social justice, and change.

Examples: Students can reflect and describe their experiences when they work with individuals outside their immediate community or country.

2. Imagine you are working in a First Nation community in Canada. a) In what ways might you see the effects of globalization on the community?

-

.

Assess if there is an unbalanced outcomes or inequity in health for the First Nations community and the rest of the communities in the country and elsewhere. Assess disparities across all sectors and resources that support community health, i.e., from education, to income, employment status, accessibility to health services, safety, government, environments, life expectancies, mortality and morbidity rates, etc.

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Chapter 33 Global Health b) How might the SDGs apply to First Nation communities in Canada?

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The UN summit discussed the need to address poverty as arguably the most pressing social determinant of health globally. Please refer to Table 31.3 for the Millennium goals and health outcomes related to hunger, education, gender equity, improved maternal health, and infectious diseases.

3. As you have come to understand the role of CHNs throughout the text, how do you now understand this role specific to a global health perspective?

CHNs must view themselves as global citizens; they must look past individual care and determine how they care for the citizens of the globe. They need to emphasize the connectivity and interplay of social, economic, political, and cultural issues, and develop their capacity in identifying tensions between personal professional interests and global interests. As CHNs address the social disparities and sufferings in the minority worlds, their ultimate goal is to create sustainable actions to achieve health for all.

4. Write a brief rebuttal to the following statement: “Public health, international health, and global health are really all the same anyway, so making distinctions in language is not meaningful or useful.”

In writing the rebuttal, students must have a clear understanding of the difference among public health, international health and global health. Refer to Table 33.1.

Group Critical Thinking Exercises 1. This is an experiential group reflection exercise – no “correct” answers; rather, we encourage facilitators to help students to think about the sub-points as indicated.

2. Global health issues that may arise include: - What are the choice of actions that you must consider given the language barrier - How do you go about protecting patient confidentiality while gathering accurate information Some implications for nursing practice that would reflect global citizenship include: - Utilizing one’s narrative imagination to try to imagine Mrs. Chen’s perspective and experience of health in a medical environment in which she is not accustomed to - Ethical considerations regarding the feelings of the granddaughter who must interpret sensitive and difficult questions, such as “Have you ever thought of harming yourself?”; need to imagine and consider what it would be like for the young girl to learn that her grandmother may be thinking of killing herself

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Chapter 33 Global Health 3. Some taken-for-granted assumptions may include: - Local nurse and health workers’ competence and knowledge is inferior to Western knowledge - The “right” way of care is the Western method - Western interventions can be implemented effectively These assumptions may result in the nurse from the minority world disregarding the perspectives of alternate approaches to health, as these assumptions may give the nurse an ethno-centric view of believing that their work is superior. Nurses may become challenged to recognize the unique context of the resource-constrained area and the reasons behind why the health clinic operates the way it does. Nurses may also be challenged in their reflexivity and their ability to imagine the roles in which others play.

Discomfort in taking action may arise when nurses are confronted with a lack of resources that are regularly available elsewhere. While the nurse may have the knowledge and capacity to determine what needs to be done, there may be an infrastructural limitation that the nurse must overcome.

Further Resources Levine, R. (2007). Case studies in global health: Millions saved. Jones and Bartlett Chavez, F., Peter, E., & Gastaldo, D. (2008). Nurses as global citizens: A global health curriculum at the U niversity of Toronto, Canada. In Tschudin, V. The globalisation of nursing: ethical, legal and political issues. Abingdon, UK: Radcliffe Publishing Ltd. Kirkham, S.R., & Browne, A.J. (2006). Toward a critical theoretical interpretation of social justice discourses in nursing. Advances in Nursing Science, 29(4), 324-339.

Center for Global Development www.cgdev.org Consortium of Universities for Global Health www.cugh.org Global Health Action www.globalhealthaction.org Global Health Education Consortium www.globalhealthedu.org International Council of Nurses www.icn.ch/ World Health Organization http://www.who.int/en

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 1 The History of Community Health Nursing in Canada

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Origins of Community Health Nursing (1 of 3)

• Indigenous medicine and healing practices were the earliest forms of healthcare in Canada in meeting the health needs of communities • First Peoples using traditional medicines and healing practices provided healthcare and knowledge to European settlers • Earliest forms of community health nursing are traced to the 17th century New France and the Duchesse d’Aiguillon sisters .

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Origins of Community Health Nursing (2 of 3)

• The Grey Nuns assisted in the development of health services and education within communities across Canada • Challenging conditions in the 19th century, including social unrest shaped the provincial organization and financing of the public health system and community health nursing.

• The development of the nursing profession, predominantly influenced by Florence Nightingale and women’s groups, including work of Mary Seacole and Lady Aberdeen .

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Origins of Community Health Nursing (3 of 3)

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Evolution of Nursing Practice (1 of 4) • Duchesse d’Aiguillon sisters work emulates today’s community health nursing practice that focuses on health inequities the determinants of health, community outreach and advocacy

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Evolution of Nursing Practice (2 of 4) • Marguerite d’Youville, who established the Grey Nuns, were the first Canadian community nursing order and established relationships with First Nation people to learn about health and healing – The Grey Nuns understood health inequity and made significant contribution to providing access to health services, food, shelter, and education for the most vulnerable – First form of ‘street outreach nursing’ in the early 1700s when the Grey Nuns began public health visits

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Evolution of Nursing Practice (3 of 4) • Jeanne Mance, Canada’s first nurse, confronted political, social, and economic forces to establish a range of community health services that include the founding of the Hotel-Dieu Hospital.

– Mance provided direct nursing care, advocated for social justice and was the administrator of the hospital

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Evolution of Nursing Practice (4 of 4) • Lady Aberdeen and women’s groups created Victoria Order of Nurses (VON) that developed community health services for the rural and poor communities and immigrant women – Local VON has a dual mandate: charitable work among the poor and provision of affordable nursing care to the working and middle class

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Socioecological Context of Community Health Nursing (1 of 3) • Socioecological challenges occurred due to immigration, inability to provide basic health to settlers and Indigenous peoples experiencing epidemics introduced by immigrants

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Socioecological Context of Community Health Nursing (2 of 3) • Health promotion influenced by Florence Nightingale and Mary Seacole use of epidemiology, statistics, awareness of environmental factors and social determinants of health – The Nightingale model of training nurses was a significant milestone in development of the profession, with the first nursing school established in St. Catharines, Ontario in 1874

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Socioecological Context of Community Health Nursing (3 of 3) • Elizabeth Smellie’s military nursing demonstrated competencies of CHN, population health, primary, secondary and tertiary prevention, emergency preparedness and disaster nursing

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Leadership in Community Health Nursing (1 of 6) • CHNs pioneers possessed a sense of adventure, independence, courage, and humanitarianism • Offered services to those living in the poorest urban districts and most isolated rural communities • Pioneer CHNs met the immediate needs of communities for direct care and midwifery and provided health and prevention education to individuals and families .

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Leadership in Community Health Nursing (2 of 6) • Volunteerism and leadership were integral in the development of CHNs. • Rural women’s groups lobbied local officials, and enabled CHNs to fulfill their professional obligations to the fullest extent.

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Leadership in Community Health Nursing (3 of 6) • The Red Cross played a pivotal role in advancing the education of PHNs by providing funding for certificate courses in public health at five Canadian universities • PHNs knowledge and scope of practice focus on maternal child programs, communicable diseases, school health, and social welfare issues

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Leadership in Community Health Nursing (4 of 6) • The Weir Report (1932) recommended that the number of nurses in Canada should be immediately doubled as well as recommendations for university standards of education and support of public health nursing as a nursing specialty

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Leadership in Community Health Nursing (5 of 6) • Epidemics of TB, diphtheria, smallpox, cholera, typhus, measles, and influenza were the greatest killer of many Indigenous populations after first contact with European settlers

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Leadership in Community Health Nursing (6 of 6) • CHNs are an integral part of health services in the North.

• Initiation of mobile health services to deliver communicable disease control.

– Created first nursing station and numerous outpost nursing stations throughout Canada serving settlers and Indigenous communities – Infant mortality rates and some morbidity rates had declined substantially

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Critical Events Influencing the Milestones of Community Health Nursing, Mid-1960s to Present

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Future of Community Health Nursing (1 of 3)

• Romanow Commission’s report (2002) recommends shifting policy toward primary healthcare, home healthcare, and health promotion, with nurses playing key role • CHNs must be part of a sustainable public health workforce with emphasis on intersectoral policy development and interprofessional collaboration

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Future of Community Health Nursing (2 of 3)

• CHNs must continue to be strong policy advocates and increasingly focus their practice on the social determinants of health • Increase in Indigenous nurses working in First Nation communities

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Future of Community Health Nursing (3 of 3)

• The Canadian Indigenous Nurses Association has been instrumental in establishing culturally competent health care and cultural safety in the North • CHNs are responding to the health inequities found in Northern Indigenous communities, collaborating with Indigenous communities and organizations addressing the Truth and Reconciliation Commitment to Action .

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Future of Community Health Nursing • CHNs remain front and centre in promoting the principles of primary health care in Northern Indigenous communities.

• Professional organizations such as CHNC support the social justice framework of nurses in the community.

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 2 Policy, Politics, and Power in Health Care

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Historical Milestones in Community Health Nursing in Canada (1 of 2) • The Canadian Constitution requires provinces to provide comparable levels of public service for comparable taxation • The federal government encourages equalization by contributing money and giving conditions under which that money is received

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Historical Milestones in Community Health Nursing in Canada (2 of 2) • Provincial government of Saskatchewan establishes publicly funded healthcare in 1947 and federal government follows suit in 1957 • Canada Health Act passes in 1984 reinforces five central points across provincial healthcare systems: 1) publicly administered 2) comprehensive 3) universal 4) portable 5) accessible

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Paradigm Shift in Community Health Nursing (1 of 2) • The Lalonde Report of 1974 presented a vision for health promotion services as a critical component of Canada’s health care system • Lalonde’s framework identified four determinants of health: environment, lifestyle, human biology, and the health care system

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Paradigm Shift in Community Health Nursing (2 of 2) • Primary health care goal is the attainment of better health services for all • Epp Framework formed the basis of the Ottawa Charter for Health Promotion • The Ottawa Charter marked a dramatic shift in health promotion

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Organizations of Community Health Nursing (1 of 5) • Many factors influence how community health nursing is organized and delivered across Canada, including emerging diseases and health emergencies.

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Organizations of Community Health Nursing (2 of 5) • Public Health Agency of Canada (PHAC) - Delivers federal government’s commitment to: – help protect the health and safety of all Canadians – focus on prevention chronic diseases and injuries – responds to public health emergencies and infectious disease outbreaks, – strengthening the practice of public health in Canada.

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Organizations of Community Health Nursing (3 of 5) • There are a limited number of Indigenous-specific policies and frameworks.

• Some provinces have no specific legislative framework for the responsibilities of health care in Indigenous communities.

– Ontario was the first province to develop an Indigenous Health and Wellness Strategy in 1990 and to develop the overarching Aboriginal Health Policy in 1994

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Organizations of Community Health Nursing (4 of 5) • Community Health Services - Most Canadian provinces and territories have moved to regional health authority structures for all health service delivery and strives to integrate most or all health services (including CHN services) – Primary Health Care – primary care is a core component – Primary Care – first contact in of clinical services – Public Health - enhances health status of communities and promotes health equity

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Organizations of Community Health Nursing (5 of 5) • Community Health Services - Most Canadian provinces and territories have moved to regional health authority structures for all health service delivery and strives to integrate most or all health services (including CHN services) – Cultural Competence - reduces health inequities and improves health outcomes – Home Care – safe care for individuals in their homes with dignity

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Policy, Politics, and Power (1 of 2) • Community health nursing practice occurs in a sociopolitical environment.

• Policy guides the work of community health nursing, and policy making is carried out within a political context

• CHNs must understand how policy and politics impact on the quality, safety, and accessibility of patient care and their working conditions.

• Power is knowing the team members and their roles, which team members are part of the decision making process, and future leaders .

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Policy, Politics, and Power (2 of 2) • Health equity is undermined when these social conditions interact to prevent people from making decisions or taking actions that would promote health.

• Fairness in the way we treat people or make decisions are core aspects of social justice.

• A key part of ensuring good health for all is identifying and enhancing systemic disadvantage.

• CHNs must effectively navigate this complex policy environment by acknowledging the implications of sociopolitical processes on their practice: micro and macro levels .

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Challenges in Community Health Nursing (1 of 3) • CHNs influence the health of individuals, families, communities, and society as a whole. Some challenges they encounter include: – Health system challenges - need for advocacy and collective action to shape system change – Lack of role clarity - need for greater role clarity for CHNs across Canada – Need for strong leadership – lack of contributes to invisibility of CHNs – Issues in interprofessional relationships – strong organizational supports needed .

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Challenges in Community Health Nursing (2 of 3) • A central strategy for all CHNs is developing leadership and community influence • The Registered Nurses Association of Ontario created “Best Practice Guideline: Developing and Sustaining Nursing Leadership” to discuss the positive impact of leadership in the workplace and community

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Challenges in Community Health Nursing (3 of 3) • Nurse leaders must create and articulate a clear purpose and vision with a broad perspective incorporating multiple aspects of communities, the political environment, and the larger health and social systems • Attributes that support community and public health nursing practice include: management practice; organizational culture; and government policy .

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 3 Nursing Roles, Functions, and Practice Settings

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Blueprint for Action • The Blueprint for Action for Community Health Nursing in Canada (2011) provides a framework for ongoing dialogue on the development of community health nursing practice in Canada • The Blueprint identifies six areas of action • The purpose of the Blueprint for Action is to inform decisions about CHN practice and promote and protect the health of Canadians

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Professional Practice Model and Standards of Practice (1 of 3) • There are eight Canadian Community Health Nurses Standards of Practice (Table 3.1) • The next version of the standards and the professional practice module will integrate Indigenous nursing and health • Current practice reflects a greater emphasis on social justice and the social and environmental determinants of health • The standards are used by employers, to implement professional development programs, inform educational curricula and guide research .

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Professional Practice Model and Standards of Practice (2 of 3)

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Professional Practice Model and Standards of Practice (3 of 3) • CHNs provide care to populations that experience health inequities and health disparities • Populations experiencing health inequities in Canada include: First Nations, Métis, Inuit; LGBTQ2S or sexual orientation; gender identity minorities; and newcomers

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Professional Practice Model and Standards of Practice (2 of 2) • CHNs can confront Indigenous health inequities by identifying prejudice among health workers and integrating trauma-informed care into their standards of practice • By providing services for all Indigenous peoples and advocating for better supports for health workers in Indigenous communities CHNs will help to address inequities

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CHN Roles, Competencies and Practice Settings (1 of 6) • Indigenous nursing involves First Nation, Inuit, and Métis nurses’ care, beliefs, values, practice, traditional knowledge and education, research, administration, and policies • Public health nursing utilizes knowledge from public health, nursing, social and environmental sciences, and research.

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CHN Roles, Competencies and Practice Settings (2 of 6) • Home health nursing is a specialized area in which the nurse, employed by a home health agency, provides clinical care in the client’s home, school, or workplace.

• Primary care nurses provide the first contact with the health care system

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CHN Roles, Competencies and Practice Settings (3 of 6) • Telehealth nurses triage of health issues; consult; provide advice, counsel, support, and educate; as well as coordinate care for chronic disease management • Outreach/street nursing see their clients where they are and focused on building relationships while maintaining a safety, dignity of and respect for the clients

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CHN Roles, Competencies and Practice Settings (4 of 6) • Rural and Northern Canada nurses work in the community, homes, schools, clinics, outpost nursing settings/stations, and First Nation, Inuit, and Métis communities.

• Military nurses are commissioned nursing officers of the Canadian Forces Medical Service.

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CHN Roles, Competencies and Practice Settings (5 of 6) • Occupational health nurses base their practice on four interrelated components: individual, health, occupational health nursing, and the environment • Parish nurse has specialized knowledge to promote health, healing, and wholeness; hired or recognized by a faith community and integrates faith and health into nursing practice

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CHN Roles, Competencies and Practice Settings (6 of 6) • Forensic nurses provide for health care needs and to collect evidence for police and the legal system in a way that respects clients’ dignity, right to choice, and self-determination.

• Community mental health nursing role involves a blending of community nursing and mental health/psychiatric nursing.

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Expansion and Regulation of Practice (1 of 2)

• In Canada there are four regulated nursing groups within the profession: RNs, nurse practitioners, licensed/registered practical nurses, and registered psychiatric nurses.

• According to the College of Nurses of Ontario, there are guiding principles to distinguish RN and L/RPN practices.

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Expansion and Regulation of Practice (2 of 2)

• Nurse practitioners (NPs) are advanced practice nurses. Titles used by NPs vary across practice settings and provinces and territories.

• Registered psychiatric nurses: educated and regulated only in the western provinces of British Columbia, Alberta, Saskatchewan, Manitoba, and the Yukon territory

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Emerging Trends in Community Nursing (1 of 2) • The practice standards for CHNs include using political and social advocacy to change the conditions that lead to marginalization and inequities • The use of Information communication technology (ICT) such as workstations and tele monitoring applications is expected of CHNs and continues to expand nursing practice

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Emerging Trends in Community Nursing (2 of 2) • Evidence-based practices are becoming increasingly important for CHNs, such as the guidelines of the Registered Nurses’ Association of Ontario (RNAO) • With rising rates of chronic preventable diseases, preparation for CHN in undergraduate nursing programs is becoming more important

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 4 Public Health Nursing

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Public Health • Public health is the organized efforts of society to prevent injury, illness, and premature death.

• Public health focuses on protecting and promoting the health of all Canadians through a combination of programs, services, and policies.

• The Public Health Agency of Canada was instituted in 2004 • The average lifespan of Canadians has increased and is attributed to advances in public health and the work of public health professionals .

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Public Health Nursing (1 of 2) • PHNs practise in various settings; focus on disease prevention, non-communicable chronic diseases, injuries, and lifestyle risks to health.

• Health of the environment is also a priority focus, especially with the threats brought on by global climate change, deterioration of the ecosystem, and land-use change.

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Public Health Nursing (2 of 2) • PHNs focus on social justice and are committed to reducing inequities in health.

• PHNs promote and advocate for the health and quality of life of mothers and children (particularly younger mothers and mothers of low socioeconomic status)

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Historical Evolution of Public Health Nursing (1 of 2) • Early PHNs worked with low-income communities which differentiated them from hospital nurses or private nurses in high-income homes • PHNs focused primarily on improving physical environmental conditions to reduce maternal and child morbidity • Many early PHNs worked for religious or charitable organizations

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Historical Evolution of Public Health Nursing (2 of 2) • As public health programs became more complex, PHNs were hired to work in civic health departments across Canada • In addition to maternal, infant and childhood mortality, PHNs were instrumental in delivering immunization and vaccination programs

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Fundamentals of Public Health Nursing (1 of 2)

• PHNs function under laws and regulations of various government bodies that oversee public health and sometimes challenge current laws to support community health • PHNs must have a working knowledge of federal, provincial, territorial governments, as well as Indigenous organizations

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Fundamentals of Public Health Nursing (2 of 2)

• PHNs are population-oriented and must possess a comprehensive knowledge base in areas such as epidemiology to assess population-level health threats • PHNs population oriented approach allows for effective intersectoral collaboration

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Competencies of Public Health Nursing (1 of 2)

Table 4.1 identifies discipline-specific competencies for Public Health Nurses: 1. knowledge derived from public health and nursing science; 2. skills related to assessment and analysis; 3. conducting policy and program planning, implementation, and evaluation;

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Competencies of Public Health Nursing (2 of 2)

Table 4.1 identifies discipline-specific competencies for Public Health Nurses: 4. achieving partnerships, collaboration, and advocacy; 5. promoting diversity and inclusiveness; 6. effective communication exchange; 7. leadership capabilities; and 8. professional responsibility and accountability. .

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Core Functions of Public Health Nursing Table 4.2 highlights the roles, responsibilities, and essential six public health functions: 1. Health protection,

2. Health surveillance, 3. Population health assessment, 4. Disease and injury prevention, 5. Health promotion, and 6. Emergency preparation and response. .

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Social Justice and Public Health Nursing (1 of 2) • PHNs focus on social justice as they work toward achieving equal rights and opportunities for individual citizens, families, communities, and populations • PHNs are committed to reducing health inequities that are unjust and avoidable by focusing on the basic prerequisites for health (i.e. shelter, education, food, and income),

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Social Justice and Public Health Nursing (2 of 2) • PHNs examined and addressed issues by lobbying for community-wide programs or systems-level policy change and through direct contact with individual citizens • PHNs advocate for healthy public policy and social justice by participating in legislative and policy-making activities that influence determinants of health and access to services

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Levels of Prevention (1 of 2) It is important to note that PHNs intervene at five levels of prevention: • Primordial prevention: initiatives prevent conditions that would enable the risk factors for disease from developing • Primary prevention: risks of illness, disease, and injury are eliminated • Secondary prevention: the disease process is suspended before symptoms occur .

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Levels of Prevention (2 of 2) It is important to note that PHNs intervene at five levels of prevention: • Tertiary prevention: the impairment or disability from the disease process is halted • Quaternary prevention: initiatives identify individuals or populations at risk of overmedicalization

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 5 Home Health Nursing in Canada

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Evolution of Home Health Nursing (1 of 4) • Seventeenth century religious orders provided first home care in Quebec in the form of direct care and disease prevention • Today, home health nursing focuses on chronic and rehabilitative healthcare for an aging population that allows people to live independently in their communities

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Evolution of Home Health Nursing (2 of 4) • Home care is recognized as an “extended health service” and is not a publicly insured under the Canada Health Act. • Federal government and all provinces and territories had launched home care programs by 1988, and in 1999 home care was extended to First Nation and Inuit communities

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Evolution of Home Health Nursing (3 of 4) • Key initiatives in home health policy: – Kirby Report (2002): recognized the need for home care and recommended federal, provincial and territorial collaboration to develop standards and incentive programs – Romanow Commission (2002): described home care as fastest growing component of healthcare and the next essential health service – First Ministers Accord on Health Care Renewal (2003): established commitment to provide for “a basket of services for acute and end of life services” .

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Evolution of Home Health Nursing (4 of 4) • While jurisdictions share a common definition of home care, there are variations in mandate, principles, and services

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Role of Home Health Nursing (1 of 2) • Home health nursing provides care to acute, chronically ill, and well clients of all ages in a variety of community settings (i.e. home, school, workplace) • Work within an interprofessional team with other community members, such as police service, support workers and physicians

• Collaborate with client and family to identify healthcare needs, goals, and necessary resources .

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Role of Home Health Nursing (2 of 2) • Apply knowledge of primary health care, nursing science, and social science; with focus on prevention of health deterioration and on health restoration, maintenance or palliation.

• Assess family’s coping and ability to provide ongoing care for a client as it is an expectation that these supports are in place to supplement the publicly funded service

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Practice, Competencies, and Outcomes (1 of 4)

• Competencies for Home Health Nursing three overarching categories: Elements of Home Health Nursing; Foundations of Home Health Nursing; and Quality and Professional Responsibilities • HHNs work according to local health authority policies and procedures, provincial legislation, nursing evidence, and doctors’ orders.

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Practice, Competencies, and Outcomes (2 of 4)

• An important core competency is to facilitate access to health care to ensure care is both respectful and culturally sensitive to avoid discrimination and ensure equitable care.

• Another aspect central to HHN is the ability to communicate and build a relationship with the client and their family.

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Practice, Competencies, and Outcomes (3 of 4)

• In Ontario, several home care organizations have collected nursing-sensitive outcomes called CHealth Outcomes for Better Information and Care (C-HOBIC).

• The C-HOBIC are a the collection of standardized information that helps to assess the outcomes of Home Health Nursing

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Practice, Competencies, and Outcomes (4 of 4)

• C-HOBIC offers an important way to understand the needs of clients for links to the community and ongoing connections with primary care providers • HHNs play a major role in individualized health promotion and preventive care by providing health assessment, support, and access to resources through home visits

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Organizational Support (1 of 2) • HHNs require supports and infrastructure to maintain high-quality clinical care and a positive work environment. These supports include the following: – Support for Evidence-Informed Decision Making and Evidence-Informed Practice ▪ an important part of the nursing care delivered in home health.

• Leaders – play a key role in shaping the workplace culture professional practice environment .

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Organizational Support (2 of 2) • HHNs require supports and infrastructure to maintain high-quality clinical care and a positive work environment. These supports include the following: • Professional Development – self-regulation and ongoing professional development is a high priority

• Clinical Networks and Organizations Structures – Need the support of clinical experts and other organizational infrastructures to provide care excellence .

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Rewards of Home Health Nursing • Autonomous nature of the role and when possible enjoy working to their full scope of practice.

• Lead for care coordination and access to additional resources and services to ensure that patient outcomes are achieved • Therapeutic relationship HHNs develop with the client and his or her family in the community

• Variety of clients and clinical situations in their caseload, and following clients over time gives a sense of connection and accomplishment. .

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Challenges in Home Health Nursing • Changing client demographics • Difficulty working conditions • Lack of education regarding home care

• Challenges of ongoing professional development • Lack of national home care strategy • Inadequate funding • Shift to informal caregivers • Lack of HHN role clarity .

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Health Equity in Home Health Nursing Given the systemic issues, it is not surprising that several vulnerable populations do not receive equitable home care in Canada. These include the following: • First Nation and Inuit Communities • People who are homeless or vulnerably housed

• People experiencing mental illness • People who live in rural and remote areas .

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Future of Home Health Nursing (1 of 2) • Home care will continue to grow: Vision 2020, a discussion document, predicted that two-thirds of nurses will be working in home care by 2020 • Access to information transforms the relationship between client and healthcare provider and allows them to enable collective decision making

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Future of Home Health Nursing (2 of 2) • Role of technology will continue to develop a health “ecosystem” around the client and their family • Technology will manage multiple sources of data input, synthesize the information, and use it to benefit the client.

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 6 Advocacy, Ethical, and Legal Considerations

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Ethical Values of Canadian Nursing CNA “Values and Ethical Responsibilities”: • providing safe, compassionate, competent, and ethical care;

• promoting health and well-being; • promoting and respecting informed decision-making; • honouring dignity;

• maintaining privacy and confidentiality; • promoting justice; • and being accountable .

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Attributes of Social Justice (1 of 4) • 10 social justice attributes: equity, human rights, democracy and civil rights, capacity building, just institutions, enabling environments, poverty reduction, ethical practice, advocacy, and partnerships • Social justice assumes that all societies experience systematic oppression and inequities (i.e. racism, sexism, heterosexism, classism), which affect some people more than others .

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Attributes of Social Justice (2 of 4) • Every individual contributes to oppression and inequity, even if unintentionally, and are responsible for contributing to the achievement of social, political, and economic parity.

• Social justice is important when situating the ethical dimensions of health-care policy within a broad political understanding of the role of health care services in society.

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Attributes of Social Justice (3 of 4) There are three important features of social justice approaches that are useful to consider when using social justice as a framework for community nursing practice.

• Social justice approaches tend to be concerned with the ethical use of power in health care.

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Attributes of Social Justice (4 of 4) • Social justice approach tends to view persons relationally as unique, connected to others, and interdependent; that is, vulnerable and unequal in power.

• Social justice tends to elicit concern for issues of everyday life and not primarily with crisis issues.

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Ethical Issues in Community Health Nursing (1 of 2) Ethical and legal issues can arise in community health nursing practice. These include: • health promotion, prevention and health protection, • and health maintenance, restoration, and palliation.

One way of addressing ethical concerns is to implement the five levels of prevention: primordial, primary, secondary, tertiary, and quaternary prevention .

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Ethical Issues in Community Health Nursing (2 of 2) Specific areas of ethical and legal concern relate to: • capacity building, • access and equity,

• and professional responsibility and accountability • negligence.

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Legal Responsibilities • Maintaining privacy and confidentiality is a legal responsibility of CHNs • CHNs are required to disclose health information on a need-to-know basis and abide by relevant privacy legislation – Some exceptions apply such as court orders, subpoenas, or emergency situations

• Other legal issues may arise from negligence resulting from a breach in the standard of care .

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Capacity Building • CHNs work collaboratively when building individual and community capacity by using strategies involving empowerment and advocacy: • Advocacy: community health nursing takes a stand for the practices, aims, and reforms that are in line with the moral goals of public health.

• CHN advocacy often has a strong social justice orientation for populations sensitive to health inequities and/or otherwise marginalized .

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Political Nature of Ethics • Ethical problems in the community can also take on a political nature • Power, in itself, is ethically neutral

• The use of power is of ethical significance • Efforts to prevent disease and injury restrict the liberty of individuals, thereby limiting their choice and autonomy (i.e. seat belt laws)

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 7 Theoretical Foundations of Community Health Nursing

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Importance of Theory • Theory, research and practice are reciprocal – Theory provides roots that anchor both practice and research in the nursing discipline – Practice and research in diverse settings contribute to development of new theories

• Theory assists practitioners, decision makers, educators, and researchers to explain what they experience, inform their actions and decisions, and articulate possible outcomes

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Importance of Theory (1 of 2) • For CHNs, theory may guide practice in situations where rigorous research-based evidence is not available • Theories can support understanding of why things are the way they are.

• Nursing theories are integrated with theories developed in public health and the social sciences to guide the practice, research, and education of CHNs.

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Importance of Theory (2 of 2) • Core concepts, patterns of knowing, and different levels of theoretical knowledge in nursing are important foundations for understanding theory and how it can be used.

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Core Public Health Concepts • Key public health concepts include social justice, population health, epidemiology, health promotion and prevention, ethics, commitment to community and health equity

• Community health nursing concepts include health equity, determinants of health, capacity building, a strengths-based approach, caring, cultural safety, and collaboration • Health equity is achieved when all people have the opportunity to reach their full health potential regardless of age, race, ethnicity, gender, or social class .

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Historical Development of Nursing Theory (1 of 4) • Nursing theories focusing on illness in clinical settings are not always easily adapted to practice of community health nursing and theories specifically about CHN are lacking • In 1987, Schultz argued that nursing tends to represent individual problems as isolated events rather than a pattern of responses in a community

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Historical Development of Nursing Theory (2 of 4) • More recent developments include nursing theories being adapted specifically to CHN • New conceptual frameworks specific to community health with emphasis on health promotion and prevention

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Historical Development of Nursing Theory (3 of 4) • Most nurse theorists assumed that community health nursing theories and models were relevant to practice with a range of populations and communities.

• Theories did not explicitly draw on Indigenous perspectives and may have been the result of very few FNMI nurses as community health nursing scholars, researchers, and leaders.

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Historical Development of Nursing Theory (4 of 4) • Perspectives of First Nation, Métis, and Inuit peoples are not well represented in community health nursing theory and practice due to little acknowledgement of the colonial roots • Two-Eyed Seeing and Two-Row Wampum demonstrate both traditional Indigenous knowledge and Western scientific understanding

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First Nations Perspective on Health and Wellness Model

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Theoretical and Conceptual Foundations (1 of 3) The CHNC model of the most important types of theoretical foundations to the discipline includes: • CHN metaparadigm

• philosophies encompassing CHN ethics and values • broad theoretical perspectives (i.e. complexity science theory, social ecological theory, feminist theory, postcolonial theory)

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Theoretical and Conceptual Foundations (2 of 3) • conceptual models and frameworks (i.e. various health promotion models, Intervention wheel) • grand, middle range, and practice (or substantive) theories

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Theoretical and Conceptual Foundations (3 of 3)

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Theory-Informed Practice in Community Health Nursing (1 of 3) • Clients: examines the client within the community, as well as nurse-client interactions, and the role of CHNs as community advocates • Indigenous peoples: First Nations Perspective on Health and Wellness model is used to guide care and decolonize and redesign health programs for First Nations in BC

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Theory-Informed Practice in Community Health Nursing (2 of 3) • People experiencing social and health inequities: interweaving of multiple social determinants offers a more inclusive look at factors that can cause oppression • Health system: theories help to broaden scope of effective and considerate care beyond treating illness in a clinical context

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Theory-Informed Practice in Community Health Nursing (3 of 3) • Nursing profession: theory can refine, guide, and develop the practice of CHNs • Policy: critical social theory support nurses to collaborate with other sectors to influence public policy and address the structural and systemic determinants of health.

• Research: theory informs research, which produces the evidence used to guide the practice of CHNs in educational, administrative, and practitioner roles .

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 8 Health Promotion

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Health and Health Promotion • Health: A dynamic process with multiple assumptions and understandings that evolve over time and evolve with varying professional perspectives and purpose.

• Health promotion: The process of enabling people to increase control over, and to improve, their health.

• An Indigenous understanding of health includes the family and community and focuses on a balance between the body, mind, emotion, and spirit.

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Health and Health Promotion • For many Indigenous people, health includes nature as an integral component.

• A key component of health promotion is the concept of empowerment • The Truth and Reconciliation Commission of Canada’s Calls to Action: – raises awareness of health-promoting changes that calls upon every Canadian’s involvement in the healing process.

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Upstream vs Downstream (1 of 2) • Upstream approaches are often prevention and promotion strategies focused on policy interventions that benefit the whole population • PHC interventions that focus on people’s wellbeing by addressing and taking action on the root causes of preventable diseases and injuries.

• Acute care services are usually tertiary prevention measures, are focused on individual treatment and cure, and are considered downstream interventions. .

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Upstream vs Downstream (2 of 2) • Upstream approaches extend beyond addressing individual behaviours and identify programs, policies, and environmental changes

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Primary Health Care (1 of 3) The underlying values of Primary Health Care (PHC) are social justice and equity.

There are five principles of PHC:

• accessibility, • public participation, • health promotion, • appropriate technology, • and intersectoral collaboration or co-operation. .

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Primary Health Care (2 of 3) The WHO has outlined eight essential components of PHC, used as guiding principles to set direction and measure success: 1. Education about health problems and prevention techniques.

2. Promotion of food supply and proper nutrition.

3. Adequate supply of safe water and basic sanitation.

4. Maternal and child healthcare, including family planning. .

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Primary Health Care (3 of 3) 5. Immunization against major infectious diseases.

6. Prevention and control of locally endemic diseases.

7. Appropriate treatment of common diseases and injuries using the PHC principle of appropriate technology.

8. Provision of essential drugs.

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Charters for Health Promotion (1 of 6) • The first international conference on health promotion was held in Ottawa in November 1986 and resulted in the production of the Ottawa Charter for Health Promotion.

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Charters for Health Promotion (2 of 6) • Five key actions: – Build healthy public policy.

– Create supportive environments for health.

– Strengthen community action.

– Develop personal skills.

– Reorient health services toward preventing diseases and promoting health.

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Charters for Health Promotion (3 of 6) • Australia 1988: Health was asserted as a human right and a sound social investment; therefore, health is a fundamental social goal • Sweden 1991: public concern about global environmental threats had grown, and the need for a focus on sustainable development was highlighted.

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Charters for Health Promotion (4 of 6) • Indonesia 1997: action was declared to have a marked impact on the social determinants of health and improving human rights and reducing inequities • Mexico 2000: acknowledged promotion of health and social development as a central duty and responsibility of governments

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Charters for Health Promotion (5 of 6) • Thailand 2005: policies and partnerships to empower communities and improve health and equity at centre of global and national development.

• Kenya 2009: health promotion the core and most cost-effective strategy to improve health and quality of life and reduce health inequities and poverty worldwide.

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Charters for Health Promotion (6 of 6) • Finland 2013: discuss how political decisions related to health are implemented in the form of practical actions; Helsinki Statement on Health in All Policies • China 2016: focused on creating a new vision for health promotion based on the United Nations 2030 Sustainable Development Goals (SDGs).

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Social Determinants of Health (1 of 2) • Paramount for nurses to understand that serious illness and early death related to poverty are connected to low social standing.

• Poor health and early death then are linked to social determinants of health, not just to accessibility to health care.

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Social Determinants of Health (2 of 2) • The Toronto Charter recognized that Canadian women, Canadians of colour, and new Canadians were significantly more at risk than others • The CNA encourages all nurses to support the health of society by promoting public policies that address the social determinants of health.

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Population Health Promotion (1 of 6) • Population health promotion is a process of taking action on the interrelated conditions that affect a population’s health to create healthy change.

• Collaborative and partnership approaches are effective community-development and relationship-building strategies employed by CHNs.

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Population Health Promotion (2 of 6) • Builds trusting relationships and rapport, builds personal confidence and skills through valuing clients’ expertise and knowledge • Engages in empowering educational strategies, connecting to broader social networks, and tapping into clients’ strengths

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Population Health Promotion (3 of 6)

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Population Health Promotion (4 of 6) The PHPM incorporates a number of values and assumptions: • comprehensive action needs to be taken on all the determinants of health • multiple entry points for planning and implementing are essential • health problems may affect some groups more than others • solutions to problems involve changing social values and structures .

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Population Health Promotion (5 of 6) • one’s health is a result of a combination of one’s own health practices plus the impact of social and physical environments in which we live, work, and play • Health promoting opportunities arise in environments with social justice and equity and where relationships are built on mutual respect and caring (rather than on power and status)

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Population Health Promotion (6 of 6) The PHPM incorporates a number of values and assumptions: • meaningful participation of community members is needed

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Four ‘Ps’ of Marketing (1 of 2) • Use of marketing principles and techniques to advance a social cause, idea, or behaviour to promote changes in social behaviours.

• The goal of social marketing is to encourage health-promoting behaviours, or to eliminate or significantly reduce behaviours that negatively impact a population’s health.

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Four ‘Ps’ of Marketing (2 of 2) • Six essential benchmarks considered the best strategic application of the “marketing mix.”, consists of the four Ps of “product,” “price,” “place,” and “promotion.”

• Other Ps might include “policy change” or “people” (e.g., training is provided to intervention delivery agents).

• Interventions that only use the promotion P are social advertising, not social marketing. .

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Social Justice Concerns (1 of 2) • “At risk” term can devolve into creating stigmas such as racism, sexism, ageism, and other prejudices that affect health care professionals’ assumptions • Can lead to oppressive behaviours toward people considered at risk.

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Social Justice Concerns (2 of 2) • Communication of risk is vital because in our current social environment, risks change rapidly with the introduction of new and varied technologies.

• Risk management approach is more amenable to implementing several different concurrent strategies to address multiple determinants of health.

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Levels of Prevention (1 of 3) • Prevention interventions can occur at primordial, primary, secondary, tertiary, or quaternary levels • Primordial level focuses on the avoidance of illness or injury, addressing issues at a distal level before they become risk factors, or by identifying specific risk factors

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Levels of Prevention (2 of 3) • Primary prevention uses the identification of potential risk factors and the mobilization of policy and public awareness to avoid injury or illness.

• Secondary prevention promotes health through the early identification of diseases and conditions and timely treatment of them and focus is to halt an illness if possible

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Levels of Prevention (3 of 3) • Tertiary prevention is initiated once an individual becomes symptomatic, or disease or injury is evident – Focus is on maintaining or restoring function and preventing further disability from the disease or injury.

• Quaternary prevention identifies people who may be at risk for medical mishaps and addresses patient safety and necessity of evidence-informed decision making – In quaternary prevention the focus shifts to ethical practices .

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Harm Reduction Philosophy (1 of 2) • Harm reduction focuses on protecting the health of, and reduce secondary harm for, individuals who engage in high-risk activities associated with poor health outcomes.

• Goal: to reduce the more immediate and related harms arising from engaging in that behaviour.

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Harm Reduction Philosophy (2 of 2) • Strategies seek to address health inequities and bring meaningful health care to individuals who might otherwise be marginalized by some health care providers.

• Goal of care is to protect health by reducing harm while recognizing complexity of social issues

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Importance of Activism Activism as a public health intervention has been used to: • effect change for the people living in poverty;

• changes for child labour; • fight for women’s right to vote; and • distribute birth control information to women

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Importance of Activism, Research, and Advocacy • It’s important for research and action to seek partnership with and promote the health of individuals and communities.

• Advocacy is a social justice issue and a mandatory component of public health and community nursing practice.

• Nursing practice within communities will create more opportunities for nursing practice focused on health promotion and different forms of advocacy and activism. .

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 9 Race, Culture, and Health

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Characteristics of Culture (1 of 4) • Culture includes language, gestures, tools, customs, and traditions that define a group’s values and organize social inter- actions.

• It is crucial that CHNs focus on the ways culture is defined and redefined, along with the power and privilege that comes with being able to define the cultures of “others.”

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Characteristics of Culture (2 of 4) • One of the main barriers to nurses’ understandings of culture is the biomedical Eurocentric foundation of nursing practice.

• Community health nursing practice emphasizes on assumptions regarding cultural contexts of the broader societal structures that underpin society.

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Characteristics of Culture (3 of 4) Characteristics of cultures include: • Culture is a social construction.

• Culture is an integrated system embedded in everyday life.

• Culture is shared.

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Characteristics of Culture (4 of 4) • Culture is largely implicit and tacit.

• Culture is fluid and dynamic.

• Culture is expressed and intersects with other social constructs such as race, gender, ethnicity, class, language, and disability.

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Diversity in Canada (1 of 5) • Statistics Canada (2016) estimates that in the next two decades, First Nation, Métis, and Inuit (FNMI) populations are likely to exceed 2.5 million persons.

• Canadian Census (2016), there were 7,540,830 foreign-born individuals who came to Canada through the immigration process, (21.9%) of Canada’s total population • The term immigrant refers to individuals who are eligible for permanent residency .

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Diversity in Canada (2 of 5) • Health status of new immigrants declines after arrival to Canada – Most vulnerable population of health decline are foreign-born visible minority women

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Diversity in Canada (3 of 5)

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Diversity in Canada (4 of 5) • Job attainment is affected by language barriers, racism, which impact the social determinants of immigrant health.

• Social isolation, experiences of refugee camps and multiple translocations related to war, and awareness of hardships of family members are risk factors for post-traumatic stress.

• New Canadians have difficulty finding a nurse practitioner or a physician .

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Diversity in Canada (5 of 5) • Health services received are often limited to episodic treatment rather than comprehensive care, • New Canadians may wait three months to be eligible for provincial health coverage.

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Culture, Race & Racism (1 of 3) • Culture is a very broad term that encompasses language, communication, relationships with the land and with food, as well as rituals, art, customs, beliefs and attitudes.

• Race has absolutely no scientific meaning. Race is a social construction that serves the purpose of justifying racist notions of the supremacy of whiteness.

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Culture, Race & Racism (2 of 3) • Racism is the systematic practice of denying people access to rights, representation, or resources based on racial differences.

• Racism becomes evident when we consider that the term race is exclusively used to describe people of colour. Referred to as racialization.

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Culture, Race & Racism (3 of 3) • Racialization in health care is racial profiling, which can create inaccurate assessment and profile of a client • Racialization is an inaccurate categorization, which is largely negative, derogatory, demeaning, and often dangerous to health and well-being.

• It is important to note that although racism is a systematic process that is created and sustained across Canada, Canadians, including nurses, can take action to dismantle it. .

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Cycle of Oppression (1 of 3) • The cycle of oppression is a way to help us understand how stereotyping and prejudice lead to societal or systemic oppressions • The cycle begins when we create and maintain stereotypes about individuals, families, and communities.

• Prejudice is a preconceived opinion and way of thinking based on stereotypes, usually operates without our direct knowledge, and is embedded in our thinking .

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Cycle of Oppression (2 of 3) • Discrimination is action or inaction based on prejudice.

• Oppression is discrimination backed up by systemic power (e.g. health systems).

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Cycle of Oppression (3 of 3)

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Cultural Competence, Safety & Humility (1 of 3)

• Culturally competence: a process through which nurses plan effective and appropriate interventions that address culturally specific health needs • Cultural competence is a lifelong process of approaching relationships with openness and humility rather than focusing on “knowing” specific cultures

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Cultural Competence, Safety & Humility (2 of 3)

• Cultural safety: defined as effective nursing practice with clients from another culture and makes issues of power explicit • Proponents of cultural safety models view cultural awareness, and competence as a starting place while cultural safety is congruent with advocacy

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Cultural Competence, Safety & Humility (3 of 3)

• Cultural humility is a recent term that enhances and extends culturally safe care.

• Cultural humility is a process of self-reflection

• In their #itstartswithme movement, the First Nations Health Authority states that system-wide change begins with every individual who works in health.

• Cultural humility and cultural competence are very much consistent with CHNC (2011) standards and competencies .

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Racism in Nursing (1 of 3) Racism in nursing includes: • barrier to health equity and social justice; • culture, values, and racism and their application to nursing; • teaching about race, racism, and health in nursing;

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Racism in Nursing (2 of 3) Racism in nursing includes: • systemic racism toward nurses of colour and racialist discourses in nursing;

• white privilege in the nursing profession; • and nurse education through a white lens, including racism in the mentor–student relationship.

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Racism in Nursing (3 of 3) • White Euro-Canadian privilege in Canada is increasingly being linked to what is called settler privilege.

• Settler privilege involves unearned, current, and historical advantages that settler Canadians rely on by virtue of the historical relationship to the original settlers

• White privilege and settler privilege offer invisible advantages across the lifespan and operate in the health fields (Table 9.2). .

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Anti-Racist and Anti-Oppressive Lens (1 of 3)

• Understanding privilege, understanding how the cycle of oppression operates, and acting for social change are key components of anti-oppression practice, including anti-racism.

• The overall process is for CHNs to learn how to actively “see” stereotyping, prejudice, and discrimination

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Anti-Racist and Anti-Oppressive Lens (2 of 3)

• It is important to see how the cycle of oppression unfolds in our everyday practice, education, research, policy making, and social action leadership.

• When we identify, or “see” specific ways that oppression and privilege operate everyday we can engage in understanding and mapping this process.

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Anti-Racist and Anti-Oppressive Lens (3 of 3)

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 10 Evidence-Informed Decision Making in Community Health Nursing

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Evidence-Informed Decision Making (1 of 2)

• The term evidence-based nursing (EBN) evolved from the initial work done in evidence-based medicine • EBN is defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of a patient

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Evidence-Informed Decision Making (2 of 2)

• In EB practice, research utilization is integrated with clinical expertise, client preference, and available resources • Evidence-informed practice is broader than research utilization.

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Research Evidence (1 of 2) • To find relevant research, practice questions need to be structured, usually consisting of the P— population, I—intervention, C—comparison, and O—outcomes.

• CHNs need skills to be able to find high-quality relevant information quickly.

• Use databases that have already been critically appraised or permit useful filters.

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Research Evidence (2 of 2) • Once the articles are found and retrieved, you must decide if their quality is sufficient so that you can be confident in using them.

• Ask librarian to assist as you research your question.

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Critical Appraisal of Research • Critical appraisal skills are the ability to decide if an article has sufficient methodological quality to warrant attention for decision making • The major questions used to evaluate studies of interventions, prevention, or qualitative research are: – Are the results valid?

– What are the results?

– Will the results help me in improving the health of clients? .

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Utilizing Research in Practice (1 of 2) • CHNs can use their critical thinking skills to ask questions and use the best available evidence to make decisions.

• Research evidence is useful for individual practitioners working with individual clients • Management and policy decisions must be evidence-based

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Utilizing Research in Practice (2 of 2) • The actual conduct (as opposed to the search and discovery) of systematic reviews has contributed to their use by clinicians and policy-level decision makers.

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Barriers of Using Research (1 of 2) • Decisions regarding the implementation of a new intervention in a community are usually made where there is no additional funding • Organization must use existing resources when beginning a new program • Increasing awareness of and value for research evidence, yet competing factors (e.g., public opinion and pressures, fiscal restraints) are noted when making policy decisions .

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Barriers of Using Research (2 of 2) • Reported difficulty in accessing and appraising published research, due to lack of access to journals or libraries; and limited knowledge on finding and appraising research

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Future Community Health Research (1 of 2) • Most common research is program evaluation using process outcomes such as numbers of clients, numbers of groups, hours spent, and reasons for home visits.

• Client outcome measurement is the next most likely information collected; for example, client mortality, morbidity, immunization status, or communicable disease outbreaks.

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Future Community Health Research (2 of 2) • CHNs are sometimes asked to log data concerning client outcome measurement for formal records or the agency may conduct periodic chart reviews or database summaries • CHNs could be involved in recruiting, collecting data, and analyzing qualitative or quantitative information for a research study.

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Community Health Nursing: A Canadian Perspective Fifth Edition

Chapter 11 Epidemiology

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The Epidemiologic Process (1 of 4) • Epidemiologists first seek to describe health-related events by answering the questions who, what, when, and where, and by following trends in the population.

• Further explorations expand descriptions by answering the questions how and why, and by examining causality and modes of transmission.

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The Epidemiologic Process (2 of 4) • This information provide predictions that guide interventions and the use of health care resources.

• Finally, controls are implemented to prevent new illness; cure individuals who are ill; and rehabilitate or prevent complications for those with a chronic disease.

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The Epidemiologic Process (3 of 4) • Hippocrates first noticed the relationship between the environment and health or disease • In a cholera epidemic (mid-1850s), John Snow noticed a relationship between cholera deaths and drinking water source

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The Epidemiologic Process (4 of 4) • Florence Nightingale used her influence and recordkeeping to implement sanitation practices that significantly decreased death rates • Modern epidemiologic studies have all been developed from these pioneering works.

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Association and Causality (1 of 3) • Association: occurs when there is reasonable evidence that a connection exists between a stressor or environmental factor and a disease or health challenge • Causation: an association that has been confirmed and there is a definite, statistical, cause-and-effect relationship between a particular stimulus and occurrence of a disease

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Association and Causality (2 of 3) • In establishing causality, two important concepts are necessary: a particular stressor must be present and sufficient amount of exposure is required to result in the disease • A model called web of causation helps CHNs to visualize the many causes or relationships that influence a given health challenge

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Association and Causality (3 of 3) Illustrations of Causation Criteria (Table 11.1) • Temporal relationship • Strength of association

• Dose-response • Specificity

• Consistency • Biologic plausibility • Experimental replication .

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Screening and Surveillance • Screening and surveillance are used by public health officials to assist in the prevention or control of certain diseases • Screening: the testing of individuals who do not have symptoms in order to detect a health problem • Surveillance: the constant watching or monitoring of diseases to assess patterns and quickly identify events that do not fit the pattern .

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Measurements in Epidemiology (1 of 4) • Data is collected and analyzed to determine the extent of a disease process and its effects on a population.

• Data must be presented with other factors such as population, time frame, or human characteristics (e.g., gender, race, age)

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Measurements in Epidemiology (2 of 4) • Collected data is related to the other factors in order to produce a numerical ratio called a rate.

– For example, a rate of teen pregnancies might be expressed as the number of live births delivered to teen mothers in the population divided by the total number

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Measurements in Epidemiology (3 of 4) Common rates include: • Mortality (death) rates: crude, specific, and proportional mortality rates

• Survival (prognosis) rates: describe the effect of a given disease and can be used to compare the efficacy of various treatments

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Measurements in Epidemiology (4 of 4) Common rates include: • Morbidity (illness) rates: picture of a population and disease over time, questions population susceptibility and effectiveness of health promotion or treatment • Prevalence and incidence are commonly used to describe morbidity in a population

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Research Study Designs (1 of 2) • Case series studies are counts of selected variables within a specific population • Cross-Sectional studies are snapshots of the present and may also be called prevalence studies

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Research Study Designs (2 of 2) • In case-control studies individuals with the disease are matched with individuals who are similar in some characteristics but have not manifested the disease • The researcher is systematically collecting and analyzing observations to make inferences and predictions

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The Expansion of Epidemiology (1 of 2) • Health promotion was a concern for early epidemiologists; contemporary nurses must look at what the person eats, what the person does, and the person’s habits • Health practitioners face the task of using epidemiologic research to influence citizens to change their daily activities to promote health

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The Expansion of Epidemiology (2 of 2) • Environmental factors may influence people in other directions • Modern CHNs face more complex challenges and epidemiology is one tool at their disposal

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