Developing Population Health Competencies Among Public Health Nurses in Georgia

Transcription

1 Public Health Nursing Vol. 23 No. 2, pp /r 2006, The Authors Journal Compilation r 2006, Blackwell Publishing, Inc. SPECIAL FEATURES: EDUCATION Developing Population Health Competencies Among Public Health Nurses in Georgia Carole C.Jakeway, Elizabeth E.Cantrell, Jackie B.Cason, and Brenda S.Talley ABSTRACT As part of a new vision for public health in Georgia, the role of the public health nurse (PHN) is shifting from a predominantly individual and clinic-based care model to a population health practice model. Based on focus groups conducted with management and frontline PHNs in 2001, nurses in Georgia were unprepared for this transition and lacked a strong understanding of population health concepts and competencies. To prepare nurses for their new and expanded responsibilities, an online population health course was developed specifically for currently employed PHNs. The Quad Council PHN Competencies (2003) provided the roadmap in identifying the population health online course and continuing education training program priority competencies for PHNs in Georgia. Along with incorporating the competencies into case studies and didactic learning, the required projects served as evidence of competency application. The population health online course was offered from fall 2000 to spring 2005 in collaboration with Georgia schools of nursing and has enabled a cohort of nurses to lead the way as Georgia transitions into a new public health model. Nurses who completed the course reported greater experience with and an understanding of population health competencies. Key words: clinical competence, competencies, competency-based education, distance learning, population health, public health nursing. The history of public health nursing is grounded in the principles of population health practice. However, in Georgia the majority of the public health nurse s (PHN) time is spent in the provision of primary care and clinical services to individuals. Major factors that have contributed to an individual and clinic-based care model are the growing percentage of uninsured in Georgia (16.4%) (United Health Foundation, 2004) Carole C. Jakeway, R.N., M.P.H., is Chief Nurse, Division of Public Health, Georgia Department of Human Resources, Atlanta, Georgia. Elizabeth E. Cantrell, M.P.H., is Statistical Analyst, Silhouette Software & Analysis, LLC, Flowery Branch, Georgia. Jackie B. Cason, A.S.N., B.S.N., M.S.N., is Assistant Professor, School of Nursing, Georgia Southwestern State University, Americus, Georgia. Brenda S. Talley, R.N., Ph.D., is Assistant Professor, School of Nursing, Georgia Southern University, Statesboro, Georgia. Correspondence to: Carole C. Jakeway, Division of Public Health, Georgia Department of Human Resources, 2 Peachtree Street, N.W., Suite15-475, Atlanta, GA ccjakeway@dhr.state.ga.us and the continued challenges presented by Georgia s mostly medically underserved populations. Ecological level influences should be considered among the determinants of health. The ecological theory of risk addressed by the Institute of Medicine (2003) clearly emphasizes the need for governmental public health to focus on the characteristics of places when promoting the health of the population. An important finding to emerge from public health research over recent years is the extent to which characteristics of places neighborhoods, schools, worksites, and even nations carry with them health risks for individuals who reside in those places. The health risks imposed by these areas are above and beyond the risks that individuals carry with them. The complex health care needs of vulnerable uninsured or underinsured segments of the population require a broad approach that addresses interaction of multiple determinants of health and illness including individual behaviors, social and economic factors, environmental conditions, and health policies (IOM, 2003). Governmental public health agencies should focus their attention on more population-focused public health services (IOM, 2003). PHNs can serve 161

2 162 Public Health Nursing Volume 23 Number 2 March/April 2006 communities through a population health approach with consideration and focus on the determinants of health. Nurses who have been educated and have practiced in a system that has devoted itself almost entirely to primary, clinical services must now augment their current skills and acquire new knowledge and skills to assume the new and expanded roles and responsibilities of a population health approach. In order to advocate for, practice, document, and be reimbursed for population health, there must be a universal understanding of population health. As the majority of PHNs in Georgia are not baccalaureate prepared, have been out of school for many years, and have performed predominantly in the role of delivering individual and clinic-based care, an identified need for education of PHNs in Georgia was evident. Before beginning the online course, a survey was conducted with the 19 district nursing directors from around the state. Of the 16 directors that responded, all supported the objectives of the online population health course. Fifteen of the directors wanted to have a population health nurse specialist in their district. District nursing directors indicated that more than half of the 1,470 PHNs needed to be prepared in population health. In an effort to enable nurses to build upon their clinical skills with population health competencies, a population health online course was developed based on a curriculum designed by both academic and practice nurses and incorporating population health competencies. Description of the Project The population health online course was designed to aid the nurse in developing and/or enhancing skills essential to population-focused practice in conjunction with clinical prevention skills already applied in the workforce. District nursing directors chose the following population health competencies as the priorities of the course: community health assessment and ; interpreting and presenting health information to local leaders, policy makers, and partners; using computer technology in the health planning and policy development es; and building and sustaining community coalitions. The population health competencies selected as priorities for the online course curriculum were consistent with the recommended competencies developed by a national committee comprised of members from a variety of national public health organizations, including the American Public Health Association and the Association of State and Territorial Health Officials. Those recommendations were developed in relation to the core public health functions and the essential public health services (United States Department of Health and Human Services, 1997) and evolved into the Core Competencies for Public Health Professionals from the Council on Linkages (COL) Between Academia and Public Health Practice. The Quad Council PHN Competencies (2003) represent the application of the competencies to public health nursing practice. Although not all of the Quad Council PHN Competencies were utilized in the online course development, a majority of the Quad Council PHN competencies domains and skills were incorporated into the population health course (Table 1). The population health online course competencies were typically more general categories encompassing the Quad Council PHN competency domains. For example, most of the skills under domain 1, analytic assessment, were included while addressing the population health competency of community health assessment and. Activities such as identifying methods of community assessment and utilizing epidemiological resources were specific to skills under the analytic assessment skills domain. Domain 2, policy development and program planning, included skills that were enhanced through activities designed around the population health competency of using computer technology in the health planning and development. These activities included identifying sources for policy information and resources for understanding policy and steps to developing local and regional plans. A pilot was conducted in fall 2000 with 15 nurses completing the online course at one school. Course revisions were made during the spring semester An additional 34 nurses completed course offerings in the fall semester 2001 and the spring semester In 2002, the Office of Nursing received a basic nurse education grant from HRSA (#D11HP00368) to continue the online course through June 2005 and enable approximately 300 nurses to complete the online population health course. The grant objectives included supporting nonbaccalaureate prepared PHNs to enroll in further education, demonstrating the benefit of population health to participating communities, creating a Population Health Scholar s Program to

3 Jakeway et al.: Developing Population Health Competencies 163 TABLE 1. Quad Council Competency and Population Health Course Competency Equivalents Quad Council Competency Domain and Skill Defines a problem Identifies relevant and appropriate data and information sources Obtains and interprets risks and benefits to the community Evaluates the integrity and comparability of data and identifies gaps in data sources Partners with communities to attach meaning to collected quantitative and qualitative data Applies data collection es, information technology applications, and computer systems storage/ retrieval strategies Recognizes how the data illuminate ethical, political, scientific, economic, and overall public health issues Determines appropriate uses and limitation of both quantitative and qualitative data Population health online course competency Example of course activity supporting competency Domain #1: Analytic assessment skills Community health assessment Participants, with input from their and mentors, identified a current population Community health assessment and Community health assessment and Community health assessment and Community health assessment and health problem in their communities Identification of methods of community assessment, generating missing data and interpreting the database, finding multiple resources for epidemiological data Risk factors for the defined problems were targeted in the assessment The significance of the problem was described, risk evaluated, cost of reducing risk, and the availability of resources to intervene in reduction of risk The key elements of population health (Health Canada, 2001) provided discussion on a population health approach in public health nursing. Collaboration across sectors and levels was a required component of the population health project A distance-learning expert provided the one-on-one computer orientation to public health nurses in their workplaces before beginning the online course In the epidemiology section of the course, participants completed the Botulism in Argentina online case study on the CDC Web site Evidence-based practice was stressed throughout the course. In the policy development/program-planning component of the project, participants based their interventions on current research that pertained to the identified public health problem States policy options and writes clear and concise policy statements Develops a plan to implement policy, including goals, outcome and objectives, and implementation steps Identifies, interprets, and implements public health laws, regulations, and policies related to specific programs Domain #2: Policy development/program planning skills Included a goal or goals from Healthy People 2010, which the project was based on, and developed a specific goal or goals for the project Outlined specific strategies/activities to achieve the goals. These strategies were based on the key elements of population health Public health laws were discussed and the public health nurse s responsibility for the interpretation and implementation of these laws. Students reviewed the top ten achievements of CDC in the 20th century and identified strategies used to obtain goals leading to achievement

4 164 Public Health Nursing Volume 23 Number 2 March/April 2006 TABLE 1. Continued. Quad Council Competency Domain and Skill Prepares and implements emergency response plans Communicates effectively both in writing and orally or in other ways Effectively presents accurate demographic, statistical, programmatic, and scientific information for professional and lay audiences Population health online course competency Domain #3: Communication skills Interprets and presents health information to local leaders, policy makers, and partners Interprets and presents health information to local leaders, policy makers, and partners Example of course activity supporting competency A unit on disaster nursing was included in the course. Participants discussed application questions from case studies online The online format of the course required effective written communication between participants and faculty The public health nurses were required to present their projects to a local county board of health or other appropriate community or professional group. Students have presented at the statewide Public Health Leaders and Nurse Educators Annual Summit Identifies the role of cultural, social, and behavioral factors in determining the delivery of public health services Domain #4: Cultural competency skills Identification of vulnerable populations in home community Collaborates with community partners to promote the health of the population Identifies community assets and available resources Develops, implements, and evaluates a community public health assessment Describes the role of government in the delivery of community health services Identifies the individual s and organization s responsibility within the context of the essential public health services and core functions Defines, assesses, and understands the health status of populations, determinants of health and illness, factors contributing to health promotion and disease prevention, and factors influencing the use of health services Understands the historical development, structure, and interaction of public health and health Domain #5: Community dimensions of practice skills Builds and sustains community coalitions Builds and sustains community coalitions Domain #6: Basic public health sciences skills Builds and sustains community coalitions Collaboration and development of partnerships and community coalitions were included in the didactic and application components of the course The community assessment component of the course was based on these competencies The community assessment component of the course is based on these competencies The course included a didactic section on the current health care delivery system in the United States Nurses were asked to give examples of ways in which public health nurses in their agencies provide the essential public health services The didactic component of the course included a discussion on the determinants of health and theories of health promotion The course included a written and pictorial presentation on the history of public health and public health nursing. Focused on a comparison of the roles of the public health nurse versus the community health nurse

5 Jakeway et al.: Developing Population Health Competencies 165 sustain population health practice, and creating a population health career path for PHNs. The population health online course included the following components to support learning and application of population health concepts and competencies: semester-long online population health course for academic credit (3 4 hr); computer skills training from a distance learning expert before the online course; state Office of Nursing support during application, enrollment, and class participation by the population health nurse consultant; mentors; communication with faculty and other nurse students; and required project implemented in the community/ workplace. Upon completion of the online course, nurses were automatically enrolled in the Scholar s Program and eligible to attend two Continuing Education (CE) distance learning Scholar s programs per year. The Scholar s Program content supported the four population health course competencies by focusing on topics such as Mobilizing for Actions through Planning and Partnerships (MAPP), grant writing, community mobilization, and using public health performance standards and outcome indicators. All programs were offered by distance learning to PHNs across the state who completed the population health online training. Participation in the online course required the completion of a community project and subsequent presentation to community leaders. The projects were real-world demonstrations of the population health competencies and covered a broad range of areas such as creating a local coalition to address tobacco use in restaurants and schools, analyzing the statistical rise in HIV in teenagers at national, state, and county levels, developing plans for a biological outbreak screening program, and adapting the state Strategic National Stockpile plan for an individual county. The course projects incorporated the 10 essential public health services and required nurses to demonstrate at least one of the four priority competencies. Evaluation Although 92% of online course participants who completed the evaluation were Satisfied or Very Satisfied with the course content and 87% considered the course valuable, less than half (40%) reported that the program positively influenced them to pursue higher education. This contrast was clarified by the 34% who reported they would not recommend the program or would recommend with changes. The reasons given for not recommending the program included the time required to participate in the class and the limited staff and time available to address population health practices in the workplace. The level of activity in the four competencies was measured after course participation using self-report. Consistently, over half of the students reported at least an adequate amount of experience in analyzing, interpreting, and presenting health information and using computer technology in the health planning and policy development. Typically, this experience was attributed to the population health project required for course completion. The more time- and resource-intensive competencies of community health assessment and and building and sustaining community coalitions were reported to be delivered with much less frequency. Lessons Learned Supervisor support is critical Unfortunately, the verbal and written commitment to population health training made by the district nursing directors around the state did not translate into providing support for PHNs to participate in the population health online class. As budgets were cut and staffing shortages increased, it became too difficult for district nursing directors and county nurse managers to encourage nurses to take the course. More aggressive recruiting techniques were developed to overcome issues related to budget cuts and the impact on the number of applicants in the spring semester 2004 and the fall semester These techniques included sending letters to each of the 159 county nurse managers/supervisors in December 2003, following up with phone calls to each of the county nurse managers/supervisors to answer questions and promote recruitment, and posting the new resource manual for PHNs on the Web site. However, these efforts were not sufficient to overcome budget constraints. Basic computer skills are necessary Offering the population health online course through distance learning compelled nurses to work with the computer, search the Internet, send and receive

6 166 Public Health Nursing Volume 23 Number 2 March/April , and use word-ing skills. Although nurses became more comfortable with this technology through participation in the online course, many were hesitant to enroll because of limited proficiency with computers. In response, the program began offering a 1-day and a multiple-day basic computer skills orientation before taking the population health online course. A distance-learning expert was contracted to provide computer skills training for enrollees in each district before class participation. Nurses who participated in the computer skills workshop and online course demonstrated improved computer skills through a pre- and post-self-assessment. Collaboration with schools of nursing is essential The Office of Nursing coordinated with multiple colleges and universities to enroll students in the population health online course. Each school used different deadlines, es, and procedures that required significant amounts of time to resolve by both students and the population health nurse consultant. In this case, the lesson was to develop strong relationships with the school s administration, registrar, and bursar s offices before the course. Specific components are necessary for a successful online class In addition to competent computer skills, supervisor/ co-worker support, access to a computer and Internet, adequate time, and support through the application and participation, students required a great deal of feedback and communication. Communication with the professor and other students through and online discussion forums was highly valued and considered important for nurses to feel satisfied with the course. Frequent and timely communication was cited as one of the main reasons a school was rated highly by the students. CE format is successful during budgetary and staffing shortages As a result of the decreased enrollment due to limited staffing, budget, and time, the Office of Nursing surveyed nurses regarding their interest in a CE format population health program. The response was favorable and, in 2004, a 3-day Introduction to Population Health CE Program was developed based on the curriculum used in the online course. The CE program was positively received and brought population health concepts to nurses who would not have been able to participate in the online course. Population health practice must be supported at the local level Feedback from participants 1 year following course completion indicated that their knowledge of population health was not being utilized in the workplace. One student wrote, The class was a valuable experience and for that length of time, it caused me to look forward to my changing role as a PH nurse. I quickly learned that there was little I could do without support from higher up. It seemed as though we talked a good talk, but the bottom line is nothing will change. The nurses still do not have personal computers; the supervisors have not had the course and did not understand its significance, and so I returned to seeing my child health patients one at a time. Soon it seemed as though the class was simply a memory. (But a good one.) Knowledge alone could not move nurses from a clinical to population health role if the work environment did not support the transition. Another nurse wrote on her evaluation of the online course, I have been a PH nurse for sixteen years, but I really had not grasped how comprehensive PH is or the idea of Population Health Care. This course has broadened my perspective and given me a better understanding of what Public Health should be. Next Steps The preparation of PHNs in the area of population health competencies has taken on new meaning in light of recent changes in public health infrastructure and pending changes in the core business of public health. Georgia public health is in the midst of major transformation. In January 2005, the Division of Public Health came under new leadership with a new acting division director. The emerging vision reflects a new definition of the core business of public health and the need for system changes to facilitate this transformation to be developed by July The population health training and competency development initiated by the Office of Nursing in 2000 provides a platform for facilitating changes in the competencies expected of PHNs to provide the new core business of public health. The 350 nurses who have completed the online course or CE program represent a cohort of nurses

7 Jakeway et al.: Developing Population Health Competencies 167 that will pave the way for the dominant role PHNs will play in the new vision of public health. Beginning in 2003, the Office of Nursing began a of gathering perspectives regarding the future practice of public health nursing in Georgia. Specific questions centered on anticipating current practices that need to be discontinued, strengthened, or further developed within the next 5 years. By December 2004, 44 PHNs had been queried. The product of these discussion groups was the Future practice of public health nursing in Georgia document that is being distributed to all 1,669 PHNs in Georgia, as well as to the district health directors, district nursing directors, district program managers, and state office staff. The description of the future role is in concert with the new leadership s vision for the core business of public health as well as reflecting the core population health competencies. Although it includes primary care, the majority of the skills listed in the document are consistent with a population health model of practice and will provide a framework for the changes in the role of public health nursing. Consensus on the future roles and activities of PHNs will be used to craft a new vision and model of Georgia public health nursing practice. Public health nursing has been identified as a leader in this transition and a stakeholder in defining the changing role from clinical service delivery to a population health model. References Institute of Medicine. (2003). The future of the public s health in the 21st century. Washington, DC: The National Academies Press. Quad Council PHN Competencies. (2003, April 3). Retrieved August 8, 2005, from United Health Care Foundation. (2004). America s Health: State Rankings 2004 Edition: Georgia. Retrieved from unitedhealthfoundation.org/shr2004/states/ Georgia.html U.S. Department of Health and Human Services (DHHS), Public Health Service. (1997). The public health workforce: an agenda for the 21st century. Full report of the Public Health Functions Project. Washington, DC: U.S. Department of Health and Human Services.

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