PUBLIC HEALTH NURSING PRACTICE FOR THE 21 ST CENTURY National Satellite Learning Conference. Learning Guide

PUBLIC HEALTH NURSING PRACTICE FOR THE 21 ST CENTURY National Satellite Learning Conference Learning Guide

PUBLIC HEALTH NURSING PRACTICE FOR THE 21 ST CENTURY: COMPETENCY DEVELOPMENT IN POPULATION- BASED PRACTICE Learning Guide Minnesota Department of Health Community Health Services Division Section of Public Health Nursing 121 East 7 th Place, St. Paul, MN 55164 Phone 651-296-6567 This project was supported by a grant to the Minnesota Department of Health from the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration at the Department of Health and Human Services, grant #6 D10 HP 30392. Suggested citation: Public Health Nursing Section, Minnesota Department of Health. (2000). Public Health Nursing Practice for the 21 st Century; Competency Development in Population-based Practice. St. Paul, MN.

Table of Contents INTRODUCTION 1 SESSION 1 Learning Objectives 5 Content 5 Content Outline 7 Learner Materials 11 Handout 1 Population-based Practice 12 Handout 2 Levels of Prevention 14 Handout 3 Levels of Practice 15 Handout 4 Definitions of Public Health Interventions 16 Handout 5 Discussion Questions 19 Pre test 20 SESSION 3 Learning Objectives 65 Content 65 Content Outline 67 Learner Materials 69 Handout 1 Public Health Nursing Process 70 Handout 2 Examples from Practice 72 Handout 3 Discussion Questions 73 Handout 4 Selected Resources 74 Pre test 76 Post test 78 Post test 22 SESSION 2 Learning Objectives 25 Content 26 Content Outline 27 Learner Materials 29 BIOGRAPHICAL SKETCHES 81 Laurel Briske 82 Linda Olson Keller 83 Sue Strohschein 84 Handout 1 Cornerstones of Public Health Nursing 30 Handout 2 Public Health in America 34 Handout 3 Population-based Public Health Practice 35 Handout 4 Community Assessment 36 Handout 5 Prioritizing Process 41 Handout 6 Categories of Public Health 43 Handout 7 Examples of 3 Public Health Problems 56 Handout 8 Discussion Questions 57 Handout 9 Selected Resources 58 Pre test 61 Post test 63 Minnesota Department of Health Public Health Nursing Section Table of Contents

Introduction T he purpose of this kit is to provide you with the learning materials from Public Health Nursing Practice for the 21 st Century: Competency Development in Population-based Practice. This National Satellite Learning Conference was produced by the Section of Public Health Nursing at the Minnesota Department of Health, in partnership with the Division of Nursing at the Health Resources and Services Administration, Department of Health and Human Services, the Centers for Disease Control and Prevention, and the Public Health Training Network. The three-part series was broadcast to a national audience of public health nurses in October, November, and December of 2000. This kit can be used by anyone wanting to learn or teach about population-based public health nursing practice. Please feel free to copy the learner materials from the Guide and adapt the presentation for your learning situation. We request that in using the videos and materials you do not alter the content and give credit to the Minnesota Department of Health. If you have comments or questions about the use of this kit, please contact us. Laurel Briske Linda Olson Keller Sue Strohschein Project Coordinator PHN Consultant PHN Consultant 651-296-9133 651-296-9176 651-296-9581 laurel.briske@ linda.keller@ sue.strohschein@ health.state.mn.us health.state.mn.us health.state.mn.us Minnesota Department of Health Introduction Section of Public Health Nursing 1 Learning Guide

Materials in this kit 3 Video Tapes 1 copy of each 3-hour satellite program Session I October 5, 2000 Session II November 2, 2000 Session III December 7, 2000 Learning Guide The learning guide contains the goals and objectives for the course, an outline of the content for each session, learner materials, discussion questions, and pre/post test questions. Public Health Interventions: Applications for Public Health Nursing Practice This manual presents in detail each of the 17 public health interventions with examples and applications for public health nursing practice. Minnesota Department of Health Section of Public Health Nursing 2 Introduction Learning Guide

Purpose This continuing education program is a series of three sessions broadcast nationally via satellite. The purpose is to enhance the knowledge, attitudes, and skills of public health nurses in population-based public health nursing practice. Goals and Objectives At the conclusion of this learning conference, learners will be able to: Describe the scope of population-based public health nursing process. Identify the principles or cornerstones underlying the practice of public health nursing. Describe the public health nursing interventions and identify the best practices associated with their successful implementation. Faculty Laurel Briske, MA, RN, CPNP Linda Olson Keller, MS, RN, CS Sue Strohschein, MS, RN The presenters are public health nurse consultants with the Section of Public Health Nursing at the Minnesota Department of Health. See the section on biographical sketches of the faculty. Minnesota Department of Health Section of Public Health Nursing 3 Introduction Learning Guide

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Session 1 Session 1 This session instructs in the concept of population-based public health nursing practice and introduces the set of 17 related interventions used to operationalize it. Learning Objectives 1. Define population-based public health nursing practice. 2. Recognize the levels of practice: community, individuals and families, and systems. 3. Identify the set of 17 interventions utilized by nurses in public health nursing practice. Content Population-based Public Health Nursing Practice The main characteristics of this practice are introduced and described. Populationbased public health nursing: 1. Focuses on entire populations possessing similar health concerns or characteristics 2. Is guided by an assessment of community need 3. Considers the broad determinants of health 4. Considers all levels of prevention with a preference for primary prevention 5. Considers all levels of practice. Minnesota Department of Health 5 Session 1 Section of Public Health Nursing Learning Objectives

The Levels of Public Health Nursing Practice Interventions Each of the public health nursing interventions identified can be applied at some or all practice levels: with individuals or families, with the communities in which they live, and/or the systems within those communities that also impact on health. This is a defining difference of population-based public health nursing practice and is discussed in depth. Public Health Nursing Interventions The set of seventeen interventions nurses practicing in public health use to accomplish their population-based work are defined and described. The interventions, defined as actions that public health nurses take on behalf of individuals, families, systems, and communities to improve or protect health status, are presented graphically as a wheel of interventions. Minnesota Department of Health 6 Session 1 Section of Public Health Nursing Content

Content Outline Session 1 is three hours in length. This section outlines each segment with times and corresponding handouts. The time is approximate and will vary with VCR speed. Video Tape Session 1 October 5, 2000 I. Introduction 6 minutes II. History of Public Health Nursing 18 minutes Includes a 9-minute clip of Sentimental Women Need Not Apply: A History of the American Nurse. 1 III. Population-based Practice Handout 1 Population-based Practice A. Definition 2 minutes B. Criteria for Population-based Practice 1. Focuses on the entire population 3 minutes 2. Guided by an assessment of population health status 2 minutes 3. Considers the broad determinants of health 1 minute 4. Considers all levels of prevention 3 minutes 1 Sentimental Women Need Not Apply: A History or the American Nurse. 1993. VHS 60 minutes: color $350. To order call 1-800-523-0118 or mediaincorporated.com Minnesota Department of Health 7 Session 1 Section of Public Health Nursing Content Outline

Handout 2 Levels of Prevention 5. Considers all levels of intervention Handout 3 Levels of Practice a. Community 9 minutes b. Systems 3 minutes c. Individual/Family 9 minutes d. Examples 12 minutes BREAK 10 minutes IV. Question and Answer Session 15 minutes V. Public Health Interventions Handout 4 Definitions of Public Health Interventions A. Definition 6 minutes Minnesota Department of Health 8 Session 1 Section of Public Health Nursing Content Outline

B. Descriptions and Examples by Wedge (Interventions that tend to be used together) 1. Red (pink) Wedge 13 minutes Surveillance Disease and other health event investigation Outreach Screening Case-finding 2. Green Wedge 7 minutes Referral and Follow-up Case Management Delegated Functions 3. Blue Wedge 7 minutes Health Teaching Counseling Consultation BREAK 10 minutes 4. Orange Wedge 7 minutes Collaboration Coalition Building Community Organizing Minnesota Department of Health 9 Session 1 Section of Public Health Nursing Content Outline

5. Yellow Wedge 9 minutes Advocacy Social Marketing Policy Development VI. Summary of Session 9 minutes VII. Example of practice using multiple interventions 10 minutes VIII. Question and Answer Session 15 minutes Handout 5 Discussion Questions for Session 1 Test your knowledge pre/post test questions Total Session Time 180 minutes 160 minutes content 20 minutes of break Minnesota Department of Health 10 Session 1 Section of Public Health Nursing Content Outline

Session 1 Learner Materials Handout 1 Population-based Practice Handout 2 Levels of Prevention Handout 3 Levels of Practice Handout 4 Public Health Interventions Handout 5 Discussion Questions for Session 1 Test your knowledge pre/post test questions The learner materials may be copied without permission. Minnesota Department of Health 11 Session 1 Section of Public Health Nursing Learner Materials

Public Health Nursing Practice for the 21 st Century: Competency Development in Population-Based Practice Session 1 Handout 1 Population-based Practice A population is a collection of individuals who have one or more personal or environmental characteristics in common. 1 A population-of-interest is a population that is essentially healthy but who could improve factors which promote or protect health. A population-at-risk is a population with a common identified risk factor or risk-exposure that poses a threat to health. Public health nursing practice is population-based if it meets all of the following criteria: 1. Focuses on entire populations possessing similar health concerns or characteristics This means focusing on everyone who is actually or potentially affected by a health concern or who share similar characteristics. Population-based interventions are not limited to only those who seek service or who are poor or otherwise vulnerable. Population-based planning always begins by identifying everyone who is in the population-of-interest or the population-at-risk. For example, it is a core public health function to assure that all children are immunized against vaccine-preventable disease. Even though limited resources may compel public health departments to target programs toward those children known to be at particular risk for being under or unimmunized, the public health system remains accountable for the immunization status of the total population of children. 2. Guided by an assessment of population health status This criteria cannot be emphasized enough. All public health programs are based on the needs of the community, which are determined through an assessment of the community s health status. As communities change, so do community needs. As community needs change, so should public health programs. This is one of the reasons that community assessment is so important. Public health departments need to assess the health status of populations on an ongoing basis, so that public health programs respond appropriately to new and emerging problems, concerns, and opportunities. 3. Considers the broad determinants of health A population-based approach examines all factors that promote or prevent health. It focuses on the entire range of factors, which determine health rather than just personal health risks or disease. Examples of health determinants include income and social status, housing, nutrition, employment and working conditions, social support networks, education, neighborhood safety and violence issues, physical environment, personal health practices and coping skills, cultural customs and values, and community capacity to support family and economic growth. Minnesota Department of Health 12 Session 1 Section of Public Health Nursing Handout 1

4. Considers all levels of prevention, with a preference for primary prevention Prevention is anticipatory action taken to prevent the occurrence of an event or to minimize its effect after it has occurred. 2 Not every event is preventable, but every event does have a preventable component. Thus, a population-based approach presumes that prevention may occur at any point - before a problem occurs, when a problem has begun but before signs and symptoms appear, or even after a problem has occurred. Primary prevention promotes health, such as building assets in youth, or keeps problems from occurring, for example, immunizing for vaccine-preventable diseases. Secondary prevention detects and treats problems early, such as screening for home safety, and correcting hazards before an injury occurs. Tertiary prevention keeps existing problems from getting worse, for instance, collaborating with health care providers to assure periodic examinations to prevent complications of diabetes such as blindness, renal disease failure, and limb amputation. Whenever possible, public health programs emphasize primary prevention. 5. Considers all levels of practice A population-based approach considers intervening at all possible levels of practice. Interventions may be directed at the entire population within a community, the systems that affect the health of those populations, and/or the individuals and families within those populations known to be at risk. Community-focused practice changes community norms, attitudes, awareness, practices, and behaviors of the population-of-interest. Systems-focused practice changes organizations, policies, laws, and power structures of the systems that affect health. Individual/family-focused practice changes knowledge, attitudes, beliefs, values, practices, and behaviors of individuals, alone or as part of a family, class, or group. Interventions at each of these levels of practice contribute to the overall goal of improving population health status. Public health professionals determine the most appropriate level(s) of practice based on community need and the availability of effective strategies and resources. No one level of practice is more important than another; in fact, most public health problems are addressed at all three levels, often simultaneously. Consider, for example, smoking rates which continue to rise among the adolescent population. At the community level of practice, public health nurses coordinate youth led, adult supported social marketing campaigns intending to change the community norms regarding adolescents tobacco use. At the systems level of practice, public health nurses facilitate community coalitions that advocate city councils to create stronger ordinances restricting over-the-counter youth access to tobacco. At the individual/family practice level, public health nurses teach middle school chemical health classes that increase knowledge about the risks of smoking, change attitudes toward tobacco use, and improve refusal skills among youth 12-14 years of age. 1. Williams, C. A., & Highriter, M. E. (1978). Community health nursing: population focus and evaluation. Public Health Reviews, 7(3-4), 197-221. 2. Turnock, B. (1997). Public Health: What it is and how it works. Gaithersburg, MD: Aspen Publishers, Inc. Minnesota Department of Health 13 Session 1 Section of Public Health Nursing Handout 1

Public Health Nursing Practice for the 21 st Century: Competency Development in Population-Based Practice Session 1 Handout 2 Levels of Prevention Prevention is anticipatory action taken to prevent the occurrence of an event or to minimize its effect after it has occurred. 2 Not every event is preventable, but every event does have a preventable component. Prevention occurs at primary, secondary, and tertiary levels: Primary prevention both promotes health and protects against threats to health. It keeps problems from occurring in the first place. It promotes resiliency and protective factors, or reduces susceptibility and exposure to risk factors. Primary prevention is implemented before a problem develops. It targets essentially well populations. Secondary prevention detects and treats problems in their early stages. It keeps problems from causing serious or long-term effects or from affecting others. It identifies risks or hazards and modifies, removes, or treats them before a problem becomes more serious. Secondary prevention is implemented after a problem has begun, but before signs and symptoms appear. It targets populations that have risk factors in common. Tertiary prevention limits further negative effects from a problem. It keeps existing problems from getting worse. It alleviates the effects of disease and injury and restores individuals to their optimal level of functioning. Tertiary prevention is implemented after a disease or injury has occurred. It targets populations who have experienced disease or injury. 2 Turnock, B. (1997). Public Health: What it is and how it works. Gaithersburg, MD: Aspen Publishers, Inc. Minnesota Department of Health 14 Session 1 Section of Public Health Nursing Handout 2

Public Health Nursing Practice for the 21 st Century: Competency Development in Population-Based Practice Session 1 Handout 3 Levels of Practice The ultimate goal of all levels of population-based practice is to improve population health. Public health interventions may be directed at entire populations within a community, the systems that affect the health of those populations, and/or individuals and families within those populations. Interventions at each of these levels of practice contribute to the overall goal of improving population health. Population-based community-focused practice changes community norms, community attitudes, community awareness, community practices, and community behaviors. They are directed toward entire populations within the community or occasionally toward target groups within those populations. Community-focused practice is measured in terms of what proportion of the population actually changes. Population-based systems-focused practice changes organizations, policies, laws, and power structures. The focus is not directly on individuals and communities but on the systems that impact health. Changing systems is often a more effective and long-lasting way to impact population health than requiring change from every single individual in a community. Population-based individual-focused practice changes knowledge, attitudes, beliefs, practices, and behaviors of individuals. This practice level is directed at individuals, alone or as part of a family, class, or group. Individuals receive services because they are identified as belonging to a population-at-risk. Public health professionals determine the most appropriate level(s) of practice based on community need and the availability of effective strategies and resources. No one level of practice is more important than another; in fact, most public health problems are addressed at all three levels, often simultaneously. Minnesota Department of Health 15 Session 1 Section of Public Health Nursing Handout 3

Public Health Nursing Practice for the 21 st Century: Competency Development in Population-Based Practice Session 1 Handout 4 Definitions of Public Health Interventions Interventions are actions taken on behalf of communities, systems, individuals, and families to improve or protect health status. 3 Surveillance describes and monitors health events through ongoing and systematic collection, analysis, and interpretation of health data for the purpose of planning, implementing, and evaluating public health interventions. [adapted from MMWR, 1988] Disease and other health event investigation systematically gathers and analyzes data regarding threats to the health of populations, ascertains the source of the threat, identifies cases and others at risk, and determines control measures. Outreach locates populations-of-interest or populations-at-risk and provides information about the nature of the concern, what can be done about it, and how services can be obtained. Case finding locates individuals and families with identified risk factors and connects them with resources. Screening identifies individuals with unrecognized health risk factors or asymptomatic disease conditions in populations. Referral and follow-up assists individuals, families, groups, organizations, and/or communities to identify and access necessary resources in to prevent or resolve problems or concerns. Case management optimizes self-care capabilities of individuals and families and the capacity of systems and communities to coordinate and provide services. Delegated functions are direct care tasks a registered professional nurse carries out under the authority of a health care practitioner as allowed by law. Delegated functions also include any direct care tasks a registered professional nurse entrusts to other appropriate personnel to perform. Health teaching communicates facts, ideas and skills that change knowledge, attitudes, values, beliefs, behaviors, and practices of individuals, families, systems, and/or communities. 3 Adapted from Nursing s Social Policy Statement, p. 9. (1995). American Nurses Publishing. Minnesota Department of Health 16 Session 1 Section of Public Health Nursing Handout 4.1

Counseling establishes an interpersonal relationship with a community, a system, family or individual intended to increase or enhance their capacity for self-care and coping. Counseling engages the community, a system, family or individual at an emotional level. Consultation seeks information and generates optional solutions to perceived problems or issues through interactive problem solving with a community, system, family or individual. The community, system, family or individual selects and acts on the option best meeting the circumstances. Collaboration commits two or more persons or organizations to achieve a common goal through enhancing the capacity of one or more of the members to promote and protect health. [adapted from Henneman, Lee, & Cohen. (1995). Collaboration: A concept analysis. J. Advanced Nursing, 21, 103-109.] Coalition building promotes and develops alliances among organizations or constituencies for a common purpose. It builds linkages, solves problems, and/or enhances local leadership to address health concerns. Community organizing helps community groups to identify common problems or goals, mobilize resources, and develop and implement strategies for reaching the goals they collectively have set. [adapted from Minkler, M. (ed.). (1997). Community Organizing and Community Building for Health, p. 30. New Brunswick, NJ: Rutgers Univ. Press.] Advocacy pleads someone s cause or act on someone s behalf, with a focus on developing the community, system, individual or family s capacity to plead their own cause or act on their own behalf. Social marketing utilizes commercial marketing principles and technologies for programs designed to influence the knowledge, attitudes, values, beliefs, behaviors, and practices of the population-of-interest. Policy development places health issues on decision-makers agendas, acquires a plan of resolution, and determines needed resources. Policy development results in laws, rules and regulations, ordinances, and policies. Policy enforcement compels others to comply with the laws, rules, regulations, ordinances and policies created in conjunction with policy development. Section of Public Health Nursing Minnesota Department of Health September 2000 Minnesota Department of Health 17 Session 1 Section of Public Health Nursing Handout 4.1

Public Health Interventions Applications for Public Health Nursing March 2001 Minnesota Department of Health Division of Community Health Services Public Health Nursing Section Minnesota Department of Health 18 Session 1 Section of Public Health Nursing Handout 4.2

Public Health Nursing Practice for the 21 st Century: Competency Development in Population-Based Practice Session 1 Handout 5 Discussion Questions Consider the following questions about today s session to help you incorporate what you have learned into your own practice. 1. What is your definition of population-based practice? 2. Is your current practice population-based? If not, how could it become more populationbased? 3. List examples of the types of activities you have done in the last month. Determine their level of practice (community level, systems level, or individual/family level). 4. Using the list of activities from above, determine which of the interventions you used. 5. Using a copy of the wheel consider each intervention and practice level. Color in the interventions and practice levels you feel competent in implementing. Which interventions are not colored in? Minnesota Department of Health 19 Session 1 Section of Public Health Nursing Handout 5

Public Health Nursing Practice for the 21 st Century: Competency Development in Population-Based Practice Session 1 PRE TEST QUESTIONS 1. Which of the following could be an example of a population-based public health nursing intervention? a. Running a foot care clinic in a senior citizen center b. Designing and implementing a media campaign to increase community awareness of the dangers of alcohol consumption during pregnancy c. Collaborating on legislation to pass a smoking ban in restaurant d. b and c e. All of the above 2. The overall goal of public health nursing home visits to prevent child abuse is to improve the health of the population of children. a. True b. False 3. A main characteristic of population-based public health nursing practice is that: a. It gives preference to primary prevention b. It gives preference to secondary prevention c. It gives preference to tertiary prevention d. It considers multiple levels of prevention without preference to any particular level of prevention e. None of the above 4. Primary prevention refers to: a. Early diagnosis and prompt treatment b. Limitation of disability c. Rehabilitation d. Prevention of exposure to risk factors e. None of the above 5. An example of primary prevention of playground injuries is: a. Changing the design of playground equipment b. First aid training of school staff by school nurse c. Coordinating emergency response with local EMS service d. Establishing standing orders for school nurse to initiate treatment of injuries 6. Which of the following determinants of health should be considered in population based public health nursing practice? a. Diet, exercise, and smoking risk in populations b. Distribution of hypertension, diabetes, and asthma in populations c. Neighborhood safety d. Income disparity within populations e. a and b f. All of the above Minnesota Department of Health 20 Session 1 Section of Public Health Nursing Pre test

7. The success of population-based interventions is measured by the number of people served. a. True b. False 8. Which of the following characteristics distinguish population-based public health practice from other forms of nursing practice? a. Preventive care located in the community b. Focus on an entire population possessing similar health concerns or characteristics c. Practice based on an assessment of community need d. a and b e. b and c f. All of the above 9. Population-based public health nursing interventions are: a. Individually and family-focused interventions b. Community-focused interventions c. Systems-focused interventions d. a and b e. b and c f. All of the above 10. Population-based public health nursing interventions are directed first at communities. a. True b. False 11. Community-focused interventions are directed at: a. Changing knowledge, attitudes and behaviors of individuals and families in the community b. Changing norms and attitudes in specific populations c. Changing behaviors in specific populations d. a and b e. b and c Minnesota Department of Health 21 Session 1 Section of Public Health Nursing Pre test

Public Health Nursing Practice for the 21 st Century: Competency Development in Population-Based Practice Session 1 Post Test Questions 1. Public health nursing practice is population-based if it: a. Focuses on care of homebound individuals b. Is based on political interest c. Places priorities on individual well being d. Is grounded in a community needs assessme nt d. Gives priority to tertiary prevention rather than primary or secondary prevention 2. An intervention is population-based if the need emerges from a systematic community assessment process. a. True b. False 3. The determinants of health include all of the following but: a. Access to health care services b. Housing c. Private health insurance d. Food, water, and air e. Personal coping skills f. Opportunities for outdoor recreation and solitude 4. Which of the following does not describe population-based public health nursing interventions as practiced in the year 2000? a. Interventions that are grounded in assessments of the community s health b. Interventions that consider the broad determinants of health c. Interventions that consider all levels of practice d. Interventions that are well-grounded in research 5. Each public health nursing intervention in the Wheel can be applied at the community level, the individual/family level, and the systems level. a. True b. False 6. Which of the following is defined as an intervention through which the public health nurse assists individuals, families, groups, organizations, and/or communities to utilize necessary resources available to prevent or resolve problems or concerns? a. Policy development b. Referral and follow-up c. Case management d. Collaboration e. Coalition building Minnesota Department of Health 22 Session 1 Section of Public Health Nursing Post test