Community/Public Health Nursing
Promoting the Health of Populations
Mary A. Nies, PhD, RN, FAAN, FAAHB Dean and Professor School of Nursing, Joint Appointment MPH Program, Division of Health Sciences, Idaho State University, Pocatello, Idaho
Melanie McEwen, PhD, RN, CNE, ANEF Associate Professor, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas
Table of Contents
Preface Unit 1. Introduction to Community Health Nursing
Chapter 1. Health: A Community View
Definitions of Health and Community
Determinants of Health and Disease
Indicators of Health and Illness
Definition and Focus of Public Health and Community Health
Preventive Approach to Health
Definition and Focus of Public Health Nursing, Community Health Nursing, and Community-Based Nursing
Population-Focused Practice and Community/Public Health Nursing Interventions
Community Health Nursing, Managed Care, and Health Reform
Chapter 2. Historical Factors: Community Health Nursing in Context
Evolution of Health in Western Populations
Advent of Modern Health Care
Consequences for the Health of Aggregates
Social Changes and Community Health Nursing
Challenges for Community and Public Health Nursing
Chapter 3. Thinking Upstream: Nursing Theories and Population- Focused Nursing Practice
Thinking Upstream: Examining the Root Causes of Poor Health
Historical Perspectives on Nursing Theory
How Theory Provides Direction to Nursing
Microscopic Versus Macroscopic Approaches to the Conceptualization of Community Health Problems
Assessing a Theory’s Scope in Relation to Community Health Nursing
Review of Theoretical Approaches
Healthy People 2020
Chapter 4. Health Promotion and Risk Reduction
Health Promotion and Community Health Nursing
Determinants Of Health
Theories in Health Promotion
Risk and Health
The Relationship of Risk to Health and Health Promotion Activities
Unit 2. The Art and Science of Community Health Nursing
Chapter 5. Epidemiology
Use of Epidemiology in Disease Control and Prevention
Calculation of Rates
Concept of Risk
Use of Epidemiology in Disease Prevention
Use of Epidemiology in Health Services
Chapter 6. Community Assessment
The Nature of Community
Assessing the Community: Sources of Data
Diagnosing Health Problems
Chapter 7. Community Health Planning, Implementation, and Evaluation
Overview of Health Planning
Health Planning Model
Health Planning Projects
Health Planning Federal Legislation
Chapter 8. Community Health Education
Connecting with Everyday Realities
Health Education in the Community
Learning Theories, Principles, and Health Education Models
The Nurse’s Role in Health Education
Framework for Developing Health Communications
Health Education Resources
Chapter 9. Case Management
Overview of Case Management
Origins of Case Management
Purpose of Case Management
Utilization Review and Managed Care
Trends that Influence Case Management
Education and Preparation for Case Managers
Case Manager Services
Case Manager Roles and Characteristics
The Referral Process
Application of Case Management in Community Health
Research in Case Management
International Case Management
Unit 3. Factors that Influence the Health of the Community
Chapter 10. Policy, Politics, Legislation, and Community Health Nursing
Overview: Nurses’ Historical and Current Activity in Health Care Policy
A Major Paradigm Shift
Structure of the Government of the United States
Overview of Health Policy
Major Legislative Actions and the Health Care System
Public Policy: Blueprint for Governance
The Effective Use of Nurses: A Policy Issue
Nurses’ Roles in Political Activities
Health Care Reform and Restructuring of the Health Care Industry
Nurses and Leadership in Health Policy Development
Chapter 11. The Health Care System
Overview: The Health Care System
Components of the Health Care System
Critical Issues in Health Care Delivery
Future of Public Health and the Health Care System
Chapter 12. Economics of Health Care
Factors Influencing Health Care Costs
Public Financing of Health Care
Philanthropic Financing of Health Care
Health Care Insurance Plans
Trends in Health Financing
Health Care Financing Reform
Roles Of the Community Health Nurse in the Economics of Health Care
Best Care at Lower Cost
Chapter 13. Cultural Diversity and Community Health Nursing
Transcultural Perspectives on Community Health Nursing
Cultural Perspectives and Healthy People 2020
Overview of Culture
Culture and Socioeconomic Factors
Culture and Nutrition
Culture and Religion
Culture and Aging
Health-Related Beliefs and Practices
Management of Health Problems: A Cultural Perspective
Management of Health Problems in Culturally Diverse Populations
Role of the Community Health Nurse in Improving Health for Culturally Diverse People
Resources for Minority Health
Chapter 14. Environmental Health
A Critical Theory Approach to Environmental Health
Areas of Environmental Health
Effects of Environmental Hazards
Efforts to Control Environmental Health Problems
Emerging Issues in Environment Health
Approaching Environmental Health at the Population Level
Critical Environmental Health Nursing Practice
Chapter 15. Health in the Global Community
Patterns of Health and Disease
International Agencies and Organizations
International Health Care Delivery Systems
Research in International Health
Health Initiatives Taking Place Throughout the World
Unit 4. Aggregates in the Community
Chapter 16. Child and Adolescent Health
Issues of Pregnancy and Infancy
Childhood Health Issues
Adolescent Health Issues
Factors Affecting Child and Adolescent Health
Strategies to Improve Child and Adolescent Health
Public Health Programs Targeted to Children and Adolescents
Sharing Responsibility for Improving Child and Adolescent Health
Legal and Ethical Issues in Child and Adolescent Health
Chapter 17. Women’s Health
Major Indicators of Health
Social Factors Affecting Women’s Health
Health Promotion Strategies for Women
Major Legislation Affecting Women’s Health
Health and Social Services to Promote the Health of Women
Levels of Prevention and Women’s Health
Roles of the Community Health Nurse
Research in Women’s Health
Chapter 18. Men’s Health
Men’s Health Status
Use of Medical Care
Theories that Explain Men’s Health
Factors that Impede Men’s Health
Men’s Health Care Needs
Primary Preventive Measures
Secondary Preventive Measures
Tertiary Preventive Measures
Chapter 19. Senior Health
Concept of Aging
Theories of Aging
Wellness and Health Promotion
Common Health Concerns
Additional Health Concerns
Elder Safety and Security Needs
Chapter 20. Family Health
Understanding Family Nursing
The Changing Family
Approaches to Meeting the Health Needs of Families
Approaches to Family Health
Family Health Assessment
Extending Family Health Intervention to Larger Aggregates and Social Action
Applying the Nursing Process
Unit 5. Vulnerable Populations
Chapter 21. Populations Affected by Disabilities
Self-Assessment: Responses to Disability
Definitions and Models for Disability
A Historical Context for Disability
Characteristics of Disability
Disability and Public Policy
Costs Associated with Disability
Healthy People 2020 and The Health Needs of People with Disabilities
The Experience of Disability
Strategies for the Community Health Nurse in Caring for People with Disabilities
Ethical Issues for People Affected by Disabilities
Chapter 22. Homeless Populations
Definitions, Prevalence, and Demographic Characteristics of Homelessness
Factors that Contribute to Homelessness
Health and Homeless Populations
Health Status of Homeless Population
Community Public Health Nursing: Care of Homeless Populations
Chapter 23. Rural and Migrant Health
Rural United States
Rural Health Disparities: Context and Composition
Specific Rural Aggregates
Application of Relevant Theories and “Thinking Upstream” Concepts to Rural Health
Rural Health Care Delivery System
Legislation and Programs Affecting Rural Public Health
Rural Community Health Nursing
Rural Health Research
New Models of Health Care Delivery for Rural Areas
Chapter 24. Populations Affected by Mental Illness
Overview and History of Community Mental Health: 1960 to the Present Day
HEALTHY PEOPLE 2020: Mental Health and Mental Disorders
Factors Influencing Mental Health
Mental Disorders Encountered in Community Settings
Identification and Management of Mental Disorders
Community-Based Mental Health Care
Role of the Community Mental Health Nurse
Unit 6. Population Health Problems
Chapter 25. Communicable Disease
Communicable Disease and Healthy People 2020
Principles of Infection and Infectious Disease Occurrence
Chain of Transmission
Breaking the Chain of Transmission
Public Health Control of Infectious Diseases
Vaccines and Infectious Disease Prevention
Vaccine Needs for Special Groups
Healthy People 2020 Focus on Immunization and Infectious Diseases
Healthy People 2020 Focus on Sexually Transmitted Diseases
Healthy People 2020 Focus on HIV/AIDS
Prevention of Communicable Diseases
Chapter 26. Substance Abuse
Etiology of Substance Abuse
Historical Overview of Alcohol and Illicit Drug Use
Prevalence, Incidence, and Trends
Adolescent Substance Abuse
Conceptualizations of Substance Abuse
Sociocultural and Political Aspects of Substance Abuse
Course of Substance-Related Problems
Legal and Ethical Concerns Related to Substance Abuse
Modes of Intervention
Social Network Involvement
Nursing Perspective on Substance Abuse
Chapter 27. Violence
Overview of Violence
History of Violence
Factors Influencing Violence
Violence from a Public Health Perspective
Prevention of Violence
Chapter 28. Natural and Man-Made Disasters
Types of Disasters
Characteristics of Disasters
Disaster Management Stages
Unit 7. Community Health Settings
Chapter 29. School Health
History of School Health
School Health Services
School Nursing Practice
School-Based Health Centers
Future Issues Affecting the School Nurse
Chapter 30. Occupational Health
Evolution of Occupational Health Nursing
Demographic Trends and Access Issues Related to Occupational Health Care
Occupational Health Nursing Practice and Professionalism
Occupational Health and Prevention Strategies
Skills and Competencies of the Occupational Health Nurse
Impact of Federal Legislation on Occupational Health
Legal Issues in Occupational Health
Chapter 31. Forensic and Correctional Nursing
Subspecialties of Forensic Nursing
Health Issues in Prison Populations
Mental Health Issues in Correctional Settings
Education and Forensic Nursing
Chapter 32. Faith Community Nursing
Faith Communities: Role in Health and Wellness
Foundations of Faith Community Nursing
Roles or Functions of the Faith Community Nurse
Education of the Faith Community Nurse
The Faith Community Nurse and Spirituality
Issues in Faith Community Nurse Practice
Chapter 33. Home Health and Hospice
Home Health Care
Types of Home Health Agencies
Certified and Noncertified Agencies
Special Home Health Programs
Reimbursement for Home Care
Nursing Standards and Educational Preparation of Home Health Nurses
Conducting a Home Visit
Documentation of Home Care
Application of the Nursing Process
Formal and Informal Caregivers
Hospice Home Care
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Library of Congress Cataloging-in-Publication Data
Community/public health nursing : promoting the health of populations / [edited by] Mary A. Nies, Melanie McEwen. — Edition 6. p. ; cm. Includes bibliographical references and index. ISBN 978-0-323-18819-7 (pbk. : alk. paper) I. Nies, Mary A. (Mary Albrecht), editor. II. McEwen, Melanie, editor. [DNLM: 1. Community Health Nursing. 2. Health Promotion. 3.
Public Health Nursing. WY 106] RT98 610.73’43–dc23 2014023359
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To Phil Yankovich, my husband, companion, and best friend, whose love, caring, and true support are
always there for me. He provides me with the energy I need to pursue my dreams.
To Kara Nies Yankovich, my daughter, for whom I wish a happy and healthy life. Her energy, joy, and
enthusiasm for life give so much to me.
To Earl and Lois Nies, my parents, for their never- ending encouragement and lifelong support. They
helped me develop a foundation for creative thinking, new ideas, and spirited debate.
Mary A. Nies
To my husband, Scott McEwen, whose love, support, and encouragement have been my foundation for the past thirty-five years. I can’t wait to see what happens
Mary A. Nies
Mary A. Nies, PhD, RN, FAAN, FAAHB is the Dean and Professor School of Nursing, Joint Appointment MPH Program, Division of Health Sciences, Idaho State University. Dr. Nies received her diploma from Bellin School of Nursing in Green Bay, Wisconsin; her BSN from University of Wisconsin, Madison; her MSN from Loyola University, Chicago; and her PhD in Public Health Nursing, Health Services, and Health Promotion Research at the University of Illinois, Chicago. She completed a postdoctoral research fellowship in health promotion and community health at the University of Michigan, Ann Arbor. She is a fellow of the American Academy of Nursing and a fellow of the American Academy of Health Behavior. Dr. Nies co-edited Community Health Nursing: Promoting the Health of Aggregates, which received the 1993 Book of the Year award from the American Journal of Nursing. Her program of research focuses on the outcomes of health promotion interventions for minority and nonminority populations in the community. Her research is involved with physical activity and obesity prevention for populations, especially women. Her research is involved with physical activity and obesity prevention for vulnerable populations.
Melanie McEwen, PhD, RN, CNE, ANEF is an Associate Professor at the University of Texas Health Science Center at Houston School of Nursing. Dr. McEwen received her BSN from the University of Texas School of Nursing in Austin; her Master’s in Community and Public Health Nursing from Louisiana State University Medical Center in New Orleans; and her PhD in Nursing at Texas Woman’s University. Dr. McEwen has been a nursing educator for more than 22 years and
is also the co-author of Community–Based Nursing: An Introduction (Elsevier, 2009) and co-author/editor of Theoretical Basis for Nursing (Lippincott, Williams and Wilkins, 2014).
Carrie Buch, PhD, RN, Associate Professor, Oakland University, School of Nursing, Rochester, Michigan
Chapter 13: Cultural Diversity and Community Health Nursing
Chapter 33: Home Health and Hospice
Patricia M. Burbank, DNSc, RN, Professor, College of Nursing, The University of Rhode Island, Kingston, Rhode Island
Chapter 7: Community Health Planning, Implementation, and Evaluation
Holly B. Cassells, PhD, MPH, RN, Professor, School of Nursing and Health Professions, University of the Incarnate Word, San Antonio, Texas
Chapter 5: Epidemiology
Chapter 6: Community Assessment
Stacy A. Drake, MSN, MPH, RN, Instructor, The University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas
Nellie S. Droes, DNSc, RN, CS, Associate Professor, Emerita, School of Nursing, East Carolina University , Rivers Building, Greenville, North Carolina
Chapter 22: Homeless Populations
Anita Finkelman, MSN, RN, Visiting Faculty, School of Nursing, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
Chapter 10: The Health Care System
Chapter 11: The Health Care System
Chapter 12: Economics of Health Care
Susan Givens, RNC-OB, MPH, LCCE, Childbirth Educator, Mount Carmel St. Ann’s Hospital, Westerville, Ohio
Chapter 16: Child and Adolescent Health
Lori A. Glenn, DNP, CNM, RN, Assistant Professor, McAuley School of Nursing, University of Detroit Mercy, Detroit, Michigan, Nurse Midwife , Hurley Medical Center, Flint, Michigan
Chapter 17: Women’s Health
Deanna E. Grimes, DrPH, RN, FAAN, Professor, University of Texas Health Science Center at Houston, Houston, Texas
Karyn Leavitt Grow, MS, BSN, RN, CCM, Manager, Case Manager, Sierra Surgery Hospital, Carson City, Nevada
Chapter 9: Case Management
Diane C. Hatton, PhD, RN, Consultant, Reno, Nevada
Chapter 22: Homeless Populations
Jené M. Hurlbut, PhD, MSN, RN, CNE, Associate Professor, Roseman University of Health Sciences , Henderson, Nevada
Chapter 18: Men’s Health
Kim Jardine-Dickerson, RN, MSN, BC, CADC, Assistant Clinical Professor, Idaho State University, Pocatello, Idaho
Chapter 24: Populations Affected by Mental Illness
Chapter 26: Substance Abuse
Angela Jarrell, PhD, RN, Nurse Consultant, Duquesne University, Pittsburgh, Pennsylvania
Chapter 31: Forensic and Correctional Nursing
Jean Cozad Lyon, PhD, APN, Hospital Surveyor, The Joint Commission, Reno, Nevada
Chapter 9: Case Management
Diane Cocozza Martins, PhD, RN, Associate Professor, College of Nursing, University of Rhode Island, Kingston, Rhode Island
Chapter 3: Thinking Upstream: Nursing Theories and Population-Focused Nursing Practice
Chapter 7: Community Health Planning, Implementation, and Evaluation
Cathy D. Meade, PhD, RN, FAAN, Senior Member and Professor, Population Science, Health Outcomes & Behavior, Moffitt Cancer Center, University of South Florida, Tampa, Florida
Chapter 8: Community Health Education
Julie Cowan Novak, DNSc, RN, CPNP, FAANP, Professor and Vice Dean, Practice and Engagement, Executive Director, UT Nursing Clinical Enterprise, UTHSCSA Student Health Center and Employee Health and Wellness Clinic, UT Health Science Center San Antonio School of Nursing, San Antonio, Texas
Chapter 15: Health in the Global Community
Catherine A. Pourciau, MSN, RN, FNP-C, Family Nurse Practitioner, Internal Medicine and Pediatric Clinic, Baker, Louisiana
Chapter 27: Violence
Chapter 29: School Health
Bridgette Crotwell Pullis, PhD, RN, CHPN, Assistant Professor of Nursing, The University of Texas Health Science Center – Houston School of Nursing, Houston, Texas
Chapter 4: Health Promotion and Risk Reduction
Bonnie Rogers, DrPH, COHN-S, LNCC, Director, NC Occupational Safety and Health and Education and Research , Center and OHN Program, University of North Carolina , School of Public Health , Chapel Hill, North Carolina
Chapter 30: Occupational Health
Mary Ellen Trail Ross, DrPH, MSN, RN, GCNS-BC, Associate Professor of Clinical Nursing , Department of Nursing Systems, University of Texas Health Science Center, Houston, Texas
Chapter 19: Senior Health
Diane Santa Maria, MSN, RN, APHN-BC, Clinical Faculty, University of Texas School of Nursing, Houston, Texas
Chapter 14: Environmental Health
Beverly Siegrist, EdD, MS, RN, CNE, Professor, Department of Nursing, Western Kentucky University, Bowling Green, Kentucky
Chapter 20: Family Health
Chapter 32: Faith Community Nursing
Edith B. Summerlin, PhD, MSN, BSN, RN, CNS, Assistant Professor, University of Texas Health Science Center at Houston , School of Nursing, Houston, Texas
Chapter 19: Senior Health
Chapter 28: Natural and Man-made Disasters
Patricia L. Thomas, PhD, RN, Director, Nursing Practice & Research , Trinity Health, Livonia, Michigan
Chapter 23: Rural and Migrant Health
Meredith Troutman-Jordan, PhD, PMHCNS-BC, Associate Professor, University of North Carolina at Charlotte , College of Health and Human Services, School of Nursing, Charlotte, North Carolina
Chapter 21: Populations Affected by Disabilities
Elaine Vallette, DrPH, RN, Dean, Nursing and Allied Health, Baton Rouge Community College, Baton Rouge, Louisiana
Chapter 27: Violence
Chapter 29: School Health
Lori Wightman, MSN, DNP, RN, NEA-BC, Chief Nursing Officer, Mercy Hospital Grayling, Grayling, Michigan
Chapter 23: Rural and Migrant Health
Joanna E. Cain, BSN, BA, RN, President and Founder, Auctorial Pursuits, Inc., Atlanta, Georgia
NCLEX Review Questions
TEACH for RN-Case Studies
Penny Leake, PhD, RN, Professor Emerita of Nursing, Luther College, Decorah, Iowa
Tiffany M. Smith, MSN, RN, PhD student/Graduate Assistant, Roseman University of Health Sciences, University of Nevada , Las Vegas, Nevada
Anna K. Wehling Weepie, DNP, RN, CNE, COI, Assistant Dean, Undergraduate Nursing and Professor, Allen College, Waterloo, Iowa
Edna M. Billingsley, MSN, RN, PMHN-C, CLNC, GNP, Assistant Professor of Nursing , Bethel University , McKenzie, Tennessee
Barbara Broome, RN, MSN, PhD, FAAN, Associate Dean and Chair Community/Mental Health Nursing, Professor, University of South Alabama College of Nursing , Mobile, Alabama
Stephanie Chalupka, EdD, RN, PCHCNS-BC, FAAOHN, Associate Dean for Nursing, Worcester State University, Worcester, Massachusetts
Colleen L. Ciano, MSN, RN, PhD (c), Instructor of Nursing, The Pennsylvania State University, Middletown, Pennsylvania
Connie Cooper, EdD, RN, CNE, Assistant Professor, Bellarmine University, Louisville, Kentucky
Michelle T. Dang, PhD, RN, APHN-BC, Assistant Professor, California State University, Sacramento, Sacramento, California
Lisa Garsman, MS, FNP-BC, Director BSN Program, Saint Peter’s University, Jersey City, New Jersey
Scharmaine Lawson-Baker, DNP, FNP-BC, FAANP, CEO/Founder, Advanced Clinical Consultants, New Orleans, Louisiana
Lisa M. LeBlanc, RN, BSN, Instructor of Nursing, Wisconsin Lutheran College, Milwaukee, Wisconsin
Patricia S. Martin, RN, MSN, Assistant Professor, University of Louisville, Louisville, Kentucky
Nancy N. Menzel, PhD, RN, PHCNS-BC, CPH, Associate Professor, Nursing, University of Nevada, Las Vegas , Las Vegas, Nevada
Lynn M. Miskovich, DNP, ANP-BC, APRN, Associate Professor of Nursing , Purdue University Calumet, Hammond, Indiana
Patti Moss, MSN, RN, Assistant Professor, Nursing, Lamar University, Beaumont, Texas
Jill M. Nocella, MSN, RN, Professor of Nursing, William Paterson University, Wayne, New Jersey
Vicky L. O’Neil, DNP, APRN, FNP-BC, Associate Professor, Dixie State College of Utah, St. George, Utah
Laura Opton, MSN, RN, CNE, Second Degree BSN Program Director, Texas Tech University Health Sciences Center, Lubbock, Texas
Susan Palmer, MSN, RN, Lecturer, Fairleigh Dickinson University, Teaneck, New Jersey
Fay Parpart, MS, RN, ANP-BC, Assistant Clinical Professor, Virginia Commonwealth University, Richmond, Virginia
Keevia Porter, DNP, MSN, NP-C, RN, Assistant Professor BSN/MSN Programs, University of Tennessee Health Science Center, College of Nursing , Memphis, Tennessee
Cynthia Portman, MSN, RN, Assistant Clinical Professor in Nursing, Department of Nursing and Rehab Sciences, Angelo State University, San Angelo, Texas
Joann Sands, ANP-BC, MSN, RN, Clinical Instructor, The State University of New York – University at Buffalo, Buffalo, New York
Charlotte Sortedahl, DNP, MPH, MS, BSN, RN, Assistant Professor, University of Wisconsin – Eau Claire, Eau Claire, Wisconsin
Marnie Lynn Sperling, DMD, MSN, RN, FN-CSA, Assistant Professor, Nursing, Caldwell College , Caldwell, New Jersey
Debbie Sweeney, RN, DNSc, Associate Professor, Nursing, Baptist College of Health Sciences, Memphis, Tennessee
Virginia Teel, DHSc, RN, Assistant Professor, Nursing, College of Coastal Georgia, Brunswick, Georgia
Julie B. Willardson, DNP, FNP-C, Assistant Professor of Nursing, Roseman University of Health Sciences, College of Nursing, South Jordan, Utah
More money is spent per capita for health care in the United States than in any other country ($8400 in 2010). However, many countries have far better indices of health, including traditional indicators such as infant mortality rates and longevity for both men and women than does the United States. The United States is one of the few industrialized countries in the world that lacks a program of national health services or national health insurance. Although the United States spent 17.9% of its gross domestic product on health care expenditures in 2010, a record high of $2.6 trillion, before full implementation of the Affordable Care Act, nearly 18.0% of the population had no health care coverage.
The greater the proportion of money put into health care expenditures in the United States, the less money there is to improve education, jobs, housing, and nutrition. Over the years, the greatest improvements in the health of the population have been achieved through advances in public health using organized community efforts, such as improvements in sanitation, immunizations, and food quality and quantity. The greatest determinants of health are still equated with factors in the community, such as education, employment, housing, and nutrition. Although access to health care services and individual behavioral changes are important, they are only components of the larger determinants of health, such as social and physical environments.
Upstream Focus The traditional focus of many health care professionals, known as a downstream focus, has been to deliver health care services to ill people and to encourage needed behavioral change at the individual level. The focus of public/community health nursing has traditionally been on health promotion and illness prevention by working with individuals and families within the community. A shift is needed to an upstream focus, which includes working with aggregates and communities in activities such as organizing and setting health policy. This focus will help aggregates and communities work to create options for healthier environments with essential components of health, including adequate education, housing, employment, and nutrition and provide choices that allow people to make behavioral changes, live and work in safe environments, and access equitable and comprehensive health care.
Grounded in the tenets of public health nursing and the practice of public health nurses such as Lillian Wald, this sixth edition of Community/Public Health Nursing: Promoting the Health of Populations builds on the earlier works by highlighting an aggregate focus in addition to the traditional areas of family and community health, and thus promotes upstream thinking. The primary focus is on the promotion of the health of aggregates. This approach includes the family as a population and addresses the needs of other aggregates or population subgroups. It conceptualizes the individual as a member of the family and as a member of other aggregates, including organizations and institutions. Furthermore, individuals and families are viewed as a part of a population within an environment (i.e., within a community).
An aggregate is made up of a collective of individuals, be it family or another group that, with others, make up a community. This text emphasizes the aggregate as a unit of focus and how aggregates that make up communities promote their own health. The aggregate is
presented within the social context of the community, and students are given the opportunity to define and analyze environmental, economic, political, and legal constraints to the health of these populations.
Community/public health nursing has been determined to be a synthesis of nursing and public health practice with goals to promote and preserve the health of populations. Diagnosis and treatment of human responses to actual or potential health problems is the nursing component. The ability to prevent disease, prolong life, and promote health through organized community effort is from the public health component. Community/public health nursing practice is responsible to the population as a whole. Nursing efforts to promote health and prevent disease are applied to the public, which includes all units in the community, be they individual or collective (e.g., person, family, other aggregate, community, or population).
Purpose of the Text In this text, the student is encouraged to become a student of the community, learn from families and other aggregates in the community how they define and promote their own health, and learn how to become an advocate of the community by working with the community to initiate change. The student is exposed to the complexity and rich diversity of the community and is shown evidence of how the community organizes to meet change.
The use of language or terminology by clients and agencies varies in different parts of the United States, and it may vary from that used by government officials. The contributors to this text are a diverse group from various parts of the United States. Their terms vary from chapter to chapter and vary from those in use in local communities. For example, some authors refer to African-Americans, some to blacks, some to European-Americans, and some to whites. The student must be familiar with a range of terms and, most important, know what is used in his or her local community.
Outstanding features of this sixth edition include its provocative nature as it raises consciousness regarding the social inequalities that exist in the United States and how the market-driven health care system contributes to prevention of the realization of health as a right for all. With a focus on social justice, this text emphasizes society’s responsibility for the protection of all human life to ensure that all people have their basic needs met, such as adequate health protection and income. Attention to the impact of implementation of the Affordable Care Act as well as the need for further reform of the systems of health reimbursement has enhanced the recognition of the need for population-focused care, or care that covers all people residing within geographic boundaries, rather than only those populations enrolled in insurance plans. Working toward providing health promotion and population-focused care to all requires a dramatic shift in thinking from individual-focused care for the
practitioners of the future. The future paradigm for health care is demanding that the focus of nursing move toward population-based interventions if we are to forge toward the goals established in Healthy People 2020.
This text is designed to stimulate critical thinking and challenge students to question and debate issues. Complex problems demand complex answers; therefore, the student is expected to synthesize prior biophysical, psychosocial, cultural, and ethical arenas of knowledge. However, experiential knowledge is also necessary and the student is challenged to enter new environments within the community and gain new sensory, cognitive, and affective experiences. The authors of this text have integrated the concept of upstream thinking, introduced in the first edition, throughout this sixth edition as an important conceptual basis for nursing practice of aggregates and the community. The student is introduced to the individual and aggregate roles of community health nurses as they are engaged in a collective and interdisciplinary manner, working upstream, to facilitate the community’s promotion of its own health. Students using this text will be better prepared to work with aggregates and communities in health promotion and with individuals and families in illness. Students using this text will also be better prepared to see the need to take responsibility for participation in organized community action targeting inequalities in arenas such as education, jobs, and housing and to participate in targeting individual health-behavioral change. These are important shifts in thinking for future practitioners who must be prepared to function in a population-focused health care system.
The text is also designed to increase the cultural awareness and competency of future community health nurses as they prepare to address the needs of culturally diverse populations. Students must be prepared to work with these growing populations as participation in the nursing workforce by ethnically and racially diverse people continues to lag. Various models are introduced to help students understand the growing link between social problems and health status, experienced disproportionately by diverse populations in the
United States, and understand the methods of assessment and intervention used to meet the special needs of these populations.
The goals of the text are to provide the student with the ability to assess the complex factors in the community that affect individual, family, and other aggregate responses to health states and actual or potential health problems; and to help students use this ability to plan, implement, and evaluate community/public health nursing interventions to increase contributions to the promotion of the health of populations.
Major Themes Related to Promoting the Health of Populations This text is built on the following major themes:
• A social justice ethic of health care in contrast to a market justice ethic of health care in keeping with the philosophy of public health as “health for all”
• A population-focused model of community/public health nursing as necessary to achieve equity in health for the entire population
• Integration of the concept of upstream thinking throughout the text and other appropriate theoretical frameworks related to chapter topics
• The use of population-focused and other community data to develop an assessment, or profile of health, and potential and actual health needs and capabilities of aggregates
• The application of all steps in the nursing process at the individual, family, and aggregate levels
• A focus on identification of needs of the aggregate from common interactions with individuals, families, and communities in traditional environments
• An orientation toward the application of all three levels of prevention at the individual, family, and aggregate levels
• The experience of the underserved aggregate, particularly the economically disenfranchised, including cultural and ethnic groups disproportionately at risk of developing health problems.
Themes are developed and related to promoting the health of populations in the following ways:
• The commitment of community/public health nursing is to an equity model; therefore, community health nurses work toward the provision of the unmet health needs of populations.
• The development of a population-focused model is necessary to close the gap between unmet health care needs and health resources on a geographic basis to the entire population. The contributions of
intervention at the aggregate level work toward the realization of such a model.
• Contemporary theories provide frameworks for holistic community health nursing practice that help the students conceptualize the reciprocal influence of various components within the community on the health of aggregates and the population.
• The ability to gather population-focused and other community data in developing an assessment of health is a crucial initial step that precedes the identification of nursing diagnoses and plans to meet aggregate responses to potential and actual health problems.
• The nursing process includes, in each step, a focus on the aggregate, assessment of the aggregate, nursing diagnosis of the aggregate, planning for the aggregate, and intervention and evaluation at the aggregate level.
• The text discusses development of the ability to gather clues about the needs of aggregates from complex environments, such as during a home visit, with parents in a waiting room of a well-baby clinic, or with elders receiving hypertension screening, and to promote individual, collective, and political action that addresses the health of aggregates.
• Primary, secondary, and tertiary prevention strategies include a major focus at the population level.
• In addition to offering a chapter on cultural influences in the community, the text includes data on and the experience of underserved aggregates at high risk of developing health problems and who are most often in need of community health nursing services (i.e., low and marginal income, cultural, and ethnic groups) throughout.
Organization The text is divided into seven units. Unit 1, Introduction to Community Health Nursing, presents an overview of the concept of health, a perspective of health as evolving and as defined by the community, and the concept of community health nursing as the nursing of aggregates from both historical and contemporary mandates. Health is viewed as an individual and collective right, brought about through individual and collective/political action. The definitions of public health and community health nursing and their foci are presented. Current crises in public health and the health care system and consequences for the health of the public frame implications for community health nursing. The historical evolution of public health, the health care system, and community health nursing is presented. The evolution of humans from wanderers and food gatherers to those who live in larger groups is presented. The text also discusses the influence of the group on health, which contrasts with the evolution of a health care system built around the individual person, increasingly fractured into many parts. Community health nurses bring to their practice awareness of the social context; economic, political, and legal constraints from the larger community; and knowledge of the current health care system and its structural constraints and limitations on the care of populations. The theoretical foundations for the text, with a focus on the concept of upstream thinking, and the rationale for a population approach to community health nursing are presented. Recognizing the importance of health promotion and risk reduction when striving to improve the health of individuals, families, groups, and communities, this unit concludes with a chapter elaborating on those concepts. Strategies for assessment and analysis of risk factors and interventions to improve health are described.
Unit 2, The Art and Science of Community Health Nursing, describes application of the nursing process—assessment, planning, intervention, and evaluation—to aggregates in the community using selected theory bases. The unit addresses the need for a population
focus that includes the public health sciences of biostatistics and epidemiology as key in community assessment and the application of the nursing process to aggregates to promote the health of populations. Application of the art and science of community health nursing to meeting the needs of aggregates is evident in chapters that focus on community health planning and evaluation, community health education, and case management.
Unit 3, Factors That Influence the Health of the Community, examines factors and issues that can both positively and negatively affect health. Beginning with an overview of health policy and legislation, the opening chapter in this unit focuses on how policy is developed and the effect of past and future legislative changes on how health care is delivered in the United States. This unit examines the health care delivery system and the importance of economics and health care financing on the health of individuals, families, and populations. Cultural diversity and associated issues are described in detail, showing the importance of consideration of culture when developing health interventions in the community. The influence of the environment on the health of populations is considered, and the reader is led to recognize the multitude of external factors that influence health. This unit concludes with an examination of various aspects of global health and describes features of the health care systems and patterns of health and illness in developing and developed countries.
Unit 4, Aggregates in the Community, presents the application of the nursing process to address potential health problems identified in large groups, including children and adolescents, women, men, families, and seniors. The focus is on the major indicators of health (e.g., longevity, mortality, and morbidity), types of common health problems, use of health services, pertinent legislation, health services and resources, selected applications of the community health nursing process to a case study, application of the levels of prevention, selected roles of the community health nurse, and relevant research.
Unit 5, Vulnerable Populations, focuses on those aggregates in the
community considered vulnerable: persons with disabilities, the homeless, those living in rural areas including migrant workers, and persons with mental illness. Chapters address the application of the community health nursing process to the special service needs in each of these areas. Basic community health nursing strategies are applied to promoting the health of these vulnerable high-risk aggregates.
Unit 6, Population Health Problems, focuses on health problems that affect large aggregates and their service needs as applied in community health nursing. These problems include communicable disease, violence and associated issues, substance abuse, and a chapter describing nursing care during disasters.
Unit 7, Community Health Settings, focuses on selected sites or specialties for community health: school health, occupational health, faith community health, and home health and hospice. Finally, forensic nursing, one of the more recently added sub-specialty areas of community health nursing, is presented in this unit, combined with correctional nursing content.
Special Features The following features are presented to enhance student learning:
• Learning objectives. Learning objectives set the framework for the content of each chapter.
• Key terms. A list of key terms for each chapter is provided at the beginning of the chapter. The terms are highlighted in blue within the chapter. The definitions of these terms are found in the Glossary located on the book’s Evolve website.
• Chapter outline. The major headings of each chapter are provided at the beginning of each chapter to help locate important content.
• Theoretical frameworks. The use of theoretical frameworks common to nursing and public health will aid the student in application of familiar and new theory bases to problems and challenges in the community.
• Healthy People 2020. Goals and objectives of Healthy People 2020 are presented in a special box throughout the text. (The updated Healthy People 2020 information is new to this edition and based on the proposed objectives.)
• Upstream thinking. This theoretical construct is integrated into chapters throughout the text.
• Case studies and application of the nursing process at individual, family, and aggregate levels. The use of case studies and clinical examples throughout the text is designed to ground the theory, concepts, and application of the nursing process in practical and manageable examples for the student.
• Research highlights. The introduction of students to the growing bodies of community health nursing and public health research literature are enhanced by special boxes devoted to specific research studies.
• Boxed information. Summaries of content by section, clinical examples, and other pertinent information are presented in colored text to aid the students’ learning by focusing on major points, illustrating concepts, and breaking up sections of “heavy” content.
• Learning activities. Selected learning activities are listed at the end of each chapter to enable students to enhance learning about the community and cognitive experiences.
• Photo novellas. Numerous stories in photograph form depicting public health care in a variety of settings and with different population groups.
• Ethical insights boxes. These boxes present situations of ethical dilemmas or considerations pertinent to particular chapters.
• Veterans’ Health boxes. New to this edition, these boxes present situations and considerations pertinent to the care of veterans.
New content in this edition • New and timely information on emerging infections (e.g., H1N1,
SARS, West Nile virus) and changing recommendations (e.g., pediatric immunization schedule) are given in the Communicable Disease chapter.
• Reflecting the need for enhanced education and information related to the specific needs and issues for our country’s veterans, most chapters include at least one box highlighting veteran’s health care in relation to the chapter’s topic.
• Most chapters contain new or updated Research Highlights boxes highlighting timely, relevant examples of the topics from recent nursing literature and Ethical Insights boxes that emphasize specific ethical issues.
Teaching and Learning Package Evolve website: The website at http://evolve.elsevier.com/nies/ is devoted exclusively to this text. It provides materials for both instructors and students.
• For Instructors: PowerPoint lecture slides, image collection, and more than 900 test bank questions with alternative item questions as well as the new TEACH for Nurses, which contains detailed chapter Lesson Plans including references to curriculum standards such as QSEN, BSN Essentials and Concepts, BSN Essentials for Public Health, and new and unique Case Studies.
• For Students: Quiz with multiple-choice questions with answers and correct answer rationales, Case Studies with questions and answers, a Glossary, and Resource Tools (supplemental material).
Acknowledgments Community/Public Health Nursing: Promoting the Health of Populations could not have been written without sharing the experiences, thoughtful critique, and support of many people: individuals, families, groups, and communities. We give special thanks to everyone who made significant contributions to this book.
We are indebted to our contributing authors whose inspiration, untiring hours of work, and persistence have continued to build a new era of community health nursing practice with a focus on the population level. We thank the community health nursing faculty and students who welcomed the previous editions of the text and responded to our inquiries with comments and suggestions for the sixth edition. These people have challenged us to stretch, adapt, and continue to learn throughout our years of work. We also thank our colleagues in our respective work settings for their understanding and support during the writing and editing of this edition.
Finally, an enormous “thank you” to Elsevier editors Jennifer Shropshire, Nancy O’Brien, and Johnny Gabbert. Their energy, enthusiasm, encouragement, direction, and patience were essential to this project.
Mary A. Nies
UNIT 1 Introduction to Community Health Nursing
OUTLINE Chapter 1. Health: A Community View Chapter 2. Historical Factors: Community Health Nursing in Context Chapter 3. Thinking Upstream: Nursing Theories and Population- Focused Nursing Practice Chapter 4. Health Promotion and Risk Reduction
A Community View Melanie McEwen, and Mary A. Nies
Definitions of Health and Community Health Community
Determinants of Health and Disease Indicators of Health and Illness Definition and Focus of Public Health and Community Health Preventive Approach to Health
Health Promotion and Levels of Prevention Prevention versus Cure Healthy People 2020
Definition and Focus of Public Health Nursing, Community Health Nursing, and Community-Based Nursing
Public and Community Health Nursing Community-Based Nursing Community and Public Health Nursing Practice
Population-Focused Practice and Community/Public Health Nursing Interventions
Community Health Interventions
The Public Health Intervention Wheel Community Health Nursing, Managed Care, and Health Care Reform
Upon completion of this chapter, the reader will be able to do the following: 1. Compare and contrast definitions of health from a public health
nursing perspective. 2. Define and discuss the focus of public health. 3. Discuss determinates of health and indicators of health and illness
from a population perspective. 4. List the three levels of prevention, and give examples of each. 5. Explain the difference between public/community health nursing
practice and community-based nursing practice. 6. Describe the purpose of Healthy People 2020, and give examples
of the topic areas that encompass the national health objectives. 7. Discuss community/public health nursing practice in terms of public
health’s core functions and essential services. 8. Discuss community/public health nursing interventions as
explained by the Intervention Wheel.
KEY TERMS aggregates community community health
community health nursing disease prevention health health promotion population population-focused nursing primary prevention public health public health nursing secondary prevention tertiary prevention
As a result of recent and anticipated changes related to health care reform, community/public health nurses are in a position to assist the U.S. health care system in the transition from a disease-oriented system to a health-oriented system. Costs of caring for the sick account for the majority of escalating health care dollars, which increased from 5.7% of the gross domestic product in 1965 to 17.9% in 2010 (National Center for Health Statistics [NCHS], 2013). Alarmingly, national annual health care expenditures reached $2.6 trillion in 2010, or an astonishing $8400 per person.
U.S. health expenditures reflect a focus on the care of the sick. In 2010, $0.31 of each health care dollar supported hospital care, $0.20 supported physician services, and $0.10 was spent on prescription drugs (double the proportion since 1980). The vast majority of these funds were spent providing care for the sick, and only $0.03 of every health care dollar was directed toward preventive public health activities (NCHS, 2013). Despite high hospital and physician expenditures, U.S. health indicators rate considerably below the health indicators of many other countries. This situation reflects a
relatively severe disproportion of funding for preventive services and social and economic opportunities. Furthermore, the health status of the population within the United States varies markedly across areas of the country and among groups. For example, the economically disadvantaged and many cultural and ethnic groups have poorer overall health status compared with middle-class Caucasians.
Nurses constitute the largest group of health care workers; therefore, they are instrumental in creating a health care delivery system that will meet the health-oriented needs of the people. According to a survey of registered nurses (RNs) conducted by the Health Resources and Services Administration, about 62% of approximately 2.6 million employed RNs in the United States worked in hospitals during 2008 (down from 66.5% in 1992). This survey also found that about 14.2%, approximately 400,000, of all RNs worked in home, school, or occupational health settings; 10.5% worked in ambulatory care settings; and 5.3% worked in nursing homes or other extended care facilities (U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions [USDHHS, HRSA, BHP], 2010).
Between 1980 and 2008, the number of nurses employed in community, health, and ambulatory care settings more than doubled (USDHHS, HRSA, BHP, 2010). The decline in the percentage of nurses employed in hospitals and the subsequent increase in nurses employed in community settings indicate a shift in focus from illness and institutional-based care to health promotion and preventive care. This shift will likely continue into the future as alternative delivery systems, such as ambulatory and home care, will employ more nurses (Rosenfeld and Russell, 2012; Way and MacNeil, 2007).
Community/public health nursing is the synthesis of nursing practice and public health practice. The major goal of public health nursing is to preserve the health of the community and surrounding populations by focusing on health promotion and health maintenance of individuals, families, and groups within the community. Thus community/public health nursing is associated with health and the identification of populations at risk rather than with an episodic
response to patient demand. The mission of public health is social justice, which entitles all
people to basic necessities such as adequate income and health protection and accepts collective burdens to make it possible. Public health, with its egalitarian tradition and vision, often conflicts with the predominant U.S. model of market justice that largely entitles people to what they have gained through individual efforts. Although market justice respects individual rights, collective action and obligations are minimal. An emphasis on technology and curative medical services within the market justice system has limited the evolution of a health system designed to protect and preserve the health of the population. Public health assumes that it is society’s responsibility to meet the basic needs of the people. Thus there is a greater need for public funding of prevention efforts to enhance the health of our population.
Current U.S. health policies advocate changes in personal behaviors that might predispose individuals to chronic disease or accident. These policies promote exercise, healthy eating, tobacco use cessation, and moderate consumption of alcohol. However, simply encouraging the individual to overcome the effects of unhealthy activities lessens focus on collective behaviors necessary to change the determinants of health stemming from such factors as air and water pollution, workplace hazards, and unequal access to health care. Because living arrangements, work/school environment, and other sociocultural constraints affect health and well-being, public policy must address societal and environmental changes, in addition to lifestyle changes, that will positively influence the health of the entire population.
With ongoing and very significant changes in the health care system and increased employment in community settings, there will be greater demands on community and public health nurses to broaden their population health perspective. The Code of Ethics of the American Nurses Association (ANA) (2001) promotes social reform by focusing on health policy and legislation to positively affect accessibility, quality, and cost of health care. Community and public health nurses, therefore, must align themselves with public health programs that promote and preserve the health of populations by
influencing sociocultural issues such as human rights, homelessness, violence, disability, and stigma of illness. This principle allows nurses to be positioned to promote the health, welfare, and safety of all individuals.
This chapter examines health from a population-focused, community-based perspective. Therefore it requires understanding of how people identify, define, and describe related concepts. The following section explores six major ideas: 1. Definitions of “health” and “community” 2. Determinants of health and disease 3. Indicators of health and disease 4. Definition and focus of public and community health 5. Description of a preventive approach to health 6. Definition and focus of “public health nursing,” “community health nursing,” and “community-based nursing”
Definitions of Health and Community Health The definition of health is evolving. The early, classic definition of health by the World Health Organization (WHO) set a trend toward describing health in social terms rather than in medical terms. Indeed, the WHO (1958, p. 1) defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
Social means “of or relating to living together in organized groups or similar close aggregates” (American Heritage College Dictionary, 1997, p. 1291) and refers to units of people in communities who interact with one another. “Social health” connotes community vitality and is a result of positive interaction among groups within the community with an emphasis on health promotion and illness prevention. For example, community groups may sponsor food banks in churches and civic organizations to help alleviate problems of hunger and nutrition. Other community groups may form to address problems of violence and lack of opportunity, which can negatively affect social health.
In the mid-1980s, the WHO expanded the definition of health to emphasize recognition of the social implications of health. Thus health is:
the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living; it is a positive concept emphasizing social and personal resources, and physical capacities. (WHO, 1986, p. 73)
Saylor (2004) pointed out that the WHO definition considers several dimensions of health. These include physical (structure/function), social, role, mental (emotional and intellectual), and general perceptions of health status. It also conceptualizes health from a macro perspective, as a resource to be used rather than a goal in and of itself.
The nursing literature contains many varied definitions of health.
For example, health has been defined as “a state of well-being in which the person is able to use purposeful, adaptive responses and processes physically, mentally, emotionally, spiritually, and socially” (Murray, Zentner, and Yakimo, 2009, p. 53); “realization of human potential through goal-directed behavior, competent self-care, and satisfying relationships with others” (Pender, Murdaugh, and Parsons, 2011, p. 22); and a state of a person that is characterized by soundness or wholeness of developed human structures and of bodily and mental functioning (Orem, 2001).
The variety of characterizations of the word illustrates the difficulty in standardizing the conceptualization of health. Commonalities involve description of “goal-directed” or “purposeful” actions, processes, responses, or behaviors and the possession of “soundness,” “wholeness,” and/or “well-being.” Problems can arise when the definition involves a unit of analysis. For example, some writers use the individual or “person” as the unit of analysis and exclude the community. Others may include additional concepts, such as adaptation and environment, in health definitions, and then present the environment as static and requiring human adaptation rather than as changing and enabling human modification.
For many years, community and public health nurses have favored Dunn’s (1961) classic concept of wellness, in which family, community, society, and environment are interrelated and have an impact on health. From his viewpoint, illness, health, and peak wellness are on a continuum; health is fluid and changing. Consequently, within a social context or environment, the state of health depends on the goals, potentials, and performance of individuals, families, communities, and societies.
Community The definitions of community are also numerous and variable. Baldwin and colleagues (1998) outlined the evolution of the definition of community by examining community health nursing textbooks. They determined that, before 1996, definitions of community focused on geographic boundaries combined with social attributes of people.
Citing several sources from the later part of the decade, the authors observed that geographic location became a secondary characteristic in the discussion of what defines a community.
In recent nursing literature, community has been defined as “a collection of people who interact with one another and whose common interests or characteristics form the basis for a sense of unity or belonging” (Allender, Rector, and Warner, 2013, p. 6); “a group of people who share something in common and interact with one another, who may exhibit a commitment with one another and may share a geographic boundary” (Lundy and Janes, 2009, p. 16); and “a locality-based entity, composed of systems of formal organizations reflecting society’s institutions, informal groups and aggregates” (Shuster, 2012, p. 398).
Maurer and Smith (2013) further addressed the concept of community and identified three defining attributes: people, place, and social interaction or common characteristics, interests, or goals. Combining ideas and concepts, in this text, community is seen as a group or collection of individuals interacting in social units and sharing common interests, characteristics, values, and goals.