discussion due tomorrow Watch the “Diary of Medical Mission Trip” videos dealing with the catastrophic earthquake in Haiti in 2010. Reflect on this n -

discussion due tomorrow
Watch the “Diary of Medical Mission Trip” videos dealing with the catastrophic earthquake in Haiti in 2010. Reflect on this natural disaster by answering the following questions: **make sure you watch video before answering these questions***
https://lc.gcumedia.com/nrs427v/diary-of-medical-mission-trip/v2.1/
https://www.redcross.org/content/dam/redcross/National/BE%20RED%20CROSS%20READY.pdf
https://www.ready.gov/community-emergency-response-team
http://www.redcross.org/get-help/disaster-relief-and-recovery-services
https://emergency.cdc.gov/

Propose one example of a nursing intervention related to the disaster from each of the following levels: primary prevention, secondary prevention, and tertiary prevention. Provide innovative examples that have not been discussed by previous students.
Under which phase of the disaster do the three proposed interventions fall? Explain why you chose that phase.
With what people or agencies would you work in facilitating the proposed interventions and why?

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discussion due tomorrow Watch the “Diary of Medical Mission Trip” videos dealing with the catastrophic earthquake in Haiti in 2010. Reflect on this n

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CHAPTER 1
Populations as Clients
By Sue Z. Green

We often think of nursing as giving meds on time, checking
an X-ray to see if the doctor needs to be called, or taking an
admission at 2:00 a.m. with a smile on our faces. Too often,
we forget all the other things that make our job what it truly
is: caring and having a desire to make a difference.Erin
Pettengill (National CPR Association, n.d.)

Essential Questions
How does expanding knowledge of population, community, and public health nursing

improve the nurses practice?
What are expected competencies for the nurse practicing within population groups?
How does the nurse apply the nursing process and collaborate with others to conduct a

populations health assessment?
Which community resources are useful during planning and interventions for a

populations health?

Introduction
Nursing care of populations involves working with larger groups of people and their
corresponding multiple health care needs. Community and public health nurses consider the
effect of ethnicity, culture, spiritual values, and geographic and socioeconomic conditions on the
wellness of the population. Diverse populations have various health disparities and health
inequities that affect their ability to maintain health and meet health care needs. A greater
understanding of historical and theoretical concepts provides a foundation for the nurses
approach to care of populations. The role of the public health nurse and the essential function of
public health services are explored in this chapter. The nursing process is applied as an

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approach to assess a community or specific population. Impediments to effective practice are
discussed to aid the nurses awareness of barriers to overcome.

Population Health

Population health is defined as the health outcomes of a group of individuals, including the
distribution of such outcomes within the group (Kindig & Stoddart, 2003, p. 381). Population
health has a goal of measuring, intervening, and improving health disparities among groups, as
well as the distribution of health, all of which is driven by assessment and statistical data. Public
health, a subcomponent of population health, is the practice of protecting and promoting quality
of life and holistic health of persons and communities through the use of science, research, and
direct care. The American Public Health Association (APHA) defines public health nursing as
the practice of promoting and protecting the health of populations using knowledge from
nursing, social, and public health sciences (American Public Health Association [APHA], 2013,
p. 2). Interdisciplinary public health practices aim to prevent disease outbreaks, injuries, and
poor health while promoting cost-effective measures that improve quality of life and health as
well as reduce environmental hazards (APHA, n.d.; Centers for Disease Control and Prevention
Foundation, 2017).

Development of the Public
Health Nursing Role

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The historical path leading to the discipline of public/community health nursing began more than
a century ago. Several nursing pioneers fashioned programs that led to the development of
organized public health delivery.

Florence Nightingale initiated health visitors in 1892, a group composed of lay female
missionaries with specialized training for instruction of health (Buhler-Wilkinson, 1985).
Much of the focus was teaching women about caring for themselves and their children.
This was the foundation of Englands district nursing today.

Lillian Wald established the term public health nurse with a focus on treating social and
economic problems along with illness. In 1893, Wald and Mary Brewster put this belief
into practice on the Lower East Side tenements of New York. Two years later, this led to
the establishment of the Henry Street Settlement and, later, the development of the
Visiting Nurses Association (VNA) (Fee & Bu, 2010).

Mary Breckinridge introduced nurse midwifery to the United States in 1925. She traveled
on horseback to deliver modern health care to the most inaccessible and poorest areas
of Appalachia in Kentucky (Frontier Nursing Service, 2015). This lead to the subsequent
development of the Frontier Nursing Service (FNS) and the expansion of public health
nursing into remote rural areas (Frontier Nursing University, n.d.).

Policy Reform
The public health profession continues to evolve. Various policy reforms in the United States
have shaped public health nursing to become what it is today. Public health needs drive
development of programs to improve public health. Sanitation reforms occurred as public health
nursing emerged. Public health education, improved waste disposal methods, and clean-water
policies reinforced the importance of the environment to the nations health. In 2004, a
presidential order, signed by President George W. Bush, established the Office of National
Coordinator for Health Information Technology, which included incentives for providers using
health information technology (HIT), motivating them to utilize electronic medical records (Bush,
2004; DeSalvo, Dinkler, & Stevens, 2015). Timely and efficient access to patient-related
information ushered in a new era of health informatics and population health. The 2010
Affordable Care Act (ACA) reinforced the importance of the use of HIT. Gradual transition of
services to outpatient or community settings further reinforce the nurses role in population
health management and health information technology.

From public health nursing, subspecialties have emerged, including school nursing, industrial
and occupational health nursing, child health nursing, tuberculosis nursing, rural nursing, and
the American Red Cross. Born from the rise of nursing specialty interest groups, the National
Organization of Public Health Nursing (NOPHN) emerged with Lillian Wald as the first president.
Many groups have since formed to address the varying needs of nurses across settings and
clinical specialties, including the American Nurses Association (ANA). The ANA, the largest
nursing organization, represents nurses across the United States, reinforcing the role of public
health nursing. The ANA recognizes and promotes the Quad Council Coalition of Public Health
Nursing Organizations (QCC or Quad Council) and public health nursings scope and standards
of practice. The ANA also supports nursing involvement in public health advocacy, education,
and policy, along with evolving health issues (American Nurses Association [ANA], n.d.).

Quad Council Coalition

The QCC comprises four nursing organizations serving public health nursing. Current

members include the Alliance of Nurses for Healthy Environments (ANHE), Public

Health Nursing Section of the American Public Health Association (PHN Section of

APHA), the Association of Community Health Nurse Educators (ACHNE), and the

Association of Public Health Nurses (APHN) (Quad Council Coalition of Public Health

Nursing Organizations [QCC], n.d.).

The QCC is the vehicle for guiding and developing current critical components and

competencies. Beginning in 2011, the QCC competencies were aligned to the Core

Competencies for Public Health Professions, a guiding document the QCC developed to

bridge academic and public health practice (Public Health Foundation, n.d.; QCC, n.d.;

Swider, Krothe, Reyes, & Cavetz, 2013). This alignment provided a mechanism to

promote nursing evidence-based competencies congruent with other public health

professions and academic practices. The nursing competencies span three tiers of

practice over various skill domains with competencies. The three tiers categorize

practice as:

Tier 1-basic or generalist
Tier 2-specialist or midlevel
Tier 3-executive and/or multi-systems level (Swider et al., 2013).

Those at the Tier 1 level work directly with the diverse populations to promote health

and prevent disease, collect and analyze data, plan programs, and conduct outreach

activities to reduce health disparities (QCC, n.d.). Tier 2 public health nurses are in

management or supervisory roles and assist in implementation of public health

programs (QCC, n.d.). Tier 3 competencies are for senior management or nurse

executive roles. Tier 3 public health nurses are responsible for administration,

organization, and operation of public health programs (QCC, n.d.).

Todays Community and Public
Health Nurses

Health promotion and care for the community and population at large reflect public/community
health nurses mission, vision, and commitments. Community health nursing and public
health nursing are terms synonymous for the role of the nurse outside institutional settings;
however, the terms are distinct from each other. Community health nursing has traditionally
focused on nursing care for acute and chronic conditions outside the traditional hospital setting,
primarily involving restorative care. Now, community health nursing involves health promotion of
individuals and families, providing care in settings such as occupational or educational systems.
Public health nursing addresses health promotion beyond an individuals or familys needs,
incorporating community aspects and global or environmental concerns. Public health nursing
focuses on groups, populations, or the health of an entire geographical sector (Canales &
Drevdahl, 2014; Kulbok, Thatcher, Park, & Meszaros, 2012; Reifsnider & Garcia, 2015).
Public health nursing is a population-focused practice. This practice concentrates on the
defined populations needs for prevention of illness and health improvement (Association of
Public Health Nurses [APHN], n.d.; ANA, n.d.; APHA, 2013). A public health nurse (PHN)
incorporates dynamics extending to small groups, or aggregates, and beyond for improvement
of a populations overall health. In turn, this improves the health of individuals and families
living, employment, and recreational environments (Swider & Kulbok, 2015). Aggregates are
persons who are grouped together because of common characteristics or location. The PHNs
educational background is traditionally a baccalaureate or advanced practice level (Reifsnider &
Garcia, 2015). To a nurse providing inpatient or primary care, a population means the patients
who are within that setting, but for a PHN, the population is inclusive of the entire aggregate
living in the community or a larger geographic sector. The PHNs population shares
commonalities of disease and risk and, unlike patients in an inpatient setting, the population

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comprises all persons irrespective of whether they request services (Reifsnider & Garcia, 2015).
Most nurses practice at individual and interpersonal levels of a community, but PHNs practice at
the organizational, community, and public policy levels as well. The PHN collaborates with other
disciplines and key community stakeholders. These stakeholders are persons who are both
involved and directly affected by the plans, actions, and outcomes of population health care. For
example, stakeholders may be local government officials, community groups, faith-based
organizations, or local business owners.

The PHNs practice involves the use of epidemiology. Epidemiology is the health science that
studies the incidence and prevalence of disease in large populations. Incidence rates denote
the emergence of a new illness. Prevalence rates reflect, in a given timeframe, the presence or
pervasiveness of disease in a population compared to the overall health of the population at
large. Epidemiologists aim to detect the source and cause of epidemics resulting from the
pervasive presence of infectious diseases.. These scientists seek to understand patterns
associated with the spread of communicable diseases and identify methods to minimize
incidence or prevent outbreak. Programs in public health originate from data obtained through
epidemiological research and focus on addressing infective agents, safeguarding biological or
human hosts, and controlling the environment to prevent the spread of disease.

Aspects of the Public Health Nursing Role

Advocates for the health of populations.
Establishes credibility with the community.
Concentrates on an aggregate or groups to improve the health of all.
Seeks prevention of illness.
Acts as a role model for leadership in provisions of health.
Fosters community organization.
Applies the ethical theory of utilitarianismmaking choices for the greater

good.
Incorporates epidemiologic knowledge and methods.
Conducts health assessment for entire populations for prevalence of disease,

risk factors, self-perceived health status, functional ability, and psychological
stressors.

Demonstrates versatility in dynamic collaborative environments.
Exhibits cultural competence with diverse populations.
Designs interventions for specific populations.
Evaluates outcomes of interventions (Harkness & DeMarco, 2015; Joyce,

OBrien, Belew-LaDue, Dorjee, & Smith, 2014; Kulbok, Thatcher, Park, &
Meszaros, 2012).

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The 10 Essential Public Health
Services
The Centers for Disease Control and Prevention (CDC) (n.d.) identifies three functions and 10
essential public health services (see Figure 1.1). Note the cyclical nature of Figure 1.1,
indicating that assessment, policy development, and assurance are ongoing. System
management features all the functions and essentials and incorporates the essential service of
research. The discipline of nursing has the ability to be involved in every aspect of the wheel.

Figure 1.1

The 10 Essential Public Health Services

Note. Adapted from The Public Health System & the 10 Essential Public Health Services, by the
Centers for Disease Control and Prevention, 2017.

Assessment
The assessment function incorporates the essential services of monitoring health status and
diagnosis and investigation of community health problems and hazards (see Figure 1.1). PHNs
are involved in data collection, community health assessment, and maintenance of data banks
on population health statistics. The PHNs use the information to identify health risks and
disparities, determine health service needs, and locate health care assets and resources to
support health and quality of life improvements (Centers for Disease Control and Prevention
[CDC], 2014). This health monitoring and identification process includes using technology, such
as geographic informational systems (GIS) to map the population for groups at higher risk
than the overall population (CDC, 2014). The monitoring and diagnosis essential service of the
assessment function involves timely identification and investigation of health threats; use of
diagnostic resources, such as state public health laboratories; and development of plans to
reduce health threats (CDC, 2014). The PHN is involved in epidemiologic investigations of
disease outbreaks, patterns of infections, environmental hazards, chronic diseases, injuries, and
any additional threat to the population, as well as developing plans for health care interventions
(see Table 1.1).

Policy Development
The development of public health policies address essential services and work to inform,
educate, and empower the public about health concerns while mobilizing the community in
support of key initiatives. (CDC, 2017b) (see Figure 1.1). The PHN builds knowledge and
shapes attitudes about health through health education initiatives, informing the public of
choices in health decision making, skills, and behaviors that contribute to a healthy quality of
life. Health promotion and education is often supported through partnerships with employers,
faith-based organizations, schools, and health care providers for implementation of initiatives
and reinforcement of health information (CDC, 2014). Public service announcements are one
mechanism in which media and marketing campaigns work to disseminate health information
(see Table 1.1). Mobilization of community partnerships also aid in the identification of health
problems and provide a source of both human and material resources. As public awareness
increases, partnerships, coalitions, and alliances develop to support prevention, screening, and
rehabilitation projects (CDC, 2014). The mobilization of partnerships serves as a foundation
toward effective local public health governance. Policies and plans develop to support both
individual and community efforts to protect health, further improve health, and prepare for
emergency response to health threats (CDC, 2014). The PHN may be involved in the
development of health policies, codes, regulations, and legislation that guide public health
protections. PHN planning for health improvement occurs at both the local and state levels,
including systematic alignment of resources for health improvement strategic planning.

Assurance

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The assurance function encompasses enforcing laws, linking people to care providers, assuring
a competent workforce, and evaluating program effectiveness (CDC, 2014). The enforcement of
laws and regulations are for the protection of health and safety. The PHN is involved in public
health emergencies requiring reinforcement, such as a quarantine, use of best practices to
achieve compliance with health regulations, and education of the public regarding laws and
regulations. Linking people in need of care to service providers involves the PHNs identification
of barriers to care for various population aggregates and coordination of appropriate services to
address, intervene, and overcome the barriers, including cultural, transportation, and language
barriers.
PHNs participate as members of the competent workforce by maintaining active licensure; using
public health competencies, such as those from the QCC; and applying the concept of lifelong
learning. PHNs assess, educate, and train other public health participants, such as students,
volunteers, or lay community health workers. Measures for continuous quality improvements are
adopted by PHNs while maintaining standards of care. PHNs seek opportunities for ongoing
leadership development, cultural competence, and improvement of health disparities. PHNs
evaluate the effectiveness, accessibility, and quality of individual and population-based public
health services. This ongoing evaluation and review of effectiveness analyzes health status and
service utilization data (CDC, 2014). This management of performance provides information
toward allocation of resources and program revisions (CDC, 2014). The information should
show how the needs of the population are met, which approaches are working, and what
requires improvement.

System Management
Research is an essential service contained throughout all three functions (CDC, 2014). This
involves surveillance of the outcomes of research and development of links between public
health practice and academic or research settings (CDC, 2014). Common research areas of
focus include epidemiological studies, health policy analyses, and public health systems
research (CDC, 2014). The PHN is involved in research activities, including initiation of
research, participation of research by other entities, reporting results, and implementation of
resulting evidence-based policies (see Table 1.1).

Table 1.1

Nursing Public Health Interventions

Intervention Definitions Examples

Assessment

Surveillance
Screening
Case finding
Investigation of disease

and health events

The continuous, systematic
collection, analysis and
interpretation of
health-related data needed
for the planning,
implementation, and
evaluation of public health
practice (World Health
Organization [WHO], n.d.)

Screening used to detect risk
factors for diseases or
undiagnosed diseases

The systematic search for at
risk persons

Track statistical data and
clusters of health events for
risk to the community and
compliance with infection
prevention/control measures

Tracking progress and
spread of the Zika virus

Testing for tuberculosis in
persons living with HIV

MRSA reported among
several high school athletes

Policy Development

Outreach
Inform, educate,

empower
Mobilize community

partnerships
Develop policies

Providing information about
health issues to the at risk
groups, special interest
populations, or the
community at large

Public service announcement
regarding influenza season
and an upcoming flu
immunization clinic

Check for Understanding

1. What aspects of national and global public health require enlarging the nurses perspective beyond the care
of the individual and family?

2. How have nurses been instrumental in the creation of the current services in public health?
3. How do public health nurses meet the publics need for services?

Theories to Inform Public Health
Nursing Practice

Assurance

Referral and follow up
Enforce laws
Link to and/or provide

care
Ensure competent

workforce
Evaluate

Assistance to identify and
access necessary resources
to resolve health issues

Referral for counseling to
victim of intimate partner
violence and encouragement
for follow-up appointments

Childhood immunization
monitoring

System Management

Incorporated within all
of the above

The research aspects of
all of the above

Provides intersection of
health, information and
communication
technologies, and research
to employ new perspectives
and innovative solutions to
care for health problems

Epidemiological studies

Methods of data input and
quality monitoring

The nursing profession adopts theories and conceptual frameworks from other disciplines, such
as behavioral change models, systems theories including family systems theories, concepts of
distributive or social justice, and community organization models (see Table 1.2). When
applying these concepts, the nurse seeks to discover the factors that influence the public to
exchange unhealthy behaviors for healthier ones and seeks to determine how programs and
revisions in community activities can promote and maintain health. Ethical care and general
systems theory are discussed next to demonstrate further applications to nursing.
Table 1.2

Psychosocial Theoretical Approaches for Community Health Care

Ethical Care
Ethical concepts relating to population health focus on the interdependence of people and what
is of benefit to the population, while maintaining respect for the individual (Barrett et al., 2016).
This social justice concept aligns well with the utilitarian ethical concept of doing the greatest
good for the greatest number. The concept of distributive justice, a component of social justice,
emphasizes the need to equalize access to resources, assets, and services for all within a
community (Devia et al., 2017). Social justice is at the foreground for combating health care

Concepts from Other Disciplines Application to Community/Public Health
Nursing

Ethics, Distributive Justice, Social Justice First aid, food, and water distribution after a
regional disaster

General Systems Theory, Family Systems
Model

Assessment of the community

Behavioral Change Models:

Transtheoretical Health Model
Health Belief Model

Smoking cessation campaign and support
groups

Community Organization Models:

Mobilizing for Action Through Planning
and Partnerships (MAPP)

PRECEDE-PROCEED Model
Community-Based Collaborative Action

Research (CBCAR)

Community and health care professionals
collaborate to improve health through
participatory decision making toward
identification of key issues and strategies to
develop and mobilize programs to achieve
health goals

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inequities and health disparities. Every human has a fundamental right to health and well-being
(WHO, 2017). Health inequities and disparities promote disease transmission, poverty, illiteracy,
contaminated air and water, inadequate nutrition, and other aspects affecting a persons health.
Nurses have knowledge, skills, and the duty to care in order to rebalance inequities and
decrease health disparities. Nurses have access to numerous resources pertaining to nursing
ethics and public health, including

ANAs Code of Ethics for Nurses with Interpretive Statements (2015)
ANAs The Nurses Role in Ethics and Human Rights (2016)
ANAs Public Health Nursing: Scope and Standards of Practice (2015)
ANAs Nursings Social Policy Statement (2010)
The ICN Position Statement on Nurses and Human Rights (2006)
The ICN Code of Ethics for Nurses (2012)
CDCs Public Health Ethics website
Principle of the Ethical Practice of Public Health (2002)
WHO Guidelines on Ethical Issues in Public Health Surveillance (2017)
Public Health Ethics: Cases Spanning the Globe (2016)

The Public Health Leadership Societys Principle of the Ethical Practice of Public Health (2002)
contains 12 principles of ethical practice of public health, often referred to as the public health
code of ethics (National Association of County and City Health Officials, n.d.). These principles
are also used by the CDC, the APHA, and the National Association of County and City Health
Officials.

Table 1.3

A Comparison of Clinical vs. Public Health Ethics Focus

Clinical Ethics Focus Public Health Ethics Focus

Individual autonomy is central;
focus is on consent and privacy

Interdependence is central; autonomy can be restricted to
protect the public

Treatment of individual disease Prevention of disease in population

Fiduciary relation to patient Public stewardship

Individual informed consent Community engagement

Individual patient benefit and
harm

Populations and communities

Note. Adapted from Good Decision Making in Real Time: Public Health Ethics Training for Local
Health Departments. Student Manual, by the Centers for Disease Control and Prevention, 2017.

General Systems Theory
General systems theory is one approach to develop a broader understanding of population
health. Ludwig von Bertalanffy proposed a way of studying components of systems by applying
Aristotles view that a whole is greater than the sum of its parts. Suprasystems, or wholes,
comprise a system, the environment around the system, and energy flowing from the system
(see Figure 1.2). Multiple systems may be contained within a suprasystem. Assessing all of the
components and the flow of energy exchanges provides a greater perspective of the
suprasystem (Von Bertalanffy, 1972; Drack, 2009). The flow of energy and system components
works to resist stressors to the system and keep equilibrium, which is a state of balance or
stability (Eshlemann & Davidhizar, 2000). Changes in the suprasystem influence systems and
subsystems. The change may be small but can yield a large impact on a subsystem. In reverse,
small changes in one part of a subsystem or system can alter the other aspects of the system
and result in larger changes in the system or suprasystem. Sometimes this is known as the
butterfly effect, which refers to the analogy that a butterfly fluttering its wings in one country
moves and stirs the air until subsequently there is a change in weather in another country, such
as a hurricane or tornado (Andrews, 2010).

Nurses use the assessment components of the nursing process to gain a perspective of the
larger whole, the individual, or family. Within the context of public health, nurses influence
individuals, families, and communities to make measurable changes toward established health
goals. Nurses observe external influences on persons, the interactions within persons and
families, and the influences from persons and families on the surrounding environment. Through
these observations, nurses gain a greater perspective of the persons or families health and life,

Individual benefit and harm Greatest net social good

Clinicians making medical
interventions

Array of interventions and professionals

Authority based on doctor or
profession

Authority based on police powers

Law more of an adversary than
an ally

Law/Policy a key tool of the profession

Justice focus limited to access
to care

Social justice and health equity central

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stressors on the life, and resources to maintain or restore equilibrium. Through the assessment
of needs, strengths, and barriers, nurses initiate steps to empower change across multiple
levels: person, family, and the community.

Figure 1.2

General Systems Theory and Energy Flow

General Systems Theory

Premises of general systems theory include the following:

A system consists of an overall whole called a susprasystem.
Inside the susprasystem are three components:

A system with internal energy exchanges, known as throughput,
Input or environment energy influences around the system, and
Output or energy exchanges coming from the system.

Studying the input, throughput, and output of the parts of the susprasystem
creates a greater perspective of the whole susprasystem (Von Bertalanffy, 1972;
Drack, 2009).

Nursing

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