35 Teen Pregnancy, 766
36 Mental Health Issues, 782
37 Alcohol, Tobacco, and Other Drug Problems, 803
38 Violence and Human Abuse, 825
PART 7 Nurses’ Roles and Functions in the Community
39 The Advanced Practice Nurse in the Community, 851
40 The Nurse Leader in the Community, 867
41 The Nurse in Home Health, Palliative Care, and Hospice, 885
42 The Nurse in the Schools, 914
43 The Nurse in Occupational Health, 937
44 Forensic Nursing in the Community, 957
45 The Nurse in the Faith Community, 970
46 Public Health Nursing at Local, State, and National Levels, 993
APPENDIXES
Appendix A: Resource Tools Available on the
Evolve Website, 1011
Appendix B: Program Planning and Design, 1012
Influencing Factors in Health Care and Population Centered Nursing
Population-centered nursing emphasizes the community where nursing is based in the population providing care on-site to individuals or group members of the population. It also emphasizes a focus on a defined population whereby the nurse seeks knowledge about the health issues or problems facing the total population so the nurse can then find ways to resolve the issues and problems for all members of the population. The focused approach seeks to improve health for all within the community’s population. In this section information emerges to show how community-based nursing and community oriented (focused) nursing are different in
approach but similar in the goal to improve health for the populations served. Since the late 1800s, public health nurses have been leaders in making improvements in the quality of health care for individuals, families, and aggregates, including populations and communities. As nurses around the world collaborate with one another, it is clear that, from one country to another, population-centered nursing has more similarities than differences. Important changes in health care have been taking place since the early 1990s, and there is data to show that changes are occurring as a result of the health care reform work in the United States. Although considerable controversy surrounded the implementation of the Patient Protection and Affordable Care Act of 2010, it is clear that change is providing more access to care and reductions in hospitalization. It is also reducing cost and providing more preventive care.
The areas in health care that have posed the greatest problems for persons over the years have been access, quality, and cost. These problems are being addressed but are still present. A number of people still have either no insurance or inadequate insurance, access to quality care is unevenly distributed across the country, and the cost of health care remains high for consumers, employers, insurers, and state and federal governments.
Changes in the health care system and delivery are attempting to address these issues. Some of the key areas of emphasis in the current efforts to reform health care include preventing disease, coordinating care, and shifting care from the hospital to the home or community facilities where possible. In the coming years, a large growth in the number of nurses employed in home health care and in nursing care facilities is expected. An area targeted for growth is that of the federal community health centers.
Nurses comprise the largest category of employees in those centers. It is also expected that more new graduates will go directly into community health work rather than working for a few years in the hospital before making that transition. This trend supports the recommendations that nurses need to be prepared at the baccalaureate level.
Over the years, funding for public health has decreased, or remained neutral, while the needs for populationcentered services have increased. The key question is whether health care reform will provide what is needed for population-centered care in America’s communities. There is much discussion about the new emphasis on prevention, community-oriented care, continuity, and the important role that nurses will play in health care. With anticipation that many of these projections will become a reality and that nurses will become increasingly
key practitioners in promoting the health of the people, they must understand the history of public health nursing and the current status of the public health system.
Part One presents information about significant factors affecting health in the United States. Changing the level and quality of services and the priorities for funding requires that nurses be involved, informed, courageous, and committed to the task. The chapters in Part One are designed to provide essential information so that nurses can make a difference in health care by understanding their own roles and their functions in populationcentered practice. Understanding how the public health system differs from the primary care system is described as well as the movement to integrate public health and primary care.
There is a core of knowledge known as “public health” that forms the foundation for population-centered public health
nursing. This core has historically included epidemiology, biostatistics, environmental health, health services administration, and social and behavioral sciences. In recent years, new areas of focus within public health have included informatics, genomics, communication, cultural competence, communitybased participatory research, evidence-based practice, policy and law, global health, ethics, and forensics. This book covers both the traditional and the newer content either in a full chapter or as a section in one or more chapters. The second decade of the twenty-first century finds the United States entering an era when more public attention is being given to efforts to protect and improve the health of the American
people and the environment. Despite what many see as a failure to make fundamental changes in the delivery and financing of health care, significant change has occurred. Federal and state initiatives, private market forces, the development of new scientific knowledge and new technologies, and the expectations of the public are bringing about changes in the health care system. With the national legislation that passed in 2010—the PatientProtectionandAffordableCareAct(ACA)(www.h hs.gov/ opa/affordable-care-act)—which in part was designed to increase access to care; concerns have been raised about the availability of adequate numbers of professional personnel to provide services, particularly in primary care and strained
health care facilities. Despite initial turbulence in implementation of the legislation, including difficulties with enrollments due to technological problems, initial reports are that good progress has been made in enrolling people and the Congressional Budget Office projected that by 2014 the number of uninsured people will decrease by 12 million and by 26 million by 2017 (Blumenthal and Collins, 2014). Blumenthal and Collins (2014) also reported that the Urban Institute projected that the proportion of uninsured people adults in the United States fell from 18% in the third quarter of 2013 to 13.4% in May of 2014.Before the passage of theACA many at the national levelwere seriously concerned about the growing cost of medical
care as a part of federal expenditures (Orszag, 2007; Orszag and Emanuel, 2010). The concern with the cost of medical care remains a national issue and Blumenthal and Collins (2014) argue that the sustainability of the expansions of coverage provided by the ACA will depend on whether the overall costs of care in the United States can be controlled. If costs are not controlled the resulting increases in premiums will become increasingly difficult for all consumers, employers, and the federal government. Other health system concerns focus on the quality and safety of services, warnings about bioterrorism, and global public health threats such as infectious diseases and contaminated foods. Because of all of these factors, the role of
public health in protecting and promoting health, as well as preventing disease and disability, is extremely important. Whereas the majority of national attention and debate surrounding national health legislation has been focused primarily on insurance issues related to medical care, there are indications of a renewed interest in public health and in population-focused thinking about health and health care in the United States. For example, incorporated into the Patient Protection and Affordable Care Act are provisions that address health promotion and prevention of disease and disability. These include (1) establishment of the National Prevention, Health Promotion, and Public Health Council to coordinate federal prevention, wellness, and public health activities and to develop a national strategy
to improve the nation’s health (www.surgeongeneral.gov/ initiatives/prevention/about), and (2) as indicated in Chapter 3 and 5, creation of a Prevention and Public Health Fund to expand and sustain funding for prevention and public health programs (Trust for America’s Health, 2013), and (3) improvement of preventive efforts by covering only proven preventive services and eliminating state cost sharing for preventive services, including immunizations recommended by the U.S. Preventive Services Task Force (USPHS 2000) (www.uspreventive servicestaskforce.org). Also, grants and technical assistance will be available to employers who establish wellness programs (www.dol.gov/ebsa/newsroom/2013/13).
Although populations have historically been the focus of public health practice, specifically defined populations are
becoming a focus of the “business” of managed care; therefore more managed care executives are joining public health practitionersin becoming population oriented.Increasingly, managed care executives and program managers are using the basic sciences and analytic tools of the field of public health. However, their focus is on using such epidemiological and statistical strategies to develop databases and analytical approaches to making decisions at the level of a defined population or subpopulation enrolled in a particular care delivery organization or those covered by a particular insurance company. A populationfocused approach to planning, delivering, and evaluating various aspects of care delivery is increasingly being used in an
effort to achieve better outcomes in the population of interest and has never been more important. Where is public health nursing in all of the changes swirling around in the world of health and health care? This is a crucial time for public health nursing, a time of opportunity and challenge. The issue of growing costs together with the changing demography of the U.S. population, particularly the aging of the population, is expected to put increased demands on resources available for health care. In addition, the threats of bioterrorism, highlighted by the events of September 11, 2001, and the anthrax scares, will divert health care funds and resources from other health care programs to be spent for public safety. Also important to the public health community is the emergence of modern-day epidemics (such as the mosquito-borne West Nile virus, the H1N1 influenza virus, and
the emerging Ebola virus crisis) and globally induced infectious diseases such as avian influenza and other causes of mortality, many of which affect the very young (see Chapters 3 and 5).
Most of the causes of these epidemics are preventable.What has all of this to do with nursing?
Understanding the importance of communityoriented, population-focused nursing practice and developing the knowledge and skills to practice it will be critical to attaining a leadership role in health care regardless of the practice setting.
The following discussion explains why those who practice community-based, prevention-oriented, populationfocused nursing will be in a very strong position to affect the health of populations and decisions about how scarce resources will be used.
PUBLIC HEALTH PRACTICE: THE
FOUNDATION FOR HEALTHY POPULATIONS AND COMMUNITIES
During the last 25 years, considerable attention has been focused on proposals to reform the American health care system. These proposals focused primarily on containing cost in medical care financing and on strategies for providing health insurance coverage to a higher proportion of the population. In the national health legislation that passed in 2010, the Patient Protection and Affordable Care Act, the majority of the provisions and the vast majority of the discussion of the bill focused on those issues (www.hhs.gov/opa/affordable-care-act). Because physician services and hospital care combined account for over half of the health care expenditures in the United States, it is understandable that changes in how such services would be paid for would receive much attention
(kaiserEDU.org, 2010). However, as stated in the Public Health Functions Steering Committee Report on the Core Functions of Public Health (1998),while it was important to make reforms in the medical insurance system there is a clear understanding among those familiar with the history of public health and its impact that such reforms alone will not be adequate to improve the health of Americans. Historically, gains in the health of populations have come largely from public health efforts. Safety and adequacy of food supplies, the provision of safe water, sewage disposal, public safety from biological threats, and personal behavioral changes, including reproductive behavior, are a few examples of public health’s influence. In 2008 Fielding and colleagues argued that there is incontrovertible evidence that public health policies and programs were primarily responsible for increasing the average
life span from 47 in 1900 to 78 in 2005, an increase of 66% in just a little over a century. They asserted that most of that increase was through improvements in sanitation, clean water supplies, making workplaces safer, improving food and drug safety, immunizing children, and improving nutrition, hygiene, and housing (Fielding et al, 2008). In an effort to help the public better understand the role public health has played in increasing life expectancy and improving the nation’s health, in 1999 the Centers for Disease Control and Prevention (CDC) began featuring information on the Ten Great Public Health Achievements in the 20th Century. The areas featured include Immunizations, Motor Vehicle Safety, Control of Infectious Diseases, Safer and Healthier Foods, Healthier Mothers and Babies, Family Plan-
ning, Fluoridation of Drinking Water, Tobacco as a Health Hazard, and Declines in Deaths from Heart Disease and Stroke (CDC, 2014). A case can be made that the payoff from public health activities is well beyond the resources directed to the effort. For example, recent data reported by the Centers for Medicare and Medicaid Services (CMS) showed that in 2012 only 3% (up from 1.5% in 1960) of all national expenditures supported by governmental entities supported public health functions (CMS, 2012). The expeditures in 2014 were the same.