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Population Health

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

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improve the nurse’s 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

population’s health assessment? ● Which community resources are useful during planning and interventions for a

population’s 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 nurse’s 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



approach to assess a ​community​ or specific population. Impediments to effective practice are discussed to aid the nurse’s 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



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 England’s 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 nation’s 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 nurse’s 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 nursing’s 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.).

Today’s 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 individual’s or family’s 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 population’s 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 population’s 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 PHN’s 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 PHN’s population shares commonalities of disease and risk and, unlike patients in an inpatient setting, the population



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 PHN’s 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 utilitarianism—making 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,

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



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.




● 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 PHN’s 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




● 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 nurse’s 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 public’s need for services?

Theories to Inform Public Health Nursing Practice


● 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



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 person’s 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

● ANA’s Code of Ethics for Nurses with Interpretive Statements (2015) ● ANA’s The Nurse’s Role in Ethics and Human Rights (2016) ● ANA’s Public Health Nursing: Scope and Standards of Practice (2015) ● ANA’s Nursing’s Social Policy Statement (2010) ● The ICN Position Statement on Nurses and Human Rights (2006) ● The ICN Code of Ethics for Nurses (2012) ● CDC’s 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 Society’s 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 Aristotle’s 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



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 Theoretical Approaches The theoretical and conceptual foundations of nursing practice incorporate the concepts of humans, environment, health, and nursing. The relationship of these concepts to one another reflect the exchange between members of the locus of care. The nurse interacts with individual clients, who in turn engage with environmental influences, socioeconomic and cultural factors, and unique attributes that inform health and well-being. Prominent nursing theoretical approaches and general premises pertaining to health and wellness have application in population health care (see Table 1.4).

Table 1.4

Nursing Theoretical Approaches for Population Health Practice

Nursing Concepts Premise Application to Population Health Practice

Anderson’s Client As Partner  Community populations are  those directly affected;  known as stakeholders; are  partners in health care

● Community involvement  as a partner,  stakeholder, and  collaborator in the  assessment of healthy  after-school activities  for local teens

● Grant writing to increase  availability of resources



King’s Theory of Goal  Attainment

Purposeful, quality  interactions between people,  groups, and community for  community functioning,  development, and health  maintenance

Community nurses use  resources such as  pamphlets, to educate the  public of the dangers of  carbon monoxide poisoning  with generator use, helping to  significantly reduce the  number of deaths the  following winter

Leininger’s Transcultural  Nursing

Understanding diverse  cultural health beliefs aids in  support of human health  choices and care

Respect and support of  alternative health practices

Neuman’s System Theory  Continuous interaction of  humans with each other and  with environmental stimuli;  expanded awareness and  competence to function and  maintain balance and  harmony in presence of  stressors and defend against  threats

● Presence of stressors  associated with aging  noted, such as isolation  from others

● Community network is  established for reducing  isolation of the elderly  through friendly visitors  and community yoga  exercise groups

Orem’s Self Care Deficit  Theory

Concept of empowerment;  clients have deficits in ability  to provide health care for  themselves; nurses assist  client with  restoration/rehabilitation of  health

The nurse provides  education, advocacy, and  skilled interventions that  assist the community to  obtain healthy lives and  empowers the community to  take charge of its health



Check for Understanding

Orlando’s Nursing Process  Assessment, planning,  implementation, and  evaluation as an organized  approach to nursing care  delivery

● Community assessment  of high suicide rates  among local teenagers

● Planning and  implementing suicide  prevention education for  a local school district

● Evaluation of  subsequent suicide  rates among local teens  of the school district

Pender’s Health Promotion  Model

Factors and relationships  contribute to  health-promoting behavior,  health enhancement, and  quality of life

Interpersonal influences of  community health helps  smokers commit to  smoking-cessation program

Roy’s Adaptation Model  Process of adaptation to the  environment/external stimuli

● Advocacy for increasing  physical accessibility to  public places

● Advocacy for changing  school lunch menus and  vending machines to  healthy nutritional  choices

Watson’s Caring  Healthy community is  holistic integration of social,  spiritual, and personal  resources to attain or  maintain health for  members’ body, mind, and  spirit

Caring and compassion  shown in aiding the homeless  population



1. Which nursing theoretical foundation that applies to individuals can be expanded to apply to population health?

2. How do nursing theoretical concepts enhance the nurse’s approach to population health care?

Community Assessment and the Nursing Process

● Communities have three components: the population, a location, and a social system; therefore, nurses assessing the communities consider the people within, the boundaries of the location, and the general environment where the community exists. Narrowing the focus begins by establishing boundaries or parameters in which to examine members of a community and the environment. Professionals can also narrow the focus by defining sets of factors, or variables, and analyzing population sets in various databases.

Population of Focus Defining and describing characteristics of the population of focus is the first step in population-focused assessment. The population may reside in a large metropolis, a small rural community, or in a particular geographical region in which members of the population are influenced by unique social, economic, and political circumstances. Certain health care conditions and disparities are more prevalent in locations with larger population size, density, and composition of characteristics. Over time, populations can grow or decline, and population characteristics can change. Demographic characteristics, including culture, gender, educational level, marital status, occupation, and income, form the basis for assessing population needs and gaps in health.

Geopolitical Place Environmental factors relevant to the geographic location affect the health of the community. One means of examining the environmental conditions influencing the quantity and quality of life for a given population is to evaluate the geopolitical location of a population. A geopolitical place consists of community boundaries, transportation infrastructure, geographic features, climate, vegetation, animals, and human-made homes and facilities. The nurse may begin by defining the place in terms of natural geographic boundaries. Various mountain ranges may surround the



community. A river or rivers may dissect the area, or border the region. Injury and natural disasters that occur are also associated with geographic location. This can include animal influences on health (e.g., kicking, bites, or attack), poisonous vegetation, outdoor recreational activities common in the area, geological activity, temperature extremes, and other adverse weather activity.

Constructed geopolitical boundaries include ZIP codes, census tracts, voting districts, suburb dimensions, school districts, health districts, and other legal or political boundaries. Man-made structural boundaries, such as streets, bridges, airports, and transportation tracks, complete the picture. Epidemiologic studies use data from specified geopolitical places to determine population ​demographics​, diversity, health services, and resources, including structural facilities.

GIS tracking can assist health professionals in defining geographical or population boundaries. Additionally, GIS can be used as a framework to organize health patterns, disparities, and behaviors related to geographic overlay. In other words, GIS helps to determine where there are disparities, health behaviors, or health deficits in an environment related to the geography of the area. The organizing system of GIS can help professionals in population health informatics to track and analyze data, define problem areas, and assess populations, so intervention can be determined and implemented.

Phenomenological Place Phenomenological place is a relational or psychological location rather than a geographical location. A phenomenological place centers on history, culture, economics, education, spiritual beliefs, values, common characteristics, or similar goals. These independent and interdependent relationships create a context in which members of the community experience belonging. An individual may belong within various phenomenological places. For example, one person may belong to a church organization, cultural heritage group, library-reading group, and a political activism group. Another person may belong to an animal shelter volunteer group, online graphic novel interest group, and a veterans’ group. Social interactions, common interests, goals, and various other characteristics assessment and analysis aids determination of health status and health needs.

The community components discussed in this chapter are foundational to understanding community assessment. Demographic characteristics of the population of focus determine the size of population for assessment and the characteristics of the population. Geopolitical and phenomenological place aid in the development of geographical, political, and psychosocial context that guides population assessment.

Assessment Approach A community assessment involves researching the safety and quality aspects of a community to understand the interactions among the population, environment, and resources. Pertinent informatics and community data retrieval from various resources measure behaviors and health status of the population. Much like conducting a health assessment, the nurse undertakes a



sequence of steps to discover subjective and objective information and then analyzes the findings. Based on the findings, the nurse identifies needs, priority outcomes, a plan, intervention, and a means to evaluate the intervention outcomes. Much like an individual health assessment, the community or population assessment happens in an organized manner to avoid overlooking subtle positive and negative findings. The process may take weeks or months and may halt the prioritization of needs while funding and resources, such as people, assemble.

The first step in a community assessment is refining the focus to a particular targeted population group or location. Although an extensive community assessment is possible, usually an initial assessment occurs on a smaller scale. When conducting a community assessment, the nurse determines what population and location will be assessed and if assistance of others or key stakeholders are needed for the assessment. The assessment process includes the gathering of data and observing the given group of people and their location for physical, psychological, sociological, economic, spiritual, and lifestyles that reveal the current health status, problems, or barriers to priority needs. Quantitative (numerical) and qualitative (explanatory or descriptive) data are utilized as resources for a community assessment. Both are collected from both primary and secondary sources of information.

Primary Sources of Data Primary sources of data include the critical assessment resources of the defined community. The people conducting the assessment directly collect the information. The components include, but are not limited to, the people/population, geopolitical or phenomenological place, health information systems, and the observable social interactions. These sources provide information that the nurse and other group members obtain directly through means such as observation and surveys. A population has parameters of variables or factors that define the assessment or analysis.

The nurse can inspect the location of and listen to the population by conducting a walking or windshield survey. A windshield survey occurs when someone drives through a defined community’s geographical location, making observations of the locale. The person seeks impressions of what life is like for the population in the neighborhood(s) and what those in the heart of the area need. Housing age and general condition, availability of public transportation, noise levels, general condition of motor vehicles, street or road conditions, traffic flow, types of businesses, sources of recreation, education, police, fire department, and health care accessibility are noted, along with natural boundaries, terrain, and climate. Observations provide evidence of spiritual beliefs, architecture style, decay or renewal, and open spaces, such as parks or vacant lots, to help form a picture of the life there. Signs of life may include notices and posters (Mengistu & Misganaw, 2006). If walking through the area, the person assessing the area may engage in conversations with people on the street, asking questions about the area. An imprint or mental snapshot forms about what the population encounters day to day. A sense of the area or people’s history, demographics, ethnicity, values, and beliefs forms. Walking and windshield surveys provide firsthand impressions of the physical environment, economy, political and governmental activity, recreation, availability of transportation, education, safety, health, social services, and communication venues (Anderson & McFarlane, 2015). Because walking or windshield surveys are not always feasible, the nurse is likely to use a secondary



resource, such as data from databases or health warehouses, to analyze the extent and significance of health status or disparities.

Secondary Sources of Data The nurse gleans pertinent data from secondary sources including research conducted by others at a previous time. Websites and public documents are resources for gathering this information. Data warehouses of epidemiological information can reveal current issues and help with trending. GIS surveys can use computer information systems to overlay information such as health variables, access to health care, transportation systems, neighborhoods, food availability, or other available data to get a clear picture of how variables interact to increase or decrease health outcomes. Further assessment continues through research of additional primary and secondary sources of data and use of technology. The results of public forums and focus groups provide additional material. These forums and focus groups are a venue for people to answer some predetermined questions about a particular topic, permitting those who would not ordinarily express an opinion an opportunity to provide input (Rotary International, n.d.).

The assessment uses a holistic approach and identifies sources of spiritual support in the community. The aim is to uncover the biological, spiritual, and psychosocial factors that compose the population studied (CDC, 2010). The nurse can detect the effect humanitarian and spiritual mission-based groups have on the community. For example, Habitat for Humanity creates safe, affordable shelters with long-lasting, life-changing effects. Support groups and counseling services may have a spiritual-based background, such as local Alcoholic Anonymous groups, bereavement groups, equine or pet therapy programs, and divorce or single parent support groups. Food banks, homeless shelters, and clothing centers operate as mission-based services. Interfaith organizations join to form larger programing, such as Interfaith Hospitality Network’s mission to provide food and temporary shelter for families. The nurse assesses the organizations’ impact on the reduction of health inequities and disparities. If an organization is not available to provide a service or discontinues a service, the nurse assesses for gaps and other possible interventions. Likewise, spiritual resources can aid nursing interventions that reduce health inequities and disparities.

The desired outcome of studying both primary and secondary sources is to form an understanding of the populations, creating a complete picture of the defined population in the community, their health status, and their health behaviors. The understanding includes awareness of community history, organizations or groups among the population, and social, political, and economic changes for the population. Comparisons to other like populations provide further understanding through the compare/contrast processes (YMCA, 2012). Health problems become more prominent. During this process, the nurse may align with community leaders who are stakeholders in the outcome or persons who become partners in the pursuit of health improvement. The terminology, ​partner in care​, indicates that an individual or a group within the population or community becomes a partner and collaborator in the public health arena, with a voice in determining the approach to care.



Table 1.5

Primary and Secondary Sources of Data

Primary Sources of Assessment Data Examples

People  ● Structured interviews of key individuals  or stakeholders who have knowledge of  particular alterations or situations

○ People in the situation  ○ Volunteers  ○ Workers with knowledge  ○ Spiritual groups

Environment  ● Feedback from the environment of the  communities functioning physically and  socially

● Determination of assets and resources

Boundaries  Statistics or description of the population’s  parameters

Demographics  ● Observations  ● Key interviews

Observation  ● Walking or windshield survey  ● Group dynamics

Secondary Sources of Assessment Data Examples



National Sources  ● U.S. Census Bureau  ● Government publications of data

State Sources  ● Birth, deaths, and disease statistics  ● Climate statistics  ● Air quality  ● Health department

Local Sources  Public school finances, school enrollment,  levels of education, day care facilities, tax  records, housing starts, government housing,  shelters, employment rates, occupations, fire  and police protection, publication of local  history media (radio, television, newspapers,  city website), waste disposal and sanitation,  water sources and treatment, hospitals and  clinics, health department, counseling  services, religious groups and facilities,  sources for food and clothing, food pantry,  welfare services

Survey  ● Random or sample selection of  members from particular groups within  the population

● Responses may provide a picture of the  larger population

Interviews and Presentations  ● Testimonies from key community  members or experts

● Presentations to/from groups



Check for Understanding

1. What nursing perceptions of the client expand when applied to a population? 2. How do primary sources enlighten the nurse’s perspective of a population? 3. How does use of secondary sources enhance the assessment of the community?

Analysis, Diagnosis, and Planning

Community Groups  ● Results of forums and/or focus groups  by market researchers

● Random selection or participants  chosen to represent different groups of  the population to discuss a topic and aid  in determining the community interest in  or significance of an issue

Geographical Information Systems (GIS)  ● U.S. Geological Survey’s GIS showing:  ○ Climate areas  ○ Where people and disease cluster  ○ Traffic  ○ Buying patterns  ○ Utility lines  ○ Pollution spread

● GIS overlay of health variables and  factors to enable analysis of health  status

Health Information Systems  Databases or data warehouses that contain  pertinent population health information



● Using a ​SWOT analysis​, the nurse categorizes the assessment findings for the population’s strengths, assets, and resources; notes weaknesses, challenges, limitations, restrictions, and overall threats to the group, and identifies both actual and potential diagnoses (see Table 1.6). The use of SWOT analysis promotes broader critical thinking about the population and environment (Community Tool Box, n.d.). Consideration of stakeholders and spiritual resources are included in this process. Table 1.6

SWOT Analysis Example


● Housing in adequate condition  ● Family shelter for those in need  ● Immunization clinics rotate though

shopping areas that are within walking  distance for most

● Multiple areas of housing for elderly  with low incomes

● Discount food warehouses on outskirts  of area

● Decreasing adolescent pregnancy rate  ● City water fluoridation system


● Lack of transportation (e.g., taxi or bus  service)

● High rate of unemployment among  young adult population

● Lack of low-income health clinics  ● Multiple downtown retailers have closed

or gone out of business, leaving  buildings empty with “For Rent” or “For  Sale” signage and boarded windows


● Faith-based initiative forming free lunch  program and gathering with those with  health care needs

● New YMCA slated for spring  construction with room for community  events

● Interdisciplinary collaboration in place  through the local health  department—currently planning


● Flooding from river every spring and fall  ● Increasing incidence of rabies  ● Power outages during summer heat

waves leave elderly without air  conditioning

● Increasing incidence of opioid overdose  ● Increasing incidence of adolescent

suicide rate



Steps in the assessment of a population are similar to the logic model commonly used by health professionals known as the ​PRECEDE-PROCEED model​ (Van Gelderen, Krumwiede, Krumwiede, & Fesnke, 2018). The PRECEDE-PROCEED model is a comprehensive method of assessing community needs for social and ecological areas for health promotion, then identifying desired outcomes and the process for health promotion program implementation. The nurse can use this model to organize the assessment of a population, including epidemiological data, environmental diagnosis, and organizational and policy data as a basis for program planning. The nurse formulates nursing diagnoses for the community based on the findings and problems determined from the community assessment. The diagnoses can incorporate all aspects of health. Prioritization of the diagnoses can narrow the focus and guide care when a broad range of health care needs exist. Prioritization Example

If the water supply is found to have unsafe levels of lead and elevated serum lead levels are found in some children and adults, then the contaminated water supply would be a higher priority than the development of a program for scoliosis screening. An appropriate nursing diagnosis based on the relevant assessment data could be:

Contamination related to chemical contamination of water AEB venous blood lead levels of above 10mg/dL in 25% of the adult and pediatric population and lead contamination of drinking water of 100 parts per billion in 90% of samples (CDC, 2015; CDC, 2017a).

Selection of nursing diagnoses leads to determining outcome identification. Prioritization may be in terms of what outcome will reach the largest segment of the population and have the highest impact. Alternatively, perhaps a smaller segment has highly critical or life-threatening need and will become the target of care. In either event, the nursing diagnoses are rank ordered. Outcomes fashioned specifically for the targeted population are measureable, relevant, and achievable (within the capacity of resources) and hold an explicit time requirement for completion. Plans, derived from the identified outcomes, often include primary, secondary, and tertiary prevention components. Primary prevention components aim to strengthen the population’s resistance to stressors and illness. Secondary prevention targets areas that have stressed the population or causes illness or weaknesses. Secondary prevention provides support to lessen or overcome the stressors. Tertiary prevention intends to halt further system imbalances of the system or population (Eshlemann & Davidhizar, 2000). Planning should contemplate what the population would be like if the area of concern is resolved, then consider what interventions would grow toward making that outcome a reality. Use of available community resources provides support of the plan. Predetermining measurement of the

adolescent suicide intervention program  for local schools and media campaign  regarding opioid overdoses



outcomes will help determine if success is evident through population behavior changes and numerical and/or percentage statistical information.

Sample Nursing Community Diagnoses

● Contamination ● Deficient community health ● Ineffective community coping ● Readiness for enhanced health maintenance ● Risk for complicated immigration transition ● Risk for injection ● Risk for injury ● Social isolation (Herdman & Kamtisuru, 2018).

Intervention and Evaluation

● The nurse has direction toward the population’s primary needs for nursing care by analyzing data, prioritizing nursing diagnoses, and determining outcomes. Then, evidence-based and best practice research regarding successful approaches by others occurs, including how to sustain success effectively. Again, the PHN may use a logic model for organization. The PROCEED portion of the PRECEDE-PROCEED model is congruent with the intervention and evaluation process. The nurse chooses achievable strategies to fit the target population, determinates resources, and seeks assistance and/or funding as needed. Perhaps, the priority is outreach to local groups regarding the importance of influenza vaccination or preparation for weather disasters. Another priority may be outreach regarding diabetic education classes at a local public health setting. Whatever the priority, by setting outcomes and determining a plan of action, the nursing process is applied to the broader population. Evaluation of results occurs upon completion of the preplanned interventions. Input into statistical programs is encouraged to provide systemic support and the discovery of trends. Statistical results support evidence of change or areas that are lagging. Future programming or improvements have more strength



toward funding and persuasion of others when backed with data reflecting improvement in health and financial implications.

Impediments to Effective Practice

● Apathy Apathy is a barrier that can impede change in population health when the population and/or

health professionals believe that change is not possible or probable. ​“Knowing is not  enough; we must apply. Willing is not enough; we must do.”—Goethe  (Institute of Medicine, 2003, iii)​Resignation to poverty, illiteracy, and other health disparities creates a vacuum for motivation to change. Beliefs that the world must have the underserved, underinsured, uninsured, and lack of funds or resources can be difficult to sway. Stigma can impede health of populations. Sexual orientation disparities, migrant status, cultural and language barriers, poverty, and illiteracy bear stigmas. Embarrassment, refusal to accept charity, fear of deportation, pride, fear of separation/removal of family members become brick walls at times, hindering access into health services.

Costs Barriers such as cost, transportation, age, and geographic location impede community access to health care programs and services. Among the ongoing barriers associated with cost for communities include lack of funds to develop physical infrastructure, hire human resources (employees) to provide services, and lobby efforts toward public policies. The insufficient number of BSN-prepared nurses creates gaps in services. In this century, policy support has grown for the preparation of those with BSN and advanced nursing practice. Fortunately, awareness is growing that the cost of illness is greater than the cost of primary and secondary preventative services, including a competent workforce. The Institute of Medicine (IOM) report, The Future of Public Health​ (IOM, 1988), revealed disarray in the public health infrastructure. Since the report’s publication, efforts have transpired to strengthen public health agencies, develop the workforce, and envision Healthy People 2010, then Healthy People 2020 initiatives



(IOM, 2003; IOM, 2011). In addition, the ACA promoted health system reform with provisions that pursued improved quality and effect, stronger workforce and health care infrastructure, and greater focus on public health and prevention (APHA, 2012). The ACA’s emphasis on wellness care supports access to and quality of care, including public health services (Berg & Dickow, 2014).

Resistance to Change Resistance to change impedes healthy behaviors. Individuals show resistance to behaviors necessary for health. Change has the connotation of losing control or choice, sacrificing pleasures, such as favorite foods, increased cost, loss of personal time, or increased work, in the form of dedicated physical exercise. Socially constructed norms, such as cultural beliefs, some spiritual practices, medical mistrust, or mistrust of government services delay progress for positive health behavior changes. Family or social support systems that do not discuss health-related information or ridicule change reduce perceptions that change is needed. A perception of lack of risk reduces the public’s preventative behaviors (You, Chen, & Liao, 2018). The health care structure and personnel affect motivation to change. Difficulty in accessing support services, such as nutritional information, diagnostic monitoring of progress, exercise facilities, or drug therapies, slows progress. The health care professional’s demeanor can impact motivation to change. Lack of health care professionals’ emphasis on the need for lifestyle change, the impression that such change does not have a high value for that professional, or the impression that the health care professional did not have confidence the person could make lifestyle changes affect the person’s motivation (Hardcastle, Maxwell-Smith, Hagger, O’Connor, & Platell, 2018). Those not motivated to make healthy behavioral changes are often those who are at the most risk (Hardcastle et al., 2015). Conflicting information, a patient’s lack of desire to arrange support, and lack of simple messages and strategies to stay healthy contribute to delay or reinforcement of change (Hardcastle et al., 2018). Research is ongoing in methods to impact these barriers to change. The nurse should conduct a self-examination of how healthy behaviors are valued and role modeled, accurate information is provided, nonjudgmental demeanors are conveyed, barriers to health care are reduced or removed, and methods of simple messages and support are within that nurse’s practice.

Reflective Summary Public/community health nursing has historical roots. The nursing role has evolved with expected competencies for public health nursing and information technology. Nursing practice targets groups of people in addition to individuals and families. An understanding of the interplay of systems is foundational to nursing care of populations. The community becomes the nurse’s client—not a singular patient, but a group of people who interact and participate in the health and wellness of the community at large. Social justice is a concept to guide ethical care within society. Disruption of health inequities and disparities are within the realm of nursing population health practice. Nurses can conduct an assessment of the community by using the nursing process, and thereby identifying and analyzing the problem areas, health disparities, and



resources for a population. This provides insight into the conditions in which the population lives, works, and plays. By working with community stakeholders, which includes spiritual groups, the nurse can make a difference in the health of larger groups.

Key Terms Aggregate:​ Grouping of persons because of common characteristics or location.

Commitment:​ Dedication or sense of duty toward someone or something.

Community:​ A group of people within an open social system who share similar goals and live within a similar area.

Community-Based Collaborative Action Research (CBCAR):​ A research approach to understanding patterns of health problems and inequities from a social justice/ecological perspective facilitated by key community stakeholders to promote human rights and health.

Community Health Nursing:​ Nursing care for acute and chronic conditions outside the traditional hospital setting with a focus of restorative care.

Demographics:​ Statistical information regarding groups of persons.

Distributive Justice: ​Fair allocation of resources and services.

Empowerment:​ Promotion of power and authority to make decisions and changes.

Epidemiology:​ The study of disease appearance, course, spread, and eradication.

Equilibrium:​ A state of balance between stressors and energies for resistance to stressors. The state of stability.

General Systems Theory:​ A structure with a network of interrelated, interacting, and exchanging features that form a complex, balanced whole that can withstand external influences and disruptions. Mathematical study of change by Dr. Ludwig von Bertalanffy.

Geographic Information Systems (GIS):​ Digital mapping system showing grouping of multiple variables, such as climate areas, clusters of people and disease, traffic, buying patterns, utility lines, and pollution spread. Capable of overlaying health variables and factors to enable analysis of health status.

Group: ​Persons placed together.

Health Disparities:​ Variables that contribute to inequities or an unequal distribution of resources for various populations; preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations; specifically relatable to social, economic, and/or environmental disadvantages.

Incidence:​ Numerical rate of newly diagnosed occurrences of a disease in a population; numerical value used as part of rate or frequency determination.



Mobilizing for Action Through Planning and Partnerships (MAPP): ​Method of c​ommunity-wide strategic planning, facilitated by public health leaders using the essential services of public health to help communities make health and quality of life improvements.

Partner in Care:​ An individual or group within the population or community who becomes a partner and collaborator in the public health arena, with a voice in determining the approach to care.

Population:​ Inhabitants of an area.

Population-Focused:​ Attention particular to a given population.

Population Health:​ Defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.

Prevalence:​ Numerical fraction or ratio of disease diagnosis (incidence) in comparison with the total population group; term used as part of rate or frequency determination.

Public Health:​ The practice of protecting and promoting quality of life of persons and communities through the use of science, research, and direct care to prevent disease outbreaks, environmental hazards, injuries, and poor health.

Public Health Nursing:​ “The practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (APHA, 2013, p. 2).

PRECEDE-PROCEED Model:​ Logic model, developed by Lawrence Green, used as a tool by health professionals to design, implement, and evaluate programs for health promotion and health behavior changes.

Social Justice:​ Treating all fairly no matter what socioeconomic background, ethnicity, age, citizenship, disability, or sexual orientation.

Stakeholder:​ Person or persons both involved and directly affected by plans, actions, and outcomes. Person with a vested interest or personal stake in the outcome.

SWOT Analysis:​ An assessment and analysis technique used to determine internal strengths, internal weaknesses, broader opportunities or external resources, and external threats for a population or an organization. Method to develop a more in-depth perspective of an issue.

Suprasystem:​ Large structure or system with smaller components or subsystems.

Vision: ​An aspiration or a plan for the future.

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