We are experiencing extraordinary changes in healthcare in this new century; changes that call upon the most creative, analytical, and innovative skills available. While the world has the resources to reduce healthcare disparities and eliminate the differences in healthcare and health outcomes that exist between various population groups across the globe, accomplishing this is a long-term and complicated task. Improvement in the social structure within which people live, and a redistribution of resources so that all people have access to the basic necessities of life, require an unprecedented global consciousness and political commitment. Ultimately, reducing health disparities and promoting health equity occur within the local community where people reside. Nurses are by far the largest group of healthcare providers worldwide and, as such, have the ability and responsibility to be change agents and leaders in implementing change in their communities. They can be the primary participants in the development of health policy that specifically addresses the unique needs of their communities. Through implementation and evaluation of culturally appropriate, community-based programs, nurses can use their expertise to remedy the conditions that contribute to health disparities. People
need to be assured that their healthcare needs will be assessed and that healthcare is available and accessible.
In the United States, public health has resurged as a national priority. Through Healthy People 2020, national goals have been set to promote a healthy population and address the issue of health disparities. The process of implementing the Healthy People 2020 objectives rests with regional and local practitioners, with nurses having a direct responsibility in the implementation process. The nurse practicing in the community has a central role in providing direct care for the ill as well as promoting and maintaining the health of groups of people, regardless of the circumstances that exist. Today, there are unparalleled challenges to the nurse’s problemsolving skills in carrying out this mission.
Whether caring for the individual or the members of a community, it is essential that nurses incorporate evidence from multiple sources in the analysis and solution of public health issues. Community and Public Health Nursing: Evidence for Practice focuses on evidence-based practice, presenting multiple formats designed to develop the abstract critical thinking skills and complex reasoning abilities necessary for nurses becoming generalists in community and public health nursing. The unique blend of both the nursing process and the epidemiologic process provides a framework for gathering evidence about health problems, analyzing the information, generating diagnoses or hypotheses, planning for resolution, implementing plans of action, and evaluating the results.
“To every complex question there is a simple answer…and it is wrong.” H. L. Mencken(writer andwit,1880–1956)
CONTENT ORGANIZATION
It is the intention of Community and Public Health Nursing: Evidence for Practice to present the core content of community and public health nursing in a succinct, logically organized, but comprehensive manner. The evidence for practice focus not only includes chapters
on epidemiology, biostatistics, and research but also integrates these topics throughout the text. Concrete examples assist students in interpreting and applying statistical data. Healthy People goals and measurable objectives serve as an illustration of the use of rates throughout the text. Additionally, we have added brief learning activities and questions throughout the text to allow students to apply the Healthy People goals to real-life scenarios. Groups with special needs, such as refugees and the homeless, have been addressed in several chapters; however, tangential topics that can be found in adult health and maternal-child health textbooks have been omitted. A chapter on environmental health concerns has been included, along with a chapter on community preparedness for emergencies and disasters. Also, a global perspective has been incorporated into many chapters.
Challenges to critical thinking are presented in multiple places throughout each chapter. Case studies are integrated into the content of each chapter and contain critical thinking questions imbedded in the case study content. Also, a series of critical thinking questions can be found at the end of each chapter (Please see the description of features below.) Considering the onus presented by Mark Twain: “Be careful about reading health books. You may die of a misprint,” every attempt has been made to present correct, meaningful, and current evidence for practice.
Part One presents the context within which the community or public health nurse practices. An overview of the major drivers of healthcare change leads to a discussion of evolving trends, such as the emphasis on patient/client-centered care, the effects of new technology upon the delivery of care, and the need for people to assume more responsibility for maintaining their health. Community and public health nursing as it presently exists is analyzed and reviewed from a historical base, and issues foreseen for both the present and immediate future are discussed. The nursing competencies necessary for competent community and public health practice are also presented.
A more in-depth discussion of the complex structure, function, and outcomes of public health and healthcare systems follows.
National and international perspectives regarding philosophical and political attitudes, social structures, economics, resources, financing mechanisms, and historical contexts are presented, highlighting healthcare organizations and issues in several developed countries. The World Health Organization’s commitment to improving the public’s health in developing countries follows, with an emphasis on refugees and disaster relief. With the burden of disease growing disproportionately in the world, largely due to climate, public policy, socioeconomic conditions, age, and an imbalance in distribution of risk factors, the countries burdened by disease often have the least capacity to institute change. Part One concludes with examination of the indicators of health, health and human rights, factors that affect health globally, and a framework for improving world health.
Part Two provides the frameworks and tools necessary to engage in evidence-based practice focused on the population’s health. Concepts of health literacy, health promotion, disease prevention, and risk reduction are explored, and a variety of conceptual frameworks are presented with a focus on both the epidemiologic and ecologic models. Epidemiology is presented as the science of prevention, and nurses are shown how epidemiologic principles are applied in practice, including the use of rates and other statistics as community health indicators. Specific research designs are also explored, including the application of epidemiologic research to practice settings.
Part Three is designed to develop the skills necessary to implement nursing practice effectively in community settings. Since healthcare is in a unique state of transformation, planning for community change is paramount. The health planning process is described, with specific attention given to the social and environmental determinants of change Lewin’s change theory, force-field analysis, and the effective use of leverage points identified in the force-field analysis demonstrate the change process in action.
Changes directed at decreasing health disparities must be culturally sensitive, client-centered, and community-oriented. A chapter on cultural diversity and values fosters the development of
culturally competent practitioners, and the process of cultural health assessment is highlighted. Frameworks of community assessment are presented and various approaches are explored. Management of care and the case management process follows. The role and scope of home care nursing practice and the provision of services is presented along with the challenges inherent with interdisciplinary roles, advances in telehealth, and other home care services.
Although content on family assessment can be found in other texts, it is an integral component of community and public health practice. Therefore, theoretical perspectives of family, and contemporary family configurations and life cycles are explored. Family Systems Nursing and the Calgary Family Assessment and Intervention Model are provided as guides to implementing family nursing practice in the community. Evidence-based maternal-child health home visiting programs and prominent issues related to family caregiving are also highlighted.
Part Four presents the common challenges in community and public health nursing. The chapter addressing the risk of infectious and communicable diseases explores outbreak investigation with analysis of data experience provided by the case studies. Public health surveillance, the risk of common foodborne and waterborne illnesses, and sexually transmitted diseases are followed by a discussion of factors that influence the emergence/reemergence of infectious diseases, examples of recent outbreaks, and means of prevention and control.
The challenge presented by violence in the community is presented with an emphasis on intimate partner violence and the role of the healthcare provider. Because of the cultural variations in substance use disorder, multifaceted approaches to the problem are discussed with the recommendation that evidence-based prevention and treatment protocols for substance use disorder are incorporated by community health nurses in all practice settings. Meeting the healthcare needs of vulnerable and underserved populations is another challenge. Health priorities for people who live in rural areas; are gay, lesbian, bisexual, or transgender; are homeless; or live in correctional institutions are reviewed.
The issues of access to quality care, chronic disease management, interaction with health personnel, and health promotion in hard-to-reach populations among these populations are also presented.
The environmental chapter demonstrates how to assess contaminants in the community by creation of an exposure pathway. The health effects of the exposure pathway can then be ascertained Individual assessment of contaminant exposures, interventions, and evaluations are also explored, ending with a focus on maintaining healthy communities. The final chapter in Part Four presents the issue of community preparedness. The types of disasters along with classification of agents are described, disaster management outlined, and the public health response explained. The role and responsibility of nurses in disasters and characteristics of the field response complete the content.
Part Five describes five common specialty practices within community and public health nursing. All have frameworks that define practice and reflect the competencies necessary for competent practice in a variety of community settings. These include application of the principles of practice to community mental health, school health, faith-oriented communities, palliative care, and occupational health nursing.
Features Found in Each Chapter
CHAPTER HIGHLIGHTS
Brief outline of the content and direction of the chapter
OBJECTIVES
Observable changes expected following completion of the chapter
KEY TERMS
Essential concepts and terminology required for comprehension of chapter content
CASE STUDIES
Vignettes presented throughout the content of each chapter, designed to stimulate critical thinkingandanalytic skills
Evidence for Practice
Examples of objective evidence obtained from research studies that provide direction for practice
It is difficult to embark on the development of a new textbook without the support of colleagues, family, and friends. A special thanks belongs to our contributors, both returning and new, who were willing to share their expertise by writing chapters filled with the passion and commitment to community and public health. In addition, we are thankful for the invaluable experiences we obtained from our community and public health work that interfaced and informed the production of this book. Those experiences ranged from developing interventions with and for women living with HIV/AIDS in Boston, to implementing community-based programs that addressed the health needs of diverse populations, to teaching students about the social determinants of health, and to assuming leadership roles on local boards that are responsible for the health of our local communities. Our editorial coordinator, John Larkin, was very helpful in answering questions, calming frustrations, and solving problems. Greg Nicholl, our development editor, provided the consistency found throughout the chapters. Thank you all for helping us create this unique approach to community and public health nursing!
RosannaF.DeMarco JudithHealey-Walsh
A SpecialThanksinMemoriamtoDr.GailA.Harkness,DPH,FAAN
The first and second editions of this textbook were led by the efforts of Dr. Gail Harkness. Gail was a mentor and friend. While she is no longer with us to help support, guide, and enliven this newest edition, we wanted to take time to honor her memory and produce this edition in her honor.
Gail was such an intelligent, warm, and wise public health expert who was most passionate about population health and epidemiology, and particularly infectious diseases past, present, and evolving. She was a prolific writer and teacher. When I met her, she reached out to me, asking if I could help her with her vision of a community health and public health textbook for nursing students that was affordable and succinct and did not just “rattle on” with facts but situated public health ideas in the context of evidence, student stories, and current disease prevention and health promotion innovations. She brought to my mentorship opportunity her global experiences from the UK (University of Leeds) to Japan (Osaka), as well as her own local
work on a town Board of Health in Massachusetts. Gail loved public health research and the evidence it yielded to inform policy decisions toward all our health. She was a graduate of the University of Rochester (undergraduate and graduate programs) in Nursing and received her Doctorate in Public Health from the University of Illinois, School of Public Health in Epidemiology and Biometry (the application of statistical analysis to biologic data).
More than being an epidemiologist, she loved the opportunity as an academician to teach nursing students at all levels to be as passionate about public health as she was. She was a professor emerita from University of Connecticut. We know her family and friends miss Gail very much, but her energy and spirit will always be in this textbook.
RosannaF.DeMarco
PART ONE
The Context of Community and Public Health Nursing
Chapter 1
PublicHealthNursing: Present,Past,andFuture
HealthcareChanges inthe21stCentury
Public HealthNursingToday
Roots ofPublic HealthNursing
Challenges for Public HealthNursinginthe21stCentury
Chapter 2
PublicHealthSystems
ImportanceofUnderstandingHow Public HealthSystems areOrganized
StructureofPublic HealthcareintheUnitedStates
Functions ofPublic HealthintheUnitedStates
Trends inPublic HealthintheUnitedStates
HealthcareSystems inSelectedDevelopedNations
Public HealthCommitments totheWorld:InternationalPublic HealthandDeveloping Countries
The Context of Community and Public Health Nursing
Chapter1
Public HealthNursing: Present, Past, and Future
Judith Healey-Walsh
For additional ancillary materials related to this chapter. please visit thePoint
Nursing is based on society’s needs and therefore exists only because of society’s need for such a service It is difficult for nursing to rise above society’s expectations, limitations, resources,andcultureofthecurrentage
PatriciaDonahue, Nursing, the Finest Art: An Illustrated History
I believe the history of public health might be written as a record of successive redefinings oftheunacceptable
GeorgeVicker
Somepeoplethink thatdoctors andnurses canputscrambledeggs back intotheshell.
DorothyCanfieldFisher,socialactivist andauthor
The only way to keep your health is to eat what you don’t want, drink what you don’t like, anddowhatyou’drather not.
